Increased Resistin Levels in Intra-abdominal Sepsis: Correlation with proinflammatory cytokines and Acute Physiology and Chronic Health Evaluation (APACHE) II scores.

OBJECTIVES: Resistin, a hormone secreted from adipocytes and considered to be a likely cause of insulin resistance, has recently been accepted as a proinflammatory cytokine. This study aimed to determine the correlation between resistin levels in patients with intra-abdominal sepsis and mortality. METHODS: Of 45 patients with intra-abdominal sepsis, a total of 35 adult patients were included in the study. This study was undertaken from December 2011 to December 2012 and included patients who had no history of diabetes mellitus and who were admitted to the general surgery intensive care units of Gazi University and Bülent Ecevit University School of Medicine, Turkey. Evaluations were performed on 12 patients with sepsis, 10 patients with severe sepsis, 13 patients with septic shock and 15 healthy controls. The patients' plasma resistin, interleukin-6 (IL-6), tumour necrosis factor alpha (TNF-α), interleukin-1 beta (IL-1ß), procalcitonin, lactate and glucose levels and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were studied daily for the first five days after admission. A correlation analysis of serum resistin levels with cytokine levels and APACHE II scores was performed. RESULTS: Serum resistin levels in patients with sepsis were significantly higher than in the healthy controls (P <0.001). A significant correlation was found between serum resistin levels and APACHE II scores, serum IL-6, IL-1ß, TNF-α, procalcitonin, lactate and glucose levels. Furthermore, a significant correlation was found between serum resistin levels and all-cause mortality (P = 0.02). CONCLUSION: The levels of resistin were significantly positively correlated with the severity of disease and were a possible mediator of a prolonged inflammatory state in patients with intra-abdominal sepsis.

Giant serous microcystic pancreas adenoma.

Serous cystadenomas are rare tumors comprising 1-2% of exocrine pancreas tumors. They are mostly known as benign conditions but malign transformation as serous cystadenocarcinoma is also reported. It is usually seen in females. Non-specific symptoms, such as abdominal pain or symptoms due to mass affect, are usually seen. A 64-year old female patient was investigated for abdominal pain. Physical and laboratory findings were normal. Abdomen ultrasonography confirmed an 11×9.5 cm solid cystic lesion and abdomen computed tomography scan confirmed a 12×11 cm lobulated cystic solid lesion which had central cystic necrotic areas extending from liver hilus inferiorly. Fine needle biopsy confirmed benign cytology and trucut biopsy of the pancreatic mass reported chronic inflamation. Nevertheless, this mass could have malignant contents and transformation potential. A laparatomy was decided due to patient's symptoms and mass effect. Due to vascular invasion of the tumor, Whipple procedure was performed. The pathology report confirmed serous microcystic adenoma. These rare tumors are usually benign but pre-operative malignity criterias are not identified. There are few differential diagnostic tools for excluding malignity. We suggest surgical resection as best treatment approach for selected cases.

Effects of nuclear factor-κB inhibitors on colon anastomotic healing in rats.

BACKGROUND: Nuclear factor (NF)-κB plays an essential role in inflammation. We tested this role by administering NF-κB-inhibitors into rats undergoing a well-established model of colonic anastomotic healing. METHODS: Wistar rats underwent laparotomy, descending colonic transection, and handsewn reanastomosis. The animals were randomized to receive either a selective NF-κB inhibitor (parthenolide 0.5 mg/kg or resveratrol 0.5 mg/kg) or an equal volume of water by gavages before operation and then daily after surgery. Animals were sacrificed either immediately after anastomotic construction (d 0) or at the third, fifth, or seventh postoperative day. RESULTS: Both parthenolide and resveratrol treatment led to early significant increases in plasma levels of IL-6. On d 7, hydroxyproline levels were significantly higher in the parthenolide and resveratrol groups. A similar pattern was observed with the bursting pressure. In contrast, gelatinase activity (MMP-2 and MMP-9 expression) was significantly higher in the control group on postoperative d 3. On d 3, expression of NF-κB activity was up-regulated in the anastomotic area. Both parthenolide and resveratrol completely attenuated NF-κB activity. Study groups also developed more marked inflammatory cell infiltration and collagen deposition on histology analysis. CONCLUSIONS: Parthenolide and resveratrol significantly improved healing and mechanical stability of colonic anastomoses in rats during the early postoperative period. Both agents may be acting to accelerate the host reparative process as well as to enhance protection of the anastomotic wound bed.

The timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreaticography in cholelithiasis coexisting with choledocholithiasis.

BACKGROUND: An accepted treatment strategy for cholelithiasis with secondary choledocholithiasis is the laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreaticography (ERCP). Although early cholecystectomy is advised, there is no consensus about the time interval between LC and ERCP. The aim of this study is to evaluate the effects of the time interval between ERCP and ERCP on operation outcomes. METHODS: Patients with cholelithiasis and a risk of choledocholithiasis underwent ERCP. Patients were grouped as those operated on between 24 and 72 h after ERCP (group 1) and those operated on more than 72 h after ERCP (group 2). Patients' age, gender, body mass index, American Society of Anesthesiologists Physical Status, abdominal ultrasonography findings, white blood cell count, total serum bilirubin, ALP, amylase, ALT, AST, GGT levels, ERCP findings, time interval between ERCP and LC, conversion rate, median postoperative hospital stay, median operation time, intraoperative complication and postoperative complication rates were collected. RESULTS: There was no significant difference between the demographics of the patients in both groups. The median operation time, median postoperative hospital stay and conversion rate in group 2 were significantly higher than those of group 1. More postoperative complications were seen in group 2. CONCLUSION: Early cholecystectomy after ERCP, within 72 h, has better outcomes, probably due to the inflammatory processes.

Vaginal evisceration after trauma unrelated to previous pelvic surgery.

BACKGROUND: Vaginal evisceration is described as extrusion of intraperitoneal contents secondary to the disruption of the vagina. It is an extremely rare emergency condition. OBJECTIVES: To describe a very rare case of vaginal evisceration that occurred after blunt trauma in a patient with no prior pelvic surgery. CASE REPORT: This report describes vaginal evisceration in a 73-year-old female with no prior pelvic surgery, after blunt trauma. The patient was handled by the cooperation of gynecology and general surgery departments. An immediate surgery was performed after stabilization of the patient and no postoperative complications occurred. CONCLUSION: Whatever be the treatment approach, emergency management of vaginal evisceration is critical to the preservation of a viable bowel. Repositioning of viable bowels into the abdominal cavity and appropriate surgical repair are cornerstones of the treatment.

Ergothioneine modulates proinflammatory cytokines and heat shock protein 70 in mesenteric ischemia and reperfusion injury.

BACKGROUND AND AIM: Ergothioneine (EGT) is a natural compound that is synthesized by soil bacteria in fungal substrates and exhibits antioxidant functions in many cell models. The purpose of this study was to investigate the effect of EGT on mesenteric ischemia and reperfusion injury. MATERIALS AND METHODS: Rats were supplemented with or without l-ergothioneine (10 mg/kg/d) for 15 days prior to intestinal ischemia. Animals were subjected to ischemia induced by clamping the superior mesenteric artery for 60 min followed by reperfusion. Serum tumor necrosis factor (TNF)-alpha and interleukin-1beta (IL-1beta) levels, tissue malondialdehide (MDA), myleoperoxidase (MPO), and heat shock protein (HSP) 70 levels, as well as histological findings, were evaluated after 1, 2, and 4 h of reperfusion. RESULTS: Serum TNF-alpha and IL-1beta levels, and tissue MDA and MPO activities at 1, 2 and 4 h after reperfusion in the EGT group, were significantly lower than the control group (P < 0.05). Tissue HSP-70 levels of the study group were significantly greater than the control group at any time point of reperfusion. No significant differences in tissue damage including morphological changes ranging from villous denudation to focal necrosis, ulceration, hemorrhage, and architectural disintegration at 1 and 2 h after reperfusion exist between the two groups; however, after 4 h of reperfusion, the tissue damage based on histopathologic scores by Chiu was considerably lower in the study group (P < 0.05). After 4 h of reperfusion, focal epithelial lifting and occasional areas of denuded villi could be seen in the samples of the treated animals, thus preserving villous height and mucosal architecture. CONCLUSION: EGT attenuates mesenteric ischemia reperfusion injury in rat intestine by increasing tissue HSP-70 and decreasing TNF-alpha, IL-1beta, MDA, and MPO levels. EGT also improves morphological alterations, which occurred after IR injury after prolonged periods of reperfusion.

