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.

Analysis of related factors associated with abnormal pancreatic ultrasound findings in critically ill children / 中华急诊医学杂志

Objective To analyze the clinical features of critically ill children with abnormal pancreatic ultrasound findings in order to explore the related risk factors for offering evidence-based diagnosis of pancreatic damage secondary to critical illness.Methods A prospective study was performed in 531 critically ill children admitted to pediatric intensive care unit(PICU) of 17 children' hospitals from January 2012 to March 2014.All patients were divided into control group(513 cases) and abnormal group(18 cases) according to the pancreatic ultrasound findings.Comparison of clinical features and biochemical indicators were made between two groups.The related risk factors associated with abnormal pancreatic ultrasound findings were analyzed by using Logistic regression analysis.ROC curves were used to evaluate the role of amylase and lipase in the diagnose of abnormal pancreatic ultrasound findings.Results The incidence of abnormal pancreatic ultrasound findings in critically ill children was 3.39%, the average age of abnormal group was significantly older than that in control group (P<0.01).There were not statistically significant differences in gender and primary disease between two groups.The incidence of hypotension was 22.2% and the incidence of abdominal muscle tension was 16.7% in abnormal group,which were statistically higher than those in control group (P<0.05).The levels of calcium, albumin of abnormal group were significantly lower than those in control group (P<0.01), and levels of serum amylase, lipase, lactate dehydrogenase in abnormal group were significantly higher than those in control group (P<0.01).The risk factors associated with abnormal pancreatic ultrasound findings were age, blood pressure, calcium,amylase.Area under the ROC curve of abnormal pancreatic ultrasound findings determined by amylase and lipase were 0.803 and 0.745,respectively (P<0.05).The sensitivity was 0.667, specificity was 0.881 when the serum amylase was 101.5 U/L, the sensitivity was 0.722, specificity was 0.928 when the serum lipase was 96.9 U/L.Conclusions The incidence of abnormal pancreatic ultrasound findings was rather low in critically ill children.The risk factors associated with abnormal pancreatic ultrasound findings were hypotension, hypocalcemia, and hyperamylasemia.The elevated serum amylase and lipase might be the most likely factors associtaed with abnormal pancreatic ultrasound findings.

Changes in pancreatic stone protein/regenerating protein of children with sepsis and pancreatic damage and its significance / 中华实用儿科临床杂志

Objective To determine the levels of blood pancreatic stone protein/ regenerating protein(PSP/reg)and to explore the value of PSP/ reg in assessing severity and predicting prognosis of sepsis with or without panc-reatic damage. Methods In this prospective study,the clinical data and blood samples to measure PSP/ reg levels in 1,3 and 7 days after admission in the Pediatric Intensive Care Unit,Hunan Children's Hospital,from the children with sepsis from September 2013 to September 2014 were collected. According to levels of pancreatic trypsin(amylase or li-pase),the children were divided into normal group,mildly elevated group(1 - 3 times),and severely elevated group (more than 3 times);based on the condition of sepsis,the children were divided into sepsis group and severe sepsis group. Chi - square test,nonparametric rank sum test,Spearman correlation and area under the receiver operating cha-racteristic curve(AUC),Kaplan - Meier survival curves were used for statistical analysis. Results (1)A total of 226 children with sepsis were included in this study,among them pancreatic trypsin was normal in 159 cases(70. 4% ), pancreatic trypsin mildly elevated in 44 cases( 19. 4% ),and pancreatic trypsin severely elevated in 23 cases (10. 2% );125 cases(55. 3% )were sepsis,and 101 cases(44. 7% ,of which 29 cases were sepsis shock)were severe sepsis.(2)The correlation between PSP/ reg and serum amylase was maximum,while PSP/ reg had some correlation with serum lipase,but there was no correlation with C - peptide,insulin,glucose.(3)When pancreatic trypsin was normal or mildly elevated,severe sepsis group had higher levels of PSP/ reg than that of sepsis group(Z = - 7. 627,- 2. 965,P =0. 000,0. 003);while pancreatic trypsin was severe elevated,there was no significant difference in PSP/ reg levels be-tween sepsis group and severe sepsis group(Z = - 0. 134,P = 0. 894).(4)The AUC of PSP/ reg and procalcitonin to assess severity of sepsis were greater than 0. 7 in the children whose pancreatic trypsin was normal or mildly elevated, and there was no significant difference between them(P ﹥ 0. 05);while the AUC of C - reactive protein and WBC were less than 0. 7.(5)PSP/ reg levels gradually increased in non - survival children in 3 and 7 days,while survival children gradually declined. The AUC of PSP/ reg to predict prognosis was 0. 775,and 60 μg/ L was viewed as the critical point, sensitivity 89% ,specificity 67% . Children with PSP/ reg levels ≤60 μg/ L had higher rate of survival than children with ﹥ 60 μg/ L(χ2 = 36. 874,P = 0. 000). Conclusions PSP/ reg is closely associated with pancreatic exocrine func-tion,but PSP/ reg still can assess severity and predict prognosis in children with sepsis and pancreatic damage.

