2008 Annual Meeting Abstracts
Blunt Pancreato-Duodenal Injury: A Multi-Center Study Of the Research Consortium Of New England Centers For Trauma (ReCONECT)
George C. Velmahos, MD, PhD1, Malek Tabbara, MD1, Ronald Gross, MD2, Peter Burke, MD3, Timothy Emhoff, MD4, Rajan Gupta, MD5, Robert J. Winchell, MD6, Lisa Patterson, MD7, Michael Rosenblatt, MD8, James Hurst, MD9, Bruce Crookes, MD10, Sheldon Brotman, MD11.
1Massachusetts General Hospital, Boston, MA, USA, 2Hartford Hospital, Hartford, CT, USA, 3Boston Medical Center, Boston, MA, USA, 4University of Massachusetts Memorial Hospital, Worchester, MA, USA, 5Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA, 6Maine Medical Center, Portland, ME, USA, 7Baystate Medical Center, Springfield, MA, USA, 8Lahey Clinic Medical Center, Burlington, MA, USA, 9Beth Israel Deaconess Medical Center, Boston, MA, USA, 10Fletcher Allen Healthcare, Burlington, VT, USA, 11Berkshires Medical Center, Pittsfield, MA, USA.
Objectives: 1. To evaluate the safety of non-operative management (NOM) and 2. identify missed injuries and related outcomes in patients with blunt pancreatic and/or duodenal injury (BPDI).
Design: Retrospective multi-center study.
Setting: 11 New England Trauma Centers (7 academic, 4 non-academic).
Patients: 230 patients (>15 years old) with BPDI admitted over 11 years (Jan 1996 - Jan 2007). BPDI was graded from 1 (lowest) to 5 (highest) according to the American Association for the Surgery of Trauma grading system.
Main Outcome Measures: 1. BPDI-related complications 2. Length of hospital stay and mortality.
Results: 96 (42%) patients with low-grade (1 and 2) BPDI were selected for NOM, 9 (9%) failed, 9 (9%) developed BPDI-related complications (3 among patients who failed NOM), and 7 (7%) died (none related to failure of NOM). The remaining 134 patients were operated urgently; 35 (26%) developed BPDI-related complications and 20 (15%) died. The diagnosis of BPDI was initially missed in 29 (13%); 23 required an operation. The sensitivity of CT was 74% for pancreatic and 67% for duodenal injuries (not different among various CT generations).
|Correctly diagnosed (N=201)||Initially missed (N=29)||p-value|
|Age > 55 years||45 (23%)||5 (17%)||0.35|
|Injury Severity Score >25||83 (41%)||14 (48%)||0.30|
|Syst blood press<100mmHg||40 (20%)||7 (24%)||0.41|
|WBC on admission||16+10||16+8||0.90|
|Amylase on admission||140+167||146+126||0.84|
|BPDI complications||36 (18%)||8 (27%)||0.21|
|Days in hospital||17+17||21+23||0.40|
|Mortality||23 (11%)||4 (14%)||0.45|
None of the four deaths among patients with initially missed injury was caused by the BPDI.
There was no correlation between time to diagnosis and length of hospital stay (Spearman’s r=0.06).
Conclusions: 1. NOM of low-grade BPDI is safe despite occasional failures. 2. Missed diagnosis of BPDI is not uncommon, as CT continues to perform poorly, but it does not seem to increase significantly the rate of adverse outcomes.