Pancreatic damage control: the pancreas is simple don't complicate it / El control de daños en el páncreas es simple. No complique las cosas

Abstract Pancreatic trauma is a rare but potentially lethal injury because often it is associated with other abdominal organ or vascular injuries. Usually, it has a late clinical presentation which in turn complicates the management and overall prognosis. Due to the overall low prevalence of pancreatic injuries, there has been a significant lack of consensus among trauma surgeons worldwide on how to appropriately and efficiently diagnose and manage them. The accurate diagnosis of these injuries is difficult due to its anatomical location and the fact that signs of pancreatic damage are usually of delayed presentation. The current surgical trend has been moving towards organ preservation in order to avoid complications secondary to exocrine and endocrine function loss and/or potential implicit post-operative complications including leaks and fistulas. The aim of this paper is to propose a management algorithm of patients with pancreatic injuries via an expert consensus. Most pancreatic injuries can be managed with a combination of hemostatic maneuvers, pancreatic packing, parenchymal wound suturing and closed surgical drainage. Distal pancreatectomies with the inevitable loss of significant amounts of healthy pancreatic tissue must be avoided. General principles of damage control surgery must be applied when necessary followed by definitive surgical management when and only when appropriate physiological stabilization has been achieved. It is our experience that viable un-injured pancreatic tissue should be left alone when possible in all types of pancreatic injuries accompanied by adequate closed surgical drainage with the aim of preserving primary organ function and decreasing short and long term morbidity.

Resumen El trauma pancreático es un tipo de trauma poco común potencialmente fatal que está asociado con lesiones de órganos abdominales o vasculares. Usualmente, los signos clínicos son tardíos aumentado el riesgo de complicaciones respecto al manejo y al pronóstico general. Debido a la baja prevalencia de la lesión del trauma, no existe consenso entre los cirujanos alrededor del mundo sobre cómo se debe diagnosticar y tratar adecuadamente este desafío quirúrgico. La precisión en el diagnóstico es difícil por la localización anatómica y las manifestaciones clínicas tardías. El abordaje quirúrgico ha ido cambiando de dirección hacia la preservación del órgano para evitar complicaciones secundarias asociada a la perdida de la función exocrina y endocrina, o de potenciales complicaciones postquirúrgicas incluyendo las dehiscencias y fistulas. El objetivo de este artículo es proponer un algoritmo de manejo del trauma pancreático a través de un consenso de expertos. Las lesiones del páncreas pueden ser manejadas con una combinación de maniobras hemostáticas, empaquetamiento pancreático, sutura de la herida y drenaje quirúrgico cerrado. La pancreatectomía distal con la perdida de tejido vital pancreático debe ser evitadas. Los principios generales de la cirugía de control de daños deben ser aplicados cuando sea necesario para un manejo quirúrgico definitivo cuando y solo cuando la estabilización fisiológica haya sido lograda. En nuestra experiencia, el tejido pancreático sano debe preservarse cuando el trauma se asocia de un manejo mediante un drenaje quirúrgico cerrado con el objetivo de preservar la función primaria del órgano y disminuir a corto y largo tiempo las morbilidades.

Pancreatitis aguda secundaria a un trauma abdominal: reporte de caso de una niña de 7 años / Acute pancreatitis secondary to an abdominal trauma: case report of a 7-year-old child

La pancreatitis consiste en la inflamación aguda del páncreas, que se caracteriza, clínicamente, por dolor abdominal. Para realizar el diagnóstico, es necesario que se presente la elevación de marcadores bioquímicos, como amilasa o lipasa pancreáticas. Esta afección es la enfermedad pancreática más frecuente tanto en niños como en adultos. Su presentación en la población pediátrica está en aumento y tiene varias etiologías, como infecciones, trauma, intoxicación y enfermedades metabólicas. Entre los mecanismos de trauma, se han descrito maltrato infantil, caídas, trauma con el manubrio de la bicicleta y accidentes de tránsito. En este artículo, se presenta un caso de pancreatitis secundaria a un trauma abdominal con el manubrio de una bicicleta en una paciente de 7 años.

Pancreatitis consists in acute inflammation of the pancreas that is clinically characterized by abdominal pain. To make the diagnosis it is necessary the elevation of biochemical markers like pancreatic amylase or lipase. It is the most frequent pancreatic disease in both children and adults. Its presentation in the pediatric population is increasing and has several etiologies such as: infections, trauma, intoxication and metabolic diseases. Trauma mechanisms have been described: child maltreatment, falls, trauma with the bicycle handle and traffic accidents. In this article, we present a case of pancreatitis secondary to an abdominal trauma with the handle of a bicycle in a patient of 7 years.