Beta-glucan attenuates inflammatory cytokine release and prevents acute lung injury in an experimental model of sepsis.

Sepsis is one of the most important risk factors in acute respiratory distress syndrome (ARDS). beta-Glucan is a potent reticuloendothelial modulating agent, the immunobiological activity of which is mediated in part by an increase in the number and function of macrophages. In this study, we investigated the putative protective role of beta-glucan against sepsis-induced lung injury. Sepsis was induced by cecal ligation and puncture (CLP) in Wistar rats. The control group received saline, and the treatment groups received beta-glucan or beta-glucan + beta-1,3-D-glucanase. Five hours thereafter, plasma tumor necrosis factor (TNF) alpha, interleukin (IL) 1beta, and IL-6 levels were determined. Presence of lung injury was determined via lung tissue myeloperoxidase (MPO) activity, intercellular adhesion molecule (ICAM) 1 levels, and histopathological examination at 18 h after CLP. In a separate set of experiments, survival was monitored for 7 days after CLP. beta-Glucan treatment led to a significant increase in survival rate (63% in glucan-treated rats vs 38% in saline-treated rats). Administration of the beta-glucan inhibitor abrogated beta-glucan's survival benefit (50%). After CLP, plasma TNF-alpha, IL-1beta, and IL-6 concentrations were increased in control animals. When beta-glucan was administered, it completely blocked the elevation of TNF-alpha, IL-1beta, and IL-6. Administration of beta-1,3-D-glucanase suppressed glucan-induced decrease in cytokines. Animals treated with beta-glucan showed a significant reduction in lung injury score, a marked decrease in ICAM-1 expression, and a significant decrease in MPO levels. In contrast, beta-1,3-D-glucanase caused a significantly increased MPO and ICAM-1 levels in the lung. These data reveal that beta-glucan treatment improved the course of CLP-induced peritonitis and attenuated the lung injury. Administration of beta-glucanase inhibited the beta-glucan activity and resulted in enhanced lung injury.

Effects of two conventional preoperative radiation schedules on anastomotic healing in the rat colon.

BACKGROUND: Preoperative radiotherapy (RT) is an increasingly popular form of adjunct therapy for rectal cancer; however, little is known about its effects on matrix metalloproteinase (MMP) expression in colonic anastomotic healing. METHODS: Wistar rats were irradiated to a total dose of 25 or 40 Gy. Four days after the end of RT, an end-to-end colorectal anastomosis was performed. Animals were sacrificed at 1, 3, and 7 days after the anastomosis. A control group was studied similarly, but was not irradiated. RESULTS: No significant differences were found in peritonitis rate and anastomotic complications. The average bursting pressure and breaking strength were only reduced significantly in the rats irradiated with 40 Gy. However, the concentration and the content of hydroxyproline in anastomotic tissues were unchanged. In irradiated rats, MMP-2 and MMP-9 were significantly increased at 40 Gy, but not at 25 Gy. On the other hand, 25-Gy irradiation induced a smaller increase in the levels of the tissue inhibitors of metalloproteinase-1 compared with the controls. CONCLUSION: Anastomotic strength is adversely affected by high-dose fractionated preoperative RT. In contrast, preoperative RT at 25 Gy in five fractions over 5 days is safe with regard to the maintenance of wound strength in colorectal anastomosis.

Spontaneous gastrosplenic fistula in primary gastric lymphoma: Surgical management.

Gastrosplenic fistula formation resulting from primary gastric malignancy is rare and should be managed as a matter of emergency. We report a patient who was diagnosed with primary non-Hodgkin's lymphoma and who underwent surgical treatment for gastrosplenic fistula.

Ischemic preconditioning improves liver regeneration by sustaining energy metabolism after partial hepatectomy under ischemia in rats.

