Pancreatology 13 (2013) 605e609
Contents lists available at ScienceDirect
Pancreatology journal homepage: www.elsevier.com/locate/pan
Original article
Pancreatic injuries in earthquake victims: What have we learnt? Kun-Lin Xie a, Jun Liu b, Gang Pan a, Wei-Ming Hu a, Mei-Hua Wan c, Wen-Fu Tang c, Xu-Bao Liu a, Hong Wu a, * a
Department of Hepato-Biliary-Pancreato Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu 610041, Sichuan, China Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China c Department of Integrated Traditional and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 August 2013 Received in revised form 5 October 2013 Accepted 8 October 2013
Objective: To analyze the clinical characteristic and management of patients with pancreatic injuries from the Wen-Chuan and Lu-Shan earthquakes. Methods: We retrospectively reviewed 39,784 patients from the Wen-Chuan earthquake and 1489 from the Lu-Shan earthquake. The demographics, clinical data, treatment strategies, and outcomes of patients with pancreatic injuries were recorded and compared between survivors of the two earthquakes. Results: Pancreatic injury occurred only in a small proportion (0.2%) in patients with trauma on admission, and most (61%) patients had Grades IeII pancreatic injuries. Blunt trauma was the leading cause of pancreatic trauma. Most patients (95%) suffered multiple injuries, of which chest injuries (61%) were the most common. Elevated serum amylase levels were observed in 50 (86%) of 58 patients, and computed tomography (CT) identified pancreatic injuries in 32 (80%) of 40 patients. A significantly higher rate (p ¼ 0.043) of pancreatic complication was present in patients with Grade III and IV injuries (38%) than in those with Grade I and II injuries (18%). Forty patients were initially treated by conservative management with 6 (15%) requiring delayed operations. Four (67%) pancreatic complications and 2 (33%) deaths occurred in patients with delayed operations. Conclusions: Repeated serum amylase analysis, CT, and laparoscopic exploration were reliable diagnostic modalities to diagnose pancreatic injury. Conservative management was safe in patients with Grade I and II injuries. Delayed operation, especially for Grade III patients, resulted in increased morbidity and mortality. Copyright Ó 2013, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.
Keywords: Pancreas Injury Earthquake
1. Introduction Wen-Chuan earthquake with a 8.0-Ms magnitude struck most areas of Sichuan province on May 12, 2008 and resulted in approximately 70,000 deaths and 370,000 injuries. Unfortunately, another earthquake with 7.0 Mw magnitude occurred in the LuShan district in Sichuan province about 5 years later on April 20, 2013 which injured about 10,000 individuals. Over the last 30 years, almost 1 million people were injured, and 400,000 died in earthquakes worldwide. Asian continent, which is economically less developed, had the greatest number of deaths and affected individuals [1]. Although the reported incidence of pancreatic injury was less than 1% of all trauma-related admissions [2], the patient outcomes were unsatisfactory, with morbidity * Corresponding author. Tel./fax: þ86 28 85422323. E-mail address: [email protected] (H. Wu).