Lesión de vía biliar en trauma cerrado: nuevas tendencias en lesiones infrecuentes / Biliar injury in closed trauma: new trends in unusual injury

Objetivo: Reportar un caso clínico de lesión de la vía biliar intrapancreática tras traumatismo abdominal cerrado. Caso clínico: Paciente que acude a urgencias por intenso dolor abdominal, tras sufrir traumatismo toraco-abdominal cerrado al caer de una bicicleta. Posteriormente a su ingreso desarrolló fiebre, ictericia y patrón analítico de colestasis. Se solicitó colangiorresonancia magnética donde no se pudo valorar correctamente la vía biliar, pero se evidenció abundante líquido intraabdominal que no correspondía a sangre. Se indicó cirugía urgente ante la sospecha de lesión biliar. Se objetivó lesión de la vía biliar intrapancreática mediante colangiografía intra-operatoria y se decidió colocación de prótesis intrabiliar mediante colangiopancreatografía retrógrada endoscópica (CPRE) intraoperatoria. Conclusión: La cirugía ha sido el tratamiento convencional para la lesión de la vía biliar, pero en la actualidad la CPRE con esfinterotomía y colocación de prótesis intrabiliar es un tratamiento adecuado y resolutivo de este tipo de lesiones pudiéndose considerar como tratamiento de primera línea.

Aim: To report a clinical case of biliar injury intrapancreatic in closed abdominal trauma. Clinical case: Patient who comes to the emergency room by severe abdominal pain after suffering thoraco-abdominal blunt trauma after falling from a bicycle. After his admission he developed fever, jaundice and analytical standards of cholestasis. Magnetic resonance which failed to correctly assess the bile duct was requested but showed plenty of intra-abdominal fluid blood that did not match. Emergency surgery for suspected biliary injury was reported. Intrapancreatic injury bile duct was observed by intraoperative cholangiography and prosthesis was decided intrabiliary by intraoperative endoscopic retrograde cholangiopancreatography (ERCP). Conclusions: Surgery has been the standard treatment for bile duct injury, but now ERCP with sphincterotomy and placement of intrabiliary prosthesis is adequate and operative treatment of these injuries and can be considered as first-line treatment.

Role of high mobility group box-1 and protection of growth hormone and somatostatin in severe acute pancreatitis

In this study, we investigated the potential role of high-mobility group box 1 (HMGB1) in severe acute pancreatitis (SAP) and the effects of growth hormone (G) and somatostatin (S) in SAP rats. The rats were randomly divided into 6 groups of 20 each: sham-operated, SAP, SAP+saline, SAP+G, SAP+S and SAP+G+S. Ileum and pancreas tissues of rats in each group were evaluated histologically. HMGB1 mRNA expression was measured by reverse transcription-PCR. Levels of circulating TNF-α, IL-1, IL-6, and endotoxin were also measured. In the SAP group, interstitial congestion and edema, inflammatory cell infiltration, and interstitial hemorrhage occurred in ileum and pancreas tissues. The levels of HMGB1, TNF-α, IL-1, IL-6 and endotoxin were significantly up-regulated in the SAP group compared with those in the sham-operated group, and the 7-day survival rate was 0%. In the SAP+G and SAP+S groups, the inflammatory response of the morphological structures was alleviated, the levels of HMGB1, TNF-α, IL-1, IL-6, and endotoxin were significantly decreased compared with those in the SAP group, and the survival rate was increased. Moreover, in the SAP+G+S group, all histological scores were significantly improved and the survival rate was significantly higher compared with the SAP group. In conclusion, HMGB1 might participate in pancreas and ileum injury in SAP. Growth hormone and somatostatin might play a therapeutic role in the inflammatory response of SAP.

effect of mesenchymal stem cell therapy on ischemia-reperfusion-induced injury of the rat pancreas: a histological and immunohistochemical study

Ischemia-reperfusion [I/R] injury plays an important role in the development of acute pancreatitis; both ischemia and reperfusion contribute to tissue loss and organ dysfunction. I/R is also reported to be one of the reasons for the inflammatory reaction occurring in grafted tissue. Mesenchymal stem cells [MSCs] are multipotent cells capable of self-renewal and differentiation into various cell lineages. This study aimed to evaluate the role of MSC therapy on l/R-induced injury of the pancreas in albino rats. The present study was performed on three groups. Group I was the control group. Group II was the I/R group in which the pancreases of rats were exposed to ischemia for 30 min after which they were reperfused for 90 min; these rats were then sacrificed 1 week [group I la] and 4 weeks [group lib] after reperfusion. Group III was the stem cell-treated group in which rats were exposed to I/R and then injected intravenously with MSCs; they were then sacrificed 1 week [group Ilia] and 4 weeks [group Illb] after reperfusion. Pancreatic sections were stained with Hand E, CD105, and insulin. Results were statistically analyzed. I/R caused changes in the form of cellular vacuolations and apoptotic changes involving the pancreatic acini. Immunohistochemical staining for insulin was markedly decreased, becoming almost absent by the fourth week. Treatment with MSCs was associated with PKH 26-labeled cells within the exocrine and endocrine portion of the pancreas. Also, CD105-positive cells were detected between the acini and within the stroma in between. The cells in the treated subgroups restored their normal appearance and regained positivity for insulin immunoreactivity