BACKGROUND: The protective effect of ischemic preconditioning (IPC) has been reported on improvement of survival, reduction of liver necrosis and enhancement of the regenerative capacity of hepatocytes after partial hepatectomy. This study was undertaken to confirm that IPC has a significant impact on regeneration of hepatocytes after partial hepatectomy in ischemically damaged liver. In addition, we sought to examine the role of adenine nucleotides in this process. METHODS: Wistar rats were subjected to 60 min of total hepatic ischemia, followed by 70% hepatectomy. The animals were subdivided into an IPC (10/15 min) group and a non-IPC (control) group. Liver function tests and arginase activity were analyzed. Hepatic adenosine triphosphate (ATP), adenosine diphosphate and adenosine monophosphate were measured using gradient high-performance liquid chromatography. The liver regeneration was identified using relative liver weight and proliferating cell nuclear antigen (PCNA) labeling index. RESULTS: IPC treatment improved serum liver enzymes and tissue arginase activity (P<0.05) when compared with the control group. The preconditioned livers were associated with upregulation of ATP expression and also increased tissue energy charge. Regenerated liver weight in the IPC group was significantly higher than in the control group (P<0.05). The PCNA labeling index in the remnant livers in the IPC group was also significantly increased at 24 and 48 h after partial hepatectomy (P<0.05). CONCLUSION: These results suggest that IPC-augmented liver regeneration after hepatectomy, probably due to the stabilization of energy metabolism in rats.

Effects of soluble fiber on matrix metalloproteinase-2 activity and healing of colon anastomosis in rats given radiotherapy.

BACKGROUND AND AIMS: Soluble fiber is fermented by colonic microflora yielding short-chain fatty acids (SCFAs) in the colon. We aimed to investigate the effect of oral administration of soluble fiber on healing of anastomosis and matrix metalloproteinase-2 activity in radiotherapy received colonic anastomosis. METHOD: Eighty-four Wistar rats were divided into six groups. All rats were performed a left colonic resection with end-to-end anastomosis. Group I received rat cow. Group II received soluble fiber orally for five consecutive days preoperatively as well as 3rd and 6th days postoperatively. Group III received SCFAs via rectum for five consecutive days preoperatively. Group IV received irradiation to the pelvis at a total dose of 24 Gy on the 10th and 5th days before the operation. Group V was exposed to irradiation like the rats in Group IV and oral treatment like the rats in Group II. Group VI received irradiation like the rats in Group IV and transrectal treatment like the rats in Group III. On the 3rd and 7th postoperative days, all the rats were anesthetized to evaluate the anastomosis healing clinically, histologically and biochemically. RESULTS: Third and 7th day bursting pressures of the rats that were fed with a normal diet and exposed to radiotherapy were significantly decreased (P<0.001). Bursting pressures of Groups V and VI on the 7th day were significantly higher than the control group's bursting pressures (P<0.05). Hydroxyproline levels of Group IV were significantly decreased (P<0.001). Following oral soluble fiber and transrectal administration of SCFAs, these low levels reached to the levels of control radiotherapy group. Matrix metalloproteinase-2 activity of all the rats that were exposed to radiotherapy was higher than the control group (P<0.001). Matrix metalloproteinase-2 enzyme levels in the Groups V and VI were lower than the ones in the Group IV (P<0.001). The histologic parameters of anastomotic healing such as epithelial regeneration, exudate, necrosis, and fibroblast levels were significantly improved by the use of oral soluble fiber and transrectal SCFAs treatment. CONCLUSION: Undesirable effects of preoperative radiotherapy on mechanical, histological and biochemical parameters can be overcome by oral soluble fiber. Oral soluble fiber administration has similar positive effects like the transrectal administration of the SCFA's.

Torsion of the greater omentum: preoperative computed tomographic diagnosis and therapeutic laparoscopy.

Primary or idiopathic segmental infarction of the greater omentum is a rare surgical condition. We describe a case of omental torsion in an adult patient who was diagnosed preoperatively by contrast-enhanced computed tomography and managed by laparoscopy.

Effects of ischemic preconditioning on regenerative capacity of hepatocyte in the ischemically damaged rat livers.

