Surgical management of pancreatic trauma: a retrospective case series.

Transcription

1 Research Article Surgical management of pancreatic trauma: a retrospective case series. Hamdy S Abdallah*, Sherif A Saber Gastrointestinal Surgery Unit, General Surgery Department, Tanta University, Tanta, Egypt Abstract Introduction: Pancreatic injuries occur in less than % of major abdominal trauma. The aim of this study was to retrospectively report our experience in the surgical management of pancreatic trauma including the patterns of injuries, diagnosis, treatment and outcomes. Materials and Methods: This study is a retrospective analysis of prospectively collected data of all patients admitted with pancreatic trauma at the Gastrointestinal Surgery Unit, General Surgery Department, Tanta University during the period from May 00 to December 07. Results: The study included males and females with a median age of years. Twenty-three patients (9%) had blunt trauma and patients (%) had penetrating trauma. The clinical presentation included hypovolemic shock, epigastric pain, vomiting and abdominal distension. Twenty-three patients (9%) required surgery for haemodynamic instability in patients (7.%), associated bowel injuries in patients (.7%) and radiographically confirmed grade III/IV pancreatic injury in 7 patients (7.9%). Eleven patients (%) had grade IV injury, patients (%) had grade III injury, patients (6%) had grade I/II injury and patients (%) had grade V injury. Twenty-two patients (%) had concomitant intra-abdominal injuries. Surgical interventions included subtotal/distal pancreatectomy and splenectomy in 9 patients (.6%), lesser sac wash out in patients (.7%), Whipple procedure in patient (.%) and damage control surgery in patient (.%). The proximal stump of the main pancreatic duct was controlled in out of the 9 patients who had subtotal/distal pancreatectomy. Post-operative complications were recorded in (7.%) patients and patient died (%). The postoperative hospital stay ranged between and days with a median of 9 days. Conclusion: pancreatic injuries are commonly associated with other intra-abdominal injuries. In the acute setting, both clinical manifestations and laboratory studies lack sensitivity. Most pancreatic injuries result direct blunt trauma to upper abdomen producing grade III/IV injury. In this subset of patients, contrast enhanced CT is both highly sensitive and specific and subtotal/distal pancreatectomy is well tolerated. Postoperative complications are frequent and mortality is due to associated major vascular injuries especially after penetrating trauma. Keywords: Blunt, Penetrating, Pancreatic trauma, Distal pancreatectomy Accepted on February 0, 0 Introduction Pancreatic injuries occur in less than % of major abdominal trauma []. The relatively protected deep position of the pancreas in the retroperitoneum means that a high-energy force is required to damage it []. Owing to its intimate relationships with major vital, visceral and vascular upper abdominal structures, 90% of pancreatic injuries involve at least one other abdominal organ []. Pancreatic injuries can be symptom free [] and physical examination is usually un-reliable in the acute setting []. Serum amylase is notoriously unreliable in the diagnosis and can be normal in the presence of a ductal disruption []. Therefore, many pancreatic injuries, especially blunt injuries, are not picked up immediately ending up with a high morbidity and a high mortality rate ranging between 9% and % []. The modality of management depends on the clinical presentation and haemodynamic stability of the patient, the degree and location of parenchymal injury, the integrity of the main pancreatic duct and the associated injuries to other organs []. The aim of this study was to report our experience in the surgical management of pancreatic trauma including the mechanism and pattern of injuries, diagnosis, treatment including perioperative decision making and outcomes. Materials and Methods Study design This study is a retrospective analysis of prospectively collected data of all patients admitted with pancreatic trauma at the Gastrointestinal Surgery Unit, General Surgery Department, Tanta University, Egypt during the period from May 00 through December 07. The medical records of these patients were reviewed. Preoperative data including the mechanism of injury, associated injuries, preoperative clinical, laboratory and radiologic data were retrieved. The operative data including the indications of surgery, operative findings, surgical technique and complications were collected. The postoperative data including the ICU admission, hospital stay and postoperative complications, readmission, interventions and mortality were also collected. Categorical data were expressed as frequencies while metric data were expressed as range, mean, standard deviation (SD) and median using Microsoft Excel 0 software. J Trauma Crit Care 0 Volume Issue