Punción aspiración de páncreas por ecoendoscópia: nuestra experiencia y concordancia de la asistencia por citopatólogo / Pancreatic endoscopic ultrasound: guided aspiration our experience and assistance for matching cytopathologist

La punción aspiración por aguja fina guiada por ultrasonido endoscópico es un método diagnóstico definitivo de patologías pancreáticas. Nuestro objetivo fue realizar revisión de las indicaciones, técnica y resultados de las punciones de páncreas y calcular el índice de concordancia entre diagnósticos preliminares en sala y la citohistología definitiva. Metodo: Se incluyeron las punciones pancreáticas realizadas desde Abril 2009-2011, se vaciaron las indicaciones, sitio de abordaje, aguja utilizada, número de pases, resultados preliminares y resultados citohistológicos definitivos y se estimó el índice de concordancia. Resultados: Se incluyeron 179 punciones, edad promedio de los pacientes 59,39 años; 55% masculinos, 45% femeninos, cuyas indicaciones fueron Lesión neoproliferativa en 67%, lesión quística 12%, pancreatopatía 14%, hiperplasia papilar 7%. El abordaje fue duodenal en 52%, gástrico 48%; se utilizó agujas 22G en 83%, 25G en 17%. No hubo asistencia en 6%. Se reportó resultado preliminar en 95% de los pacientes, con ellos se calculó el índice Kappa obteniéndose un valor de 0,791 reportándose una fuerza de concordancia buena. Conclusión: La punción es una excelente herramienta para obtener de forma poco invasiva la citohistología del páncreas y con un buen intervalo de coincidencia entre el diagnóstico inicial y final si tenemos citopatólogo en la sala.

The fine needle aspiration cytology guided by endoscopic ultrasound is a method of definitive diagnosis of pancreatic diseases. Our objective was to review the indications, technique and results of the pancreatic punctures and calculate the index of agreement between the preliminary diagnoses in the room and the final cytohistologic report. Method: Were included the total of pancreatic punctures performed from April 2009-2011. The indications, the puncture site, needle used, number of passes, preliminary results and final results cytohistologic parameters and estimated concordance index, were emptied in a table. Results: We included 179 punctures, mean age of patients 59.39 years, 55% male, 45% female, whose indications were tumor in 67%, cystic lesion 12%, inflammatory disease 14%, papillary hyperplasia7%. The approach was duodenal in 52%, gastric 48%, 22G needle was used in 83%, 25G at 17%. There was no attendance by 6%. Preliminary result was reported in 95% of patients, we calculated the Kappa index of 0.791 obtaining a value to be reported a good strength of agreement. Conclusion: The puncture is an excellent tool for minimally invasive form of cytohistology of the pancreas that has a good range of overlap between the initial and final diagnosis if cytopathologist is in the room.

Tumor pseudopapilar de páncreas: tumor sólido poco frecuente / Pseudopapillary tumor of pancreas:: a solid infrequent tum

El tumor pseudopapilar de páncreas o tumor de Frantz, descrito por primera vez en 1959 por Gruber Frantz; constituye menos del 1% de las neoplasias pancreáticas. Es más frecuente en mujeres jóvenes, entre la segunda y tercera década de la vida, aunque también ha sido descrita en hombres, con una relación mujer: hombre de 1:10. Evaluar en un período de un año la frecuencia de presentación de los tumores pseudopapilares de páncreas, su manifestación clínica, las características ultrasonográficas y citológicas. Un estudio descriptivo, retrospectivo llevado a cabo entre Marzo de 2010 y Marzo de 2011. Los equipos utilizados fueron: Olympus GFUM130/Q130 y procesador Aloka. Encontramos 2 (0,94%) casos de un total de 212 ultrasonidos endoscópicos biliopancreáticos. Los dos del sexo femenino de 16 y 44 años, con manifestación clínica de pancreatitis aguda y hemorragia Se describieron las lesiones como heterogéneas con diámetros variables de 4,6 a 7,25 cm, en contacto con la vena mesentérica superior, desplazándola hacia la periferia, dilatación y tortuosidad del conducto de Wirsung. A ambas se le realizó punción aspiración con aguja 22 G con adecuado contenido serohemático, en uno de los casos fundamentalmente hemático y enviados a patólogo experta en citopatología. Para evaluación de estas lesiones pancreáticas el ultrasonido endoscópico (USE), las identifica como una masa bien definida, encapsulada, con aspecto mixto sólido-quístico que causa desplazamiento de estructuras adyacentes sin invadir las mismas. Esta neoplasia tiene crecimiento lento con curso indolente y sin alteraciones constitucionales. La punción por aguja fina con estudio citopatológico del mismo es una herramienta fundamental ya que en ella se evidencia papilas ramificadas con estroma mixoide y fibrovascular, células tumorales monomórficas, con núcleo redondo y citoplasma espumoso eosinofílico. El tratamiento de elección fue la resección quirúrgica, como lo descrito en la literatura...