BACKGROUND: Liver regeneration after partial hepatectomy is regulated by several factors that activate or inhibit hepatocyte proliferation. A short period of ischemia-reperfusion (IR), called ischemic preconditioning (IPC), protects the liver against subsequent sustained ischemic insults. The present study investigated the effects of IPC on liver regeneration after partial hepatectomy under IR in rats. MATERIALS AND METHODS: Male Wistar rats were subjected to 45 min of total hepatic ischemia, and 70% hepatectomy was performed just before reperfusion. Animals were pre-treated with either IPC (10/15 min) (IPC + PHx group) or not (ischemia + PHx). The survival rate, serum transaminases, tumor necrosis factor (TNF)-alpha, and interleukin (IL)-6 levels, hepatocyte proliferation and histological change of the remnant liver were measured in both groups and compared with non-ischemic controls subjected to 70% hepatectomy alone (PHx group). RESULTS: The survival rate was significantly better in the IPC + PHx group than in the ischemia + PHx group. Furthermore, IPC reduced liver injury determined by liver histology and serum transaminases. There was an early rise in serum TNF-alpha and IL-6 levels in the ischemia + PHx group. Compared with non-ischemic controls, IPC significantly decreased TNF-alpha, but not IL-6 during the late (24 and 48 h) phases of reperfusion. Rats subjected to 70% hepatectomy and 45 min of hepatic ischemia showed significantly reduced hepatocyte proliferation (mitotic index, proliferating cell nuclear antigen, and relative liver weight) when compared with animals subjected to hepatectomy alone. However, hepatocyte proliferation was markedly increased in rats pretreatment with IPC when compared with ischemic controls. CONCLUSION: These results suggest that ischemic pre-conditioning ameliorates the hepatic injury associated with ischemia-reperfusion and has a stimulatory effect on liver cell regeneration that may make it valuable as a hepatoprotective modality. Il-6 appears to be key mediator in promoting regeneration after combined ischemia and hepatic resection.

Ergothioneine pretreatment protects the liver from ischemia-reperfusion injury caused by increasing hepatic heat shock protein 70.

BACKGROUND: Reperfusion of the liver after ischemia induces the expression of the heat shock genes and the synthesis of the heat shock proteins (HSP). We studied the effects of the natural antioxidant ergothioneine (EGT) treatment on the expression of HSP70 in ischemic-reperfused (IR) liver. METHODS: Adult male Wistar rats were randomly divided into three groups: Sham group given standard laboratory chow and water for 3 weeks followed by sham operation; Control group given standard laboratory chow and water for 3 weeks followed by liver IR injury; EGT group given standard laboratory chow supplementation l-ergothioneine (1.2 mg/kg/d body weight) administered by gavage and water for 3 weeks followed by liver IR injury. Ten rats from each group were killed to determine serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactic dehydrogenase (LDH), tissue malondialdehyde (MDA), HSP70 levels, and histologic changes at 30, 60, and 120 min of reperfusion, respectively. Survival was followed for 1 week. RESULTS: IR caused significant increase in serum AST, ALT, LDH, and tissue MDA levels. As compared with the control group, animals treated with EGT experienced a significant decrease in serum AST, ALT, and LDH levels in all reperfusion periods. Tissue MDA levels in animals receiving EGT were significantly reduced as compared with control group at 30 min and 60 min after reperfusion. After ischemia, reperfusion caused a remarkable production of HSP70 in the control group. When the rats were pretreated with EGT, the levels of HSP70 increased significantly in their livers after reperfusion compared with the control group. Liver injury in the EGT-treated animals was lower to that in the control group. The 7-day survival rate was significantly improved (from 50% to 80%) by EGT pretreatment. CONCLUSION: HSP70 has been shown to induce tolerance against warm IR injury in rat livers. EGT pretreatment protects the liver from IR injury by over-expression of HSP and the subsequent suppression of lipid peroxidation.

Portal vein resection for a portal vein thrombus caused by nonfunctioning islet cell carcinoma: report of a case.

We report a case of nonfunctioning islet cell carcinoma of the pancreas causing a tumor thrombus in the portal vein. The patient was a 60-year-old woman whose presenting symptoms were abdominal pain, vomiting, and weight loss. We performed a subtotal pancreatectomy and splenectomy combined with partial resection of the portal vein. Histopathological studies confirmed the diagnosis of nonfunctioning islet cell carcinoma of the pancreas with a tumor thrombus in the portal vein. The patient's postoperative course was uneventful and she is doing well 25 months after the operation.

Comparison of the results of early, delayed and elective surgery in biliary pancreatitis.