2 Citation: Abdallah HS, Saber SA. Surgical management of pancreatic trauma: a retrospective case series. J Trauma Crit Care. 0;():-9 Results Patients characteristics and mechanism of injury Over the study period, patients with pancreatic injuries received surgical treatment at our unit. They included males and females with a median age of years (range 6-). All patients had negative past medical history with no history of regular medications, alcohol or drug abuses. The mechanism of injury included blunt trauma in patients (9%) and penetrating trauma in (%) patients. Blunt injuries included motor vehicle accidents in (%), auto-pedestrian injuries in (0%), civilian assaults in (6%), bicycle-related in (%) and animal kick in (%). Penetrating injuries were due to gunshot in patient (%) and stabbing in the other (%) (Table ). Clinical presentation and treatment planning The time interval between sustaining the injury and arrival to the emergency room (ER) ranged between hours and days (two patients with overlooked pancreatic injuries were referred to our center days after trauma). The clinical presentation included hypovolemic shock in patients (%), epigastric pain in patients (7%), vomiting in 6 patients (%) and abdominal distension in patients (0%). Peritoneal signs were positive on abdominal examination in 9 patients (6%). After initial fluid resuscitation of the haemodynamically unstable patient, patients were responders, patients showed transient response and patients did not respond. The non-responders and the transient responders had free intra-abdominal fluid on focused abdominal sonography in trauma (FAST) and were carried out to the operating room (OR) for exploratory laparotomy. Two patients (%) had pneumoperitoneum on abdominal series indicating associated bowel injury and were also transferred to the OR for abdominal exploration. The patients who responded to initial fluid resuscitation and the patients without haemodynamic instability or pneumoperitoneum on abdominal series (No=9; 76%) were further evaluated by contrast enhanced computed tomography (CECT). CECT showed grade IV pancreatic injuries (transection of the pancreatic neck) (Figure ) in 0 patients (0%) and grade III pancreatic injuries (transection of the pancreatic body) in 7 patients (%) and were explored over the first hours post-admission and all had subtotal/distal pancreatectomy. In patients (%), CECT showed grade I and II injuries of the pancreatic body and were managed non-operatively. Laboratory investigations were performed in 9 patients and revealed raised pancreatic enzymes in 7 patients (7%) and raised white blood cell count (WBC) count in patients (%) (Table ). Operative findings The indications of surgery were haemodynamic instability due to intra-abdominal bleeding in patients (/; 7.%), associated bowel injuries in patients (/;.7%) and radiographically confirmed pancreatic transection (grade III/IV injury) in 7 patients (7/; 7.9%) (Table ). The time interval between sustaining the injury and arrival to the OR ranged between hours and days. The severity of injuries was measured on the organ injury severity scale proposed by Moore et al. [6]. Eleven patients (%) with blunt trauma had parenchymal transection at the level of the pancreatic neck (grade IV, Figures a and b). Seven more patients (%) with blunt trauma had parenchymal transection at the level of the pancreatic body (grade III). Two patients (%) had massive disruption of the pancreatic head (grade V) together with extensive laceration of the duodenum, distal common bile duct and major vascular injuries due to gunshot in one (Figure ) and blunt injury in the other (Figure ). One patient (%) with a stab wound had distal parenchymal transection (grade III) with laceration of the splenic vein, the stomach and the transverse colon. Two patients (%) with Table. Patients characteristics. Variable No % 6 Gender Male Female Age Range Median Figure. CECT showing proximal pancreatic transection (grade IV). P: proximal stump, D: distal stump, * site of transection. 6- Mechanism of injury Blunt Penetrating Motor vehicle accidents Auto-pedestrian injuries Civilian assaults Bicycle-related Animal kick Gunshot Stabbing Clinical presentation Hypovolemic shock Epigastric pain Vomiting Abdominal distension +ve peritoneal signs Laboratory investigations Raised pancreatic enzymes Raised WBC count J Trauma Crit Care 0 Volume Issue Figure a. Operative view of the same case in Figure. Red arrow: splenic artery, blue arrow: splenic vein.