The pancreatic pseudopapilar tumor or Frantz’s tumor was described for the first time by Gruber Frantz in 1959, and represents less than 1% of the pancreatic neoplasia. It is more frequent in young women, between the second and third decade of life, even though it has also been described in men, with a women:men relationship of 1:10. Evaluate during one year the frequency of pseudopapillary tumors of pancreas, and their clinic, ultrasonographyc and cytological features. It is a descriptive and retrospective study, carried out from March 2010 to March 2011. We used an Olympus GF-UM130/Q130 endoscopic ultrasound equipment with Aloka software. 2 cases were found (0.94%) in a total of 212 endoscopic ultrasounds of gallbladder and pancreas. Both cases were females of 16 and 44 years old, with clinic manifestations of acute pancreatitis and digestive bleeding, respectively. The lesions were heterogeneous, with variable diameters from 4.60 to 7.25 cm, making contact with the upper mesenteric vein, displacing it to the periphery, along with an enlarged and tortuous Wirsung conduct. Puncture and aspiration with a 22G needle and the appropriate serohematic content, were the procedures performed to the patients, being one of them mainly hematic. The samples were evaluated by a pathologist expert in cytopathology. The tumors of the pancreas were identified as well defined masses, encapsulated, with a mix solid-cystic appearance, which cause displacement of adjacent structures without invading them. This neoplasia had slow growth, indolent development and no constitutional alterations. Puncture of the tumors with a fine needle and their cytopathologic evaluation were basic tools to study this neoplasia, since they allowed us to identify branched papilla with mix fibrovascular stroma and monomorphic tumor cells, with round nucleus and foamy cytoplasm. The treatment of choice was surgical resection, such as reported in literature. It has achieved a 97% survival...

Pancreatitis traumática: revisión del tema y presentación de caso / Traumatic pancreatitis: review on the theme and presentation of a case

El traumatismo pancreático se está incrementando actualmente, y esto podría ser causado por accidentes de vehículo a alta velocidad o a una mejor detección de las lesiones pancreáticas. Se presentó un caso de trauma pancreático ingresado en el servicio del Hospital Provincial Clínico Quirúrgico Docente José R. López Tabrane, de Matanzas, teniendo en cuenta la importancia y severidad de algunas de sus formas, y que el diagnóstico, en ocasiones, de las formas más leves no se realiza. Se realizó una revisión de la bibliografía actualizada sobre esta patología para una mejor comprensión del caso...

Pancreatic trauma is increasing currently, and that may be caused by high speed car accidents or by a better detection of the pancreatic lesions. We present a case of pancreatic trauma admitted in the service of the Teaching Surgico-clinical Provincial Hospital Jose R. Lopez Tabranes, of Matanzas, taking into account the importance and severity of some of its forms, and that some of its most mild forms are not diagnosed sometimes. We made a review of the updated literature on this disease for a better comprehension of the case...

Resultados del tratamiento quirúrgico en un traumatismo pancreaticoduodenal / Results of the surgical treatment in a pancreaticoduodenal trauma

Introducción: la ruptura del páncreas y el duodeno es un evento poco común, cuyas cifras oscilan entre el 2 y el 4 por ciento de los traumatismos abdominales. La mayoría ocurre en heridas abdominales penetrantes y en traumatismos compresivos en accidentes de tránsito. Métodos: se presenta una serie de 19 pacientes operados por traumatismo pancreaticoduodenal, en 5 hospitales clinicoquirúrgicos de Ciudad de La Habana, desde 2008 a 2010. Se realizó un estudio retrospectivo, mediante el uso de encuestas diseñadas a tal efecto, aplicadas a los cirujanos actuantes en el período estudiado. Resultados: el 63 por ciento de los pacientes fueron por traumatismos cerrados, con predominio de accidentes de tránsito, la mayoría clasificados como grado I (15 pacientes), y 2 pacientes como grado II. Ambos grupos acumularon el 90 por ciento de las lesiones. El procedimiento quirúrgico más frecuentemente empleado fue la pancreatectomía distal con esplenectomía. Se complicaron 8 pacientes (42 por ciento), y la más frecuente fue la fístula pancreática externa en 4 pacientes, seguida por la peritonitis en 2; fallecieron 3 (15 por ciento), distribuidos de la manera siguiente: de 13 pacientes clasificados como grado I, falleció 1 (7 por ciento), y 2 pacientes clasificados como grado III (100 por ciento). Conclusiones: para obtener resultados favorables en este tipo de paciente es necesaria una clasificación acertada según la localización y severidad de las lesiones, así como una adecuada selección del procedimiento quirúrgico(AU)