Pathological changes of pancreas and changes of serum amylase and lipase in septic rat / 中国小儿急救医学

Objective To systematically observe the damage of pancreas and changes of serum amy-lase and lipase in septic rat at different time points after the septic rat model being established. Methods Fifty-four male rats were randomly divided into sham group,sepsis group and normal control group. In the sepsis group,rats were given cecal ligation and puncture so as to produce a model of the rat′s intestinal septic shock. In sham group,after opening the abdominal cavity of the rats,only the cecum was pulled out of the abdominal cavity,then the abdominal cavity was satisfied and stitched. The arterial blood and pancreatic tis-sues of the rats in both sepsis and sham groups were collected for detection of serum amylase and lipase and observation of damage of pancreas by light and electron microscopy at 3 h,6 h,12 h,24 h after the model be-ing established. Results The levels of serum amylase of sepsis group showed a rising trend over time,and peaked at 24 h(2 779. 83 U/L), which showed no difference among 4 time points. There was no significant difference of serum amylase among 3 groups at each time point except for 12 h value. The levels of serum li-pase in both sepsis and sham group were higher than that in normal control group at 3 h(P<0. 05),while de-creased to the level of normal control group at 24 h. By light microscope,pathological changes of pancreas in the sham groups were that lobule was slightly widened; mild interstitial edema,vasodilation and a little in-flammatory cell infiltration were occasionally found;most of the lobular structure was complete. In the sepsis group,pancreatic pathological changes aggravated with time prolonged. Pancreatic lobules gap widened,inter-stitial were infiltrated by the inflammatory cell,flocculus brim structure was fuzzy,focal necrosis was found occasionally,islet structure was complete at 3 h. Pancreatic lobule was significantly wider,more inflammatory cell infiltrated,necrosis enlarged at 6 h,and pancreatic lobule was obvious edema,more inflammatory cell in-filtration and focal necrosis were found at 12 h. Vascular of pancreatic lobule was dilatation and congestion, pancreatic lobule and islet edge blurred,more lobular necrosis at 24 h. The modified Schmidt scoring of sham group and sepsis group at 3 h,6 h,12 h,24 h were 2. 0,3. 6,3. 4,3. 6 and 4. 6,6. 0,6. 8,7. 6,respectively. By transmission electron microscope,the ultrastructure of pancreatic cell in sham group was normal,mitochondri-al and lysosomal swelling were found occasionally. When in the sepsis group,the nucleus was normal,some mitochondria was swelling and cracking, lysosomes was swelling at 3 h, nucleus was complete, a part of swelling mitochondria and lysosomes appeared vacuolated necrosis at 6 h,and karyopyknosis and chromatin condensation were found,more mitochondria and lysosomes were swelling necrosis and vacuolar degenerated, rough endoplasmic reticulum was swelling at 12 h,cell karyopyknosis and chromatin condensation were obvi-ous,a large number of mitochondria and lysosome, endoplasmic reticulum were swelling, dilatation and vacuolar necrosis at 24 h. The modified Schmidt scoring showed no significant correlation with the levels of serum amylase and lipase in sepsis group(r=0. 472,P=0. 199;r=0. 260,P=0. 499). Conclusion The pancreas was damaged in the septic rat. The pathological changes of pancreas were obvious at 6 h after sepsis onset. The characteristics of the pancreas ultrastructure change includes the changes of the mitochondria and lysosome in the early period,clear vacuoles necrosis of mitochondria and lysosome,and destruction of nucleus and the endoplasmic reticulum. There is no significant correlation between pancreatic pathological changes and serum amylase as well as lipase,serum amylase and lipase can′t indicate the extent of pancreas damage in sepsis.