ranging 30%e50% [3,4] and mortality ranging 9%e46% [5,6]. For these reasons, we retrospectively investigated 83 patients with pancreatic injuries from the Wen-Chuan (n ¼ 64) and Lu-Shan (n ¼ 19) earthquakes. Our aim was to describe the clinical characteristics and analyze the diagnosis, management, and patient outcomes with pancreatic injuries in earthquakes to more effectively manage them. 2. Patients and methods We retrospectively reviewed the medical records of 41,273 victims of the Wen-Chuan (n ¼ 39,784) and Lu-Shan (n ¼ 1489) earthquakes. These records included demographic information, onspot situation, transfer information, hospital admission, imaging and laboratory examinations, and type of injuries, treatment, final diagnosis, and outcomes. Patients were diagnosed with pancreatic injuries according to the surgical findings and imaging results
1424-3903/$ e see front matter Copyright Ó 2013, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pan.2013.10.002
606
K.-L. Xie et al. / Pancreatology 13 (2013) 605e609
including computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and ultrasonography. Two consultants graded the severity of pancreatic injury according to the American Association for the Surgery of Traumae Organ Injury Score (AASTeOIS; Table 1) [7]. Abbreviated Injury Scale (AIS) 2005 and New Injury Severity Score (NISS) were employed to indicate injury severity and predict morbidity [7,8]. Proximal and distal pancreatic injuries were defined as those occurring in the right and left of the mesenteric vessels, respectively. Pancreatic complications (PCs) were defined as pancreatic fistula by the presence of fluid amylase 3 times greater than the serum amylase 3 days after operation. Pancreatic pseudocyst was defined by the presence of encapsulated peripancreatic fluid accumulation, as detected by CT, and pancreatitis was defined by a continued serum amylase levels >400 IU/ml accompanied by abdominal pain. Non-PCs included intraabdominal abscess, pleural effusion, acute respiratory distress syndrome (ARDS), pneumonia, and renal failure. Values are presented as medians (interquartile range). The ManneWhitney U test, Pearson’s chi-squared test, and binary logistic regression were used for statistical analysis. A probability (p) value of 24 h Interval from injury to operation (h) Conservative management Delayed operation LOS (d) Complications PCs Grade IeII Grade IIIeIV NON-PCs Mortality
Wen Chuan earthquake n ¼ 64
Lu Shan earthquake n ¼ 19
42(22e52) 30/34 2(1e3) 17 (12e22)
29(16e47) 11/8 3(1.5e3) 26 (17e29)
10 (16%) 39 (61%) 18 (28%) 6 (9%) 12 (19%) 26 (41%) 13 (20%) 9 (14%) 0 32/39 (82%) 39 (61%) 32 (8e62) 34 (53%) 5 (7.8%) 18 (13e34)
4 (21%) 12 (63%) 5 (26%) 3 (16%) 2 (11%) 6 (32%) 5 (26%) 2 (11%) 1 (5%) 19/19 (100%) 0 10 (4e30) 6 (32%) 1 (5.3%) 12 (9e20)
8/41 (20%) 10/23 (43%) 24 (38%) 4 (6%)
1/10 (10%) 2/9 (22%) 5 (26%) 0
Pa
0.21 0.44b 0.25 0.01 0.73b 1.0b 1.0b 0.42b 0.51b 0.60b 0.55b 1.0b 0.23b 0.08b
Contents lists available at ScienceDirect
Pancreatology journal homepage: www.elsevier.com/locate/pan
Original article
Pancreatic injuries in earthquake victims: What have we learnt? Kun-Lin Xie a, Jun Liu b, Gang Pan a, Wei-Ming Hu a, Mei-Hua Wan c, Wen-Fu Tang c, Xu-Bao Liu a, Hong Wu a, * a
Department of Hepato-Biliary-Pancreato Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu 610041, Sichuan, China Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China c Department of Integrated Traditional and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 August 2013 Received in revised form 5 October 2013 Accepted 8 October 2013
Objective: To analyze the clinical characteristic and management of patients with pancreatic injuries from the Wen-Chuan and Lu-Shan earthquakes. Methods: We retrospectively reviewed 39,784 patients from the Wen-Chuan earthquake and 1489 from the Lu-Shan earthquake. The demographics, clinical data, treatment strategies, and outcomes of patients with pancreatic injuries were recorded and compared between survivors of the two earthquakes. Results: Pancreatic injury occurred only in a small proportion (0.2%) in patients with trauma on admission, and most (61%) patients had Grades IeII pancreatic injuries. Blunt trauma was the leading cause of pancreatic trauma. Most patients (95%) suffered multiple injuries, of which chest injuries (61%) were the most common. Elevated serum amylase levels were observed in 50 (86%) of 58 patients, and computed tomography (CT) identified pancreatic injuries in 32 (80%) of 40 patients. A significantly higher rate (p ¼ 0.043) of pancreatic complication was present in patients with Grade III and IV injuries (38%) than in those with Grade I and II injuries (18%). Forty patients were initially treated by conservative management with 6 (15%) requiring delayed operations. Four (67%) pancreatic complications and 2 (33%) deaths occurred in patients with delayed operations. Conclusions: Repeated serum amylase analysis, CT, and laparoscopic exploration were reliable diagnostic modalities to diagnose pancreatic injury. Conservative management was safe in patients with Grade I and II injuries. Delayed operation, especially for Grade III patients, resulted in increased morbidity and mortality. Copyright Ó 2013, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.