Introduction: rupture of pancreas and duodenum is a uncommon event, whose figures fluctuate between the 2 and the 4 percent of the abdominal traumata. Most occur in penetrating abdominal wounds and in compressive traumata in road accidents. Methods: a total of 19 patients were operated on due to a pancreaticoduodenal trauma in five clinical surgical hospitals of Ciudad de La Habana from 2008 to 2010. A retrospective study was conducted using the surveys designed to that end, applied to acting surgeons during the study period. Results: the 63 percent of patients had closed traumata with predominance of road accidents, most qualified as grade I (15 patients) and two patients as grade III. Both groups accounted for the 90 percent of injuries. The more frequent surgical procedure used was the distal pancreatectomy with splenectomy. Eight patients had complications (42 percent) where the most frequent one was the external pancreatic fistula in 4 patients, followed by peritonitis in two patients; three dyed (15 percent), distributed as follow: from13 patients classified as degree I, one dyed (7 percent) and two patients classified as degree III (100 percent). Conclusions: to obtain favorable results in this type of patient, it is necessary an appropriate classification according to location and severity of the injuries, as well as a proper selection of the surgical procedure(AU)

Duodenopancreatectomia no trauma: relato de caso / Duodenopancreatectomy in trauma: case report

A duodenopancreatectomia é rara no trauma, entretanto, em algumas situações é necessária, como ocorre nas lesões complexas da confluência biliopancreática. O grau da lesão, tipo do trauma, estabilidade hemodinâmica e a condição homeostática do paciente no momento da cirurgia são fatores que determinam a técnica cirúrgica a ser utilizada no trauma. Este relato objetiva demonstrar tipo de lesão grave e rara no trauma com seu resultado, além da opção de reconstrução do trânsito biliar e anastomose pancreato-duodenal.

The duodenopancreatectomy is rare in trauma, however, in some situations it is necessary, eg in complex lesions of the Duodeno-pancreatic confluence. The degree of injury, type of trauma, hemodynamic stability and homeostatic condition of the patient at the time of surgery are the factors that determine the surgical technique to be used in trauma. This case report aims to demonstrate a type of rare and severe injury in trauma with the result, plus the option of biliary transit reconstruction and pancreato-duodenal anastomosis.

Tumor pseudopapilar del páncreas: reporte de caso / Pancreatic pseudopapilar tumor: case report

El tumor pseudopapilar del páncreas es una entidad muy poco frecuente que afecta preferentemente a mujeres jóvenes. Se trata de un carcinoma quístico con bajo potencial maligno que se diagnostica generalmente de forma incidental pues no hay signos ni síntomas patognomónicos de dicha enfermedad. La resección quirúrgica es curativa en la mayoría de los casos y el pronóstico es excelente aun si hay metástasis al momento del diagnóstico. Se presenta el caso de una paciente de sexo femenino de 21 años de edad, sin antecedentes personales de importancia, quien consultó por dolor abdominal agudo. Se realizó tomografía computarizada, la cual reportó una masa de 75 x 80 x 76 mm en la cola del páncreas, por lo que se llevó a cirugía realizándose pancreatrectomía distal con resección completa del tumor y preservación esplénica. El estudio de anatomía patológica reportó tumor pseudopapilar del páncreas. La paciente tuvo una evolución satisfactoria y hasta el seguimiento a los 16 meses persiste asintomática y no ha presentado recurrencia.

Pseudo papillary tumor of the pancreas is a rare entity most commonly seen in young females. This neoplasm it is a cystic carcinoma of low malignant potential usually diagnosed incidentally because an abscense of typical signs or symptoms. Surgical resection it is usually curative with excellent prognosis even when metastasis are present at the time of diagnosis. We report the case of a 21-year-old female who presented with abdominal pain with no previous history of any abdominal discomfort or pain. Computed tomography showed a 75 x 80 x 76 mm solid mass located at the tail of the pancreas. A distal pancreatectomy with preservation of the Spleen was performed. Pathology reported: pseudo papillary tumor of the pancreas. Evolution was satisfactory with no complication and the follow up at 16 months showed no recurrence. Histological examination confirmed the diagnosis and the complete resection of this tumor has an excellent prognosis with rare recurrences.