BACKGROUND/AIMS: To evaluate the results of the patients who underwent surgery for biliary pancreatitis, with respect to timing of operation. METHODS: 192 Patients underwent surgery for biliary pancreatitis between January 1990 and December 1999. The patients were retrospectively separated into three groups: early surgery (within 72 hours after admission), delayed surgery (between 3 and 15 days after admission) and elective surgery (after 15 days). RESULTS: There were 98 patients in the early surgery group, 46 in the delayed surgery group and 48 in the elective surgery group. The number of Ranson's criteria present was between 3 and 5 in 58.2% of the cases in the early surgery group and in 54.3% of the cases in the delayed surgery group, whereas 62.5% of the cases in the elective surgery group had 0-2. APACHE II score was in the 6-10 range in 43.9% of the cases in the early surgery group and in 39.1% of the cases in the delayed surgery group, whereas 66.7% of the cases in the elective surgery group had between 0 and 5. The most frequent operations in the early and delayed surgery groups was cholecystectomy, common bile duct exploration, and T-tube placement (60.2% and 69.6%, respectively), whereas it were laparoscopic cholecystectomy in the elective surgery group (66.7%). Pancreatitis-related complication rates in the early, delayed and elective surgery groups were 20.4%, 17.4% and 8.3%, respectively. Mortality rates were 5.1% and 4.3% in the early and delayed surgery groups, respectively. There was no deaths in the elective surgery group. CONCLUSION: In biliary pancreatitis, surgery should not be considered as a primary option until the resolution of the pancreatic inflammation and its systemic effects. It should be employed only when the clinical picture does not ameliorate in spite of conservative treatment.

Short and long-term effects of bacterial translocation due to obstructive jaundice on liver damage.

BACKGROUND/AIMS: The present study was conducted to determine if obstructive jaundice promotes bacterial translocation and to evaluate the changes in hepatic histopathology in patients with benign biliary obstruction. METHODOLOGY: Between January 1996 and January 1998, 19 patients treated for benign biliary obstruction were studied. Fourteen patients with symptomatic cholelithiasis were taken as the control group. Patient characteristics, preoperative and post-operative laboratory tests with an interval of 7 days were recorded. In all patients, bile and mesenteric lymph nodes samples were taken for bacterial growth and histopathologic changes were studied on the liver excised during surgery. RESULTS: In the control group, bacterial growth was observed in the bile and mesenteric lymph nodes cultures in one (7.1%) and two patients (14.3%), respectively. In the study group, 8 patients (42%) had positive bile cultures and 12 patients (63.2%) had positive mesenteric lymph nodes cultures, respectively. Histopathologic examination of the liver revealed significant increase in the rate of periductal and portal fibrosis in the jaundiced patients, compared with control group (p < 0.001). Postoperative complications in the study group were wound infection (3 cases), renal failure (2 cases), ARDS (1 cases) and intraabdominal abscess (1 cases). In the control group, one patient had wound infection and one had atelectasis. Two patients with jaundice died of multiple organ failure and respiratory failure. In long-term follow-up (mean 17 months), when sclerosing cholangitis and secondary biliary cirrhosis developed in one patient each in the study group, no long-term complication occurred in the control group. CONCLUSIONS: Our clinical results demonstrate that extrahepatic biliary obstruction promotes bacterial translocation and this process is an important cause of morbidity and mortality in patients with jaundice. Also, obstructive jaundice subsequently leads to significant functional and morphological damage in the liver.

[Surgical alternatives in complex pancreatic injuries]. / Kompleks pankreas yaralanmalarinda cerrahi yaklasimlar.

BACKGROUND: Objective of this study is to analyze the treatment outcomes of patients undergoing surgery for complex pancreatic injuries in our center over a 20-year period. METHODS: Between January 1980 and December 2001, medical records of 11 patients who underwent surgical intervention for complex pancreatic trauma were investigated retrospectively. RESULTS: The study group consisted of nine males and two female patients with a mean age of 36 years. Six patients had stab wounds, three had motor vehicle accidents and two had gunshot wounds. The mean value of Injury Severity Score (ISS) was 32. Among six patients with Grade III injury, five were managed by distal pancreatectomy and one by external drainage. In three patients with Grade IV injury each underwent distal pancreatectomy, subtotal pancreatectomy and pancreaticoduodenectomy. The remaining two patients with Grade V injury were managed by pancreaticoduodenectomy. In the postoperative course, pancreatic fistula was observed in two patients and peripancreatic abscess and pancreatitis in one patient each. Endocrine insufficiency occurred in one patient who underwent subtotal pancreatectomy. Operative mortality was 18.2%. CONCLUSION: Owing to the retroperitoneal location of the pancreas and its proximity to major vascular structures, associated organ injuries play a significant role in morbidity and mortality.