Keywords: Pancreas Injury Earthquake
1. Introduction Wen-Chuan earthquake with a 8.0-Ms magnitude struck most areas of Sichuan province on May 12, 2008 and resulted in approximately 70,000 deaths and 370,000 injuries. Unfortunately, another earthquake with 7.0 Mw magnitude occurred in the LuShan district in Sichuan province about 5 years later on April 20, 2013 which injured about 10,000 individuals. Over the last 30 years, almost 1 million people were injured, and 400,000 died in earthquakes worldwide. Asian continent, which is economically less developed, had the greatest number of deaths and affected individuals [1]. Although the reported incidence of pancreatic injury was less than 1% of all trauma-related admissions [2], the patient outcomes were unsatisfactory, with morbidity * Corresponding author. Tel./fax: þ86 28 85422323. E-mail address: [email protected] (H. Wu).
ranging 30%e50% [3,4] and mortality ranging 9%e46% [5,6]. For these reasons, we retrospectively investigated 83 patients with pancreatic injuries from the Wen-Chuan (n ¼ 64) and Lu-Shan (n ¼ 19) earthquakes. Our aim was to describe the clinical characteristics and analyze the diagnosis, management, and patient outcomes with pancreatic injuries in earthquakes to more effectively manage them. 2. Patients and methods We retrospectively reviewed the medical records of 41,273 victims of the Wen-Chuan (n ¼ 39,784) and Lu-Shan (n ¼ 1489) earthquakes. These records included demographic information, onspot situation, transfer information, hospital admission, imaging and laboratory examinations, and type of injuries, treatment, final diagnosis, and outcomes. Patients were diagnosed with pancreatic injuries according to the surgical findings and imaging results
1424-3903/$ e see front matter Copyright Ó 2013, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pan.2013.10.002
606
K.-L. Xie et al. / Pancreatology 13 (2013) 605e609
including computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and ultrasonography. Two consultants graded the severity of pancreatic injury according to the American Association for the Surgery of Traumae Organ Injury Score (AASTeOIS; Table 1) [7]. Abbreviated Injury Scale (AIS) 2005 and New Injury Severity Score (NISS) were employed to indicate injury severity and predict morbidity [7,8]. Proximal and distal pancreatic injuries were defined as those occurring in the right and left of the mesenteric vessels, respectively. Pancreatic complications (PCs) were defined as pancreatic fistula by the presence of fluid amylase 3 times greater than the serum amylase 3 days after operation. Pancreatic pseudocyst was defined by the presence of encapsulated peripancreatic fluid accumulation, as detected by CT, and pancreatitis was defined by a continued serum amylase levels >400 IU/ml accompanied by abdominal pain. Non-PCs included intraabdominal abscess, pleural effusion, acute respiratory distress syndrome (ARDS), pneumonia, and renal failure. Values are presented as medians (interquartile range). The ManneWhitney U test, Pearson’s chi-squared test, and binary logistic regression were used for statistical analysis. A probability (p) value of 24 h Interval from injury to operation (h) Conservative management Delayed operation LOS (d) Complications PCs Grade IeII Grade IIIeIV NON-PCs Mortality
Wen Chuan earthquake n ¼ 64
Lu Shan earthquake n ¼ 19
42(22e52) 30/34 2(1e3) 17 (12e22)
29(16e47) 11/8 3(1.5e3) 26 (17e29)
10 (16%) 39 (61%) 18 (28%) 6 (9%) 12 (19%) 26 (41%) 13 (20%) 9 (14%) 0 32/39 (82%) 39 (61%) 32 (8e62) 34 (53%) 5 (7.8%) 18 (13e34)
4 (21%) 12 (63%) 5 (26%) 3 (16%) 2 (11%) 6 (32%) 5 (26%) 2 (11%) 1 (5%) 19/19 (100%) 0 10 (4e30) 6 (32%) 1 (5.3%) 12 (9e20)
8/41 (20%) 10/23 (43%) 24 (38%) 4 (6%)
1/10 (10%) 2/9 (22%) 5 (26%) 0
Pa
0.21 0.44b 0.25 0.01 0.73b 1.0b 1.0b 0.42b 0.51b 0.60b 0.55b 1.0b 0.23b 0.08b