Trauma pancreático / Pancreatic trauma

El páncreas es un órgano intraabdominal en posición retroperitoneal, cuyo traumatismo es poco frecuente. La clasificación por grados ha ayudado a la práctica de tratamientos más eficaces y la disminución del número de complicaciones. Estas últimas aparecen como consecuencia del traumatismo o del tratamiento quirúrgico, el cual puede ser simple o implicar grandes resecciones. Se presenta el caso de un paciente sufrió un trauma abdominal cerrado de 3 días de evolución. Se realizaron exámenes diagnósticos y por la clínica y los complementarios se decidió realizar el tratamiento quirúrgico. El objetivo de este trabajo fue exponer los elementos clínicos, resultados de complementarios y hallazgos quirúrgicos en este paciente, así como incentivar la sospecha de esta afección en el traumatismo abdominal(AU)

Pancreas is an intra-abdominal organ in retroperitoneal location chow trauma is uncommon. Degree classification helps in more effective treatment practice and in decrease of complications appeared s consequence of traumas or the surgical treatment, which may be simple or involves large resections. The case of a patient with closed abdominal trauma of 3 days course. Diagnostic and clinic and complementary examinations were carried out being necessary surgical treatment. The aim of present paper was to expose the clinical elements, complementary results and surgical findings in this patient, as well as to motivate the suspicion of this affection in abdominal trauma(AU)

Trauma do pâncreas: fatores preditivos de morbidade e mortalidade relacionados a índices de trauma / Trauma of pancreas: predictor's factors of morbidity and mortality related to trauma index

Contexto: Embora incomuns, lesões traumáticas do pâncreas estão associadas a significativos níveis de complicações e mortalidade. OBJETIVO: Definir os fatores preditivos de morbidade e mortalidade em pacientes vítimas de trauma pancreático. MÉTODO: Foram estudados 131 pacientes atendidos pela Disciplina de Cirurgia do Trauma no Hospital de Clínicas da Universidade Estadual de Campinas, SP, no período entre janeiro de 1994 a dezembro de 2007, com seus parâmetros epidemiológicos, fisiológicos e anatômicos, sendo comparados e analisados aos fatores preditivos de evolução, com estudo estatístico. Resultados: Trauma penetrante, com predomínio de ferimentos por projétil de arma de fogo ocorreu em 64 por cento dos casos. A maioria, 91,6 por cento, era do sexo masculino e a idade média de 29,8anos. A morbidade global foi de 64,9 por cento, com 29 por cento de complicações diretamente relacionadas ao pâncreas, como fístulas e sangramento. A mortalidade foi de 27,5 por cento, principalmente em decorrência de choque hipovolêmico e falência de múltiplos órgãos e sistemas. Houve maior morbidade e mortalidade em pacientes com lesões complexas (graus IV e V) do pâncreas quando comparadas com lesões menos graves (graus I e II), porém a morbidade e mortalidade neste grupo não foram desprezíveis, devido a valores alterados de escore de trauma revisado ("revised trauma score"), valores elevados de índice de gravidade da lesão ("injury severity score") e "abdominal trauma index". Conclusões: Valores alterados de "revised trauma score", pressão arterial sistólica menor que 90 mm Hg, valor de "injury severity score" menor ou igual a 15 e valor de "abdominal trauma index" maior ou igual a 25 são fatores relacionados a aumento da morbidade. Valores anormais de "revised trauma score", valores de "injury severity score" e "abdominal trauma index" superiores a 25, pressão arterial sistólica inferior a 90 mm Hg são fatores preditivos de aumento de mortalidade...

Context: Although relatively uncommon, traumatic pancreatic injury is associated with significant morbidity and mortality. OBJECTIVE: To define the predictors' factors of increase in the morbidity and mortality in patients with pancreatic trauma. METHOD: In this casuistic 131 patients were studied, since January 1994 through December 2007, with theirs epidemiological, physiological and anatomic parameters compared and the analysis of the predictive values for the occurrence of bad evolution, with an appropriate statistical study. Results: Penetrating trauma occurred in 64 percent and blunt trauma in 36 percent, and 91.6 percent was male. The mean age was 29,8 years. The global morbidity in this series was 64.9 percent with 29 percent prevalence of pancreas related complications, such as pancreatic fistula and bleeding occurrence. The overall mortality was 27.5 percent and occurred by hemorrhagic shock and multiple organs and system failed. CONCLUSIONS: Higher morbidity and mortality was related with complex injuries of the pancreas (grade IV and V), but morbidity and mortality in the group of injuries grade I and II are not minimal in patients with changed values of revised trauma score and high values of injury severity score and abdominal trauma index. Systolic blood pressure lower 90 mm Hg, changed values of revised trauma score index, values of injury severity score higher 15 and values of abdominal trauma index higher 25 are predictive factors of morbidity. Changed values of revised trauma score, values of injury severity score or abdominal trauma index higher 25, systolic blood pressure are predictive factors of mortality in patients with pancreatic trauma. Low values of TRISS are predictive of higher morbidity and mortality, but high values of TRISS are not predictives of satisfactory evolution.