Pancreatic function in 64 non-survival patients with sepsis and non-sepsis / 中华急诊医学杂志

Objective To study the exocrine pancreatic function in critically ill children with septic shock,sepsis and hyperlactacidemia.Methods A total of 64 critical pediatric patients were admitted from Jan 2009 to Oct 2012,and clinical and laboratory findings including pancreatic function,and histopathological features and score after autopsy were reviewed.Results (1) Compared with non-septic shock children,the pancreatic pathology score and serum lipase in septic shock group were significantly higher and serum calcium was significantly reduced (P ＜0.05) ; (2) The pancreatic histopathology score was significantly increased in patients with elevated plasma lactate ≥2 times (P ＜0.05),but there were no significant differences in serum calcium and blood amylase and lipase between patients with elevated plasma lactate level and patients with normal plasma lactate level; (3) The concentrations of serum amylase,lipase and urinary amylase were significantly increased in patients with pancreatic histopathology score ＞4 points compared with score ≤4 points patients,but there were no significant differences in above three biomarkers between patients with score ≤3 points and patients with score ＞3 points.Conclusions The pancreas is vulnerable to damage easily occurred in septic shock children especially complicated with hyperlactacidemia.The pancreatic histopathology score ＞ 4 points can be as a sensitive and reliable indicator of pancreas damage.

Hyperglycemia in children with sepsis / 中国小儿急救医学

Sepsis is one of common diseases in pediatrics,critically ill children tend to suffer multiple organ damage that will increase children's risk of death.Hyperglycemia is an important symbol of metabolic disorder after onset of sepsis,with the deepening of understanding that sepsis can cause the pancreatic damage.Therefore,not all hyperglycemia is a representation of transient or stress state.To control hyperglycemia of sepsis in children can help to reduce their complications and mortality.In this review,it will deal with the occurrence of sepsis in children with blood glucose disturbance,regulation and prognosis.

Endocrine changes in children with pancreatic damage:an up-to-date review / 中国小儿急救医学

The variety of primary or secondary pancreatic diseases or injuries in children can cause the changes of pancreatic endocrine function,leading to the structural damage of pancreatic endocrine cells and the dysfunction,which can worsen the disease progression and prognosis.The etiology of pancreatic damage is complex,little is known about the pathogenesis.But the change of pancreatic endocrine function caused by pancreatic damage has clinical significance.Based on current studies and animal experiments,this review covered the etiology and pathogenesis of pancreatic endocrine dysfunction in children with pancreatic damage,which would help promote the cognitive level and the research development in this new field and provide new ideas for the research of pancreatic damage.

Clinical and pathologic characteristics of pancreatic necrosis in critically ill children / 世界急诊医学杂志（英文）

@#BACKGROUND: Pancreatic damage in critically ill patients is associated with the progressive failure of multiple organs, but little is known about its clinical characteristics. At present, no guidelines are available for the diagnosis and management of pancreatic damage. This study was undertaken to analyze the clinical and pathologic characteristics of pancreatic necrosis in critically ill children, and to find some biological markers of pancreatic damage or pancreatic necrosis. METHODS: We retrospectively reviewed the clinical data, laboratory results, and autopsy findings of 25 children, who were admitted to Hunan Children's Hospital, China from 2003 to 2009, and died of multiple organ failure. The autopsy revealed pancreatic necrosis in 5 children, in whom sectional or gross autopsy was performed. RESULTS: The 5 children had acute onset and a fever. Two children had abdominal pain and 2 had abdominal bulging, flatulence and gastrointestinal bleeding. Four children had abnormal liver function, characterized by decreased albumin and 3 children had elevated level of C-reactive protein (CRP). B-ultrasonography revealed abnormal acoustic image of the pancreas in all children, and autopsy confirmed pancreatic necrosis, which may be associated with the damage of the adrenal gland, liver, lung, heart, spleen, kidney, intestine, thymus, mediastinal and mesenteric lymph nodes and other organs. Children 1 and 2 died of acute hemorrhagic necrotizing pancreatitis (AHNP);children 3-5 died of multiple organ dysfunction syndrome (MODS) due to pancreatic necrosis. CONCLUSION: Pancreatic damage or pancreatic necrosis in critically ill children is characterized by acute onset, severity, short course, multiple organ damage or failure. It may be asymptomatic in early stage, and easy to be ignored.

Pancreatic enzymes in evaluation of pancreatic damage in critically ill children / 中国小儿急救医学

Critically ill children are often complicated with multiple organ damage. When the pancreas was involved, kinds of pancreatic enzymes would elevate, which suggested the high risk complication of pancreatic damage was really existed. The changes of pancreatic enzymes under different critical conditions such as shock, surgery, injury, etc. were reviewed, as well as the clinical significance of different pancreatic enzymes, so as to provide evidence for acknowledge the early biological signs in early phase of critically ill children with pancreatic damage,to decrease the mortality of complications and to improve the prognosis of critically ill children.