Effects of ischemia/reperfusion on beta cells of pancreas and protective effects of melatonin treatment / Efectos de la isquemia/reperfusión sobre células beta del páncreas y efectos protectores del tratamiento de melatonina

Oxygen free radicals are considered to be important components involved in the pathophysiological tissue alterations observed during ischemia-reperfusion (I/R). In this study, we investigated the putative protective effects of melatonin treatment on pancreatic I/R injury. Sprague Dawley male rats were subjected to 30 min of pancreatic pedicle occlusion followed by 90 min reperfusion. Melatonin (10 mg/kg. s.c) was administrated 30 min prior to ischemia or I/R application. At the end of the reperfusion periods, rats were decapitated. Pancreatic samples were taken for transmission electron microscopy. The results indicated that ischemia created b cell damage as evidenced by dilatation between the nucleus inner and outer membrane and degeneration on islets of Langerhans cells, was reversed by melatonin treatment. As melatonin administration reversed these microscopic damage, it seems likely that melatonin protects pancreatic tissue against oxidative damage.

Los radicales libres del oxígeno son considerados como uno de los componentes más importantes que participan en las alteraciones fisiopatológicas del tejido durante la isquemia-reperfusión (I/R). En este estudio, se investigó el supuesto efecto protector del tratamiento de melatonina sobre la lesión pancreática I/R. Ratas Sprague Dawley machos fueron sometidas a 30 minutos de oclusión del pedículo pancreático seguido de 90 minutos de reperfusión. La melatonina (10 mg/kg) fue administrada 30 minutos antes de la isquemia o de la aplicación I/R. Al finalizar los periodos de reperfusión, las ratas fueron decapitadas. Fueron tomadas muestras pancreáticas para el análisis en microscopía electrónica de transmisión. Los resultados indicaron que la isquemia ocasionó daño en las células beta demostrado por la dilatación entre el núcleo interior y la membrana exterior y la degeneración de los islotes de células pancreáticas, los que fueron revertidos por el tratamiento de melatonina. Como la administración de melatonina revirtió estos daños microscópicos, parece probable que ella proteja al tejido pancreático contra el daño oxidativo.

Baço acessório intrapancreático: achados de imagem / Intrapancreatic accessory spleen: imaging findings

Baços acessórios consistem em proliferações de tecido esplênico, com prevalência relatada de 10% a 30% em estudos de autópsias e de 45% a 65% em pacientes submetidos a esplenectomia. Quando este tecido se localiza em meio ao tecido pancreático, são denominados baços acessóriosintrapancreáticos, sendo esta a segunda localização mais frequente, representando cerca de 16,8%dos casos. Esta entidade apresenta um interesse particular, por tratar-se de l esão benigna, geralmente incidental, cujo diagnóstico diferencial deve ser feito com lesões primárias pancreáticas.Neste caso devem ser afastados tumores neuroendócrinos (de ilhotas pancreáticas), adenocarcinoma e metástases. Na investigação por imagem, os baços acessórios intrapancreáticos se manifestamcom aspecto semelhante ao baço nativo em todos os métodos. À ultrassonografia, aparecem como imagem circunscrita hipoecóica homogênea, e na tomografia computadorizada e ressonânciamagnética apresentam, respectivamente, densidade, características de sinal e realce semelhantes ao baço. Nos casos em que o aspecto de imagem permanecer inespecífico, o diagnósticopode ser sugerido pela cintilografia com hemácias marcadas com tecnécio-99m, atualmente considerado o exame padrão ouro. Todas estas modalidades fornecem elementos para o diagnósticocom segurança, evitando procedimentos invasivos desnecessários.

Accessory spleens consist of spleen tissue proliferations, with an estimated prevalence of 10% to 30% in autopsies studies and 45% to 65% in patients submitted to splenectomy. Accessory spleens can occur within the pancreatic tissue (intrapancreatic accessoryspleen), representing the second most frequent localization (about 16.8% of the cases). This entity is of particular interest, since it is a benign lesion, generally incidentally detected, that should be differentiated from pancreatic endocrine neoplasm, pancreatic adenocarcinoma and metastasis. Intrapancreatic accessory spleen has similar imaging manifestations to native spleen in all imaging modalities. At ultrasound, it appears as a homogeneous, hypoechoic, circumscribed image. At computed tomography and magnetic resonance imaging it has similar density, signal characteristics and enhancement pattern in comparison to the spleen. In somecases, where the image findings remain nonspecific, the diagnosis may be suggested by technetium-99m radiolabeled red blood cells scintigraphy, currently considered the gold standard test. This aspect allows a confident imaging diagnosis, preventing unnecessary invasive procedures.

Prognostic Determinants in Patients with Traumatic Pancreatic Injuries

The aim of this study was to identify factors that predict morbidity and mortality in patients with traumatic pancreatic injuries. A retrospective review was performed on 75 consecutive patients with traumatic pancreatic injuries admitted to the Emergency Medical Center at Masan Samsung Hospital and subsequently underwent laparotomy during the period January 2000 to December 2005. Overall mortality and morbidity rates were 13.3% and 49.3%, respectively. A multivariate regression analysis revealed that greater than 12 blood transfusions and an initial base deficit of less than -11 mM/L were the most important predictors of mortality (p<0.05). On the other hand, the most important predictors of morbidity were surgical complexity and an initial base deficit of less than -5.8 mM/L (p<0.01). These data suggests that early efforts to prevent shock and rapidly control of bleeding are most likely to improve the outcome in patients with traumatic pancreatic injuries. The severity of pancreatic injury per se influenced only morbidity.

Diagnosis and treatment of 42 cases of multiple injuries with pancreatic injury / 华中科技大学学报（医学）（英德文版）

In order to summarize the clinical diagnosis and treatment methods for 42 cases of multiple injuries with pancreatic injury, a retrospective analysis on 42 cases of multiple injuries with pancreatic injury from January 1990 to January 2006 was carried out in our hospital. Most cases were associated with hemopneumothorax and rib fractures (52.3%), shock (50%), multiple fractures (47.6%), and severe brain injury (26.1%). In 42 cases, one case died of severe hemorrhagic shock, and the remaining 41 cases (97.6%) were cured (including 40 cases receiving surgical operation and one case receiving the conservative treatment). Postoperative complications occurred in 16 cases (21 cases/times): pancreatic fistula (5 cases/times) and incisional wound infection (5 cases/times), intra-abdominal infection (3 cases/times), stress ulcer (3 cases/times), pleural effusion (3 cases/times), pulmonary infection (one case) and wound dehiscence (1 case). The principle therapy of multiple injuries with pancreatic injury is to rescue life, followed by active treatment to prevent injuries which giving rise to the abnormal respiratory and circulatory functions, management of cerebral hernia and other injuries which endangers life at last, and the pancreatic injury to increase the survival rate and survival quality.

Exclusión pilórica en lesión duodeno-pancreática combinada: reporte de 2 casos / Pyloric exclusion for traumatic duodenal and pancreatic lesions: report of two cases

Introducción: Las lesiones traumáticas de duodeno y páncreas constituyen una entidad quirúrgica de tratamiento difícil, especialmente, si se trata de trauma combinado. Debido a su ubicación retroperitoneal; afortunadamente, las injurias de estos órganos no son frecuentes. Objetivo: Proporcionar conocimientos actualizados sobre el diagnóstico y manejo de las lesiones duodeno-pancreáticas combinadas con énfasis en la exclusión pilórica como método de tratamiento quirúrgico. Sede: Hospital de segundo nivel de atención. Diseño: Presentación de 2 casos clínicos: caso 1: paciente varón, con trauma cerrado de abdomen; y, caso 2: paciente varón, con trauma penetrante de abdomen por arma de fuego. Resultados: Los dos pacientes fueron sometidos a una laparotomía exploradora, realizándose la exclusión pilórica, con rafia duodenal, gastrostomía, yeyunostomía; acompañados de pancreatectomía distal en el caso 1 y colecistectomía en el caso 2. En este último, se presentó una complicación séptica: un absceso pancreático que involucró el colon transverso, tratándose mediante laparostomía y hemicolectomía derecha e ileostomía. La estancia hospitalaria fue de 33 días (caso 1) y 97 días (caso 2). Conclusiones: El presente artículo pretende comunicar una conducta para el cirujano que enfrenta este tipo de trauma, analizando la técnica de la exclusión pilórica.

Due to their retroperitoneal location, traumatic lesions of pancreas and duodenum are difficult to treat. Pyloric exclusion is a therapeutic alternative for these lesions. We report a 22 years old male with a blunt abdominal trauma and a 23 years old male with a gunshot abdominal wound. Both were operated, performing a pyloric exclusion, with duodenal suture, gastrostomy and jejunostomy. A distal pancreatectomy was performed in the first patient a cholecystectomy in the second. The latter had a pancreatic abscess that involved transverse colon as complication. He was treated with a laparostomy, hemicolectomy and ileostomy. Hospital stays were 33 and 97 days in each case.

Left gastric artery pseudoaneurysm following traumatic pancreatic transection.

A 24-year-old man presented to us 10 days after suffering blunt trauma to the abdomen. He was diagnosed with pancreatic transection and underwent distal pancreatectomy and splenectomy. Two weeks after the operation, he developed intra-abdominal haemorrhage. Selective visceral angiogram revealed left gastric artery pseudoaneurysm, which had embolised. His recovery was uneventful. To our knowledge, ruptured left gastric artery pseudoaneurysm following pancreatic trauma, has not been reported before. In this article, we discuss some vascular complications of pancreatic trauma.