3 Abdallah/Saber Figure b. Operative view of the same case in Figure. Red arrow: splenic artery, blue arrow: splenic vein. Figure. Operative view of Fig (V) injury caused by gunshot. PV: portal vein, SMV: superior mesenteric vein, P: proximal pancreas, J: jejunum. Table. Operative details. Variable No % Treatment modalities Operative Non-operative 9 Indications of surgery Hypovolemic shock with +ve FAST Associated bowel injury Grade III/V injury on CECT Total Operative treatment Subtotal pancreatectomy Distal pancreatectomy Lesser sac drainage Whipple procedure DCS Total Proximal pancreatic duct stump Controlled by stitches Controlled by linear stapler Controlled by Histoacryl No control Total blunt trauma explored for associated bowel injuries were found to have both contusions and lacerations of the pancreatic body without ductal injury (grade I/II) together with duodenal injuries. The commonest location of injuries was the body (, %) followed by the neck (, %) and finally the head (, %). Twenty one patients (%) had ductal disruption (grades III-V) while patients (6%) had not (Table ). Associated injuries Four patients (6%) had extra-abdominal injuries including multiple rib fractures with haemothorax and/or pneumothorax in patients (%) and right upper extremity bone fractures in patient (%). One patient (%) had thoraco-abdominal gunshot injury with pneumothorax. Twenty-two patients (%) had concomitant intra-abdominal injuries including grade I and II liver injury in patients (6%), duodenal perforation/laceration in patients (6%), superficial splenic lacerations or subcapsular haematoma (grade I and II) in patients (%), retroperitoneal/ mesenteric hematomas in patients (%), diaphragmatic laceration in patients (%), common bile duct (CBD) injury in Figure. Operative view of Fig (V) injury caused by blunt trauma. PV: portal vein, CBD: common bile duct, IVC: inferior vena cava, P: proximal pancreas, LRV: left renal vein, D: distal pancreas, D: divided st part of the duodenum. patient (%), perforation of the stomach and transverse colon in patient (%) and right renal artery thrombosis in patient. Three patients (%) had vascular injuries. Three patients (%) had isolated pancreatic injuries (Table ). Treatment modalities Surgical interventions included subtotal pancreatectomy and splenectomy in patients (7.%), distal pancreatectomy and splenectomy in patients (.%) (Figure ), lesser sac drainage (in addition to repair of duodenal injury) in patients (.7%), Whipple procedure in patient (.%) and damage control surgery (DCS) in patient (.%). Overall, patients (6%) needed packed red blood cells transfusion with a median of units/patient. In out of the 9 patients (7.9%) who had subtotal/distal pancreatectomy, it was possible to identify the proximal stump of the main pancreatic duct and control it using polypropylene stitches followed by closure of the overlying parenchyma after fish mouth fashioning. In 6 patients (.6%), the proximal stump was stapled using GIA stapler. The patient who were explored days after trauma had significant pancreatitis and it was not J Trauma Crit Care 0 Volume Issue

4 Citation: Abdallah HS, Saber SA. Surgical management of pancreatic trauma: a retrospective case series. J Trauma Crit Care. 0;():-9 possible to identify the proximal stump of the duct; in one patient (.%) Histoacryl glue was applied over the pancreatic stump and in the other one (.%) nothing was done (Table ). One patient ( years), was explored for an epigastric stab wound. The stab transfixed the stomach, the pancreatic body and the splenic vein. Distal pancreatectomy and splenectomy were performed. Post-operatively, the patient developed a colo-cutaneous fistula due to overlooking the perforation of the transverse colon and it was treated by segmental colonic resection month later. Another patient ( years old) was explored for haemoperitoneum and haemodynamic instability after auto-pedestrian injury. There was extensive laceration of the head and neck of the pancreas, transection of the st part of the duodenum, avulsion of the CBD and the pancreatic head from the nd part of the duodenum, avulsion of the gastroduodenal artery from the common hepatic artery and contusion of the root of the mesentry with congestion and induration of the overlying small bowel. This patient was submitted to pylorus-preserving pancreatecoduodenectomy procedure and a nd look was planned to assess the viability of the small bowel. CT scan, performed 6 hours after surgery, showed a viable small bowel, right subphrenic collection and non-perfused right kidney due to right renal artery thrombosis. Grade of injury Grade IV Grade III Grade I-II Grade V Site of injury Body Neck Head Table. Characteristics of the injuries. Associated injuries Liver injury Duodenal perforation Splenic injury Retropritoneal /mesenteric haematoma Diaphragmatic injury Common bile duct injury Gastric perforation Colon perforation Right renal artery thrombosis Isolated injury Variable No % Forty eight hours after surgery, the nd look revealed viable small bowel and a sub-phrenic bile collection that was evacuated and drained and the patient passed well. Six months later, this patient was red-admitted with an incisional hernia and left-sided component separation and mesh hernioplasty were performed. A 7 years old male patient was explored for a thoraco-abdominal gunshot. The trajectory traversed the right pleural space, the right copula of the diaphragm and transfixed the right lobe of the liver. There was a large retroperitoneal haematoma involving the region of the pancreatic head and neck extending to the right perinephric region and the mesentery of the right colon with a large haemoperitoneum. Exploration of the haematoma revealed extensive laceration with tissue loss of the st part of the duodenum, the head and the neck of the pancreas with laceration of the portal vein (PV) and superior mesenteric veins (SMV). The PV and SMV were suture repaired and the splenic vein ligated, then, the injured bowel suture ligated, the liver and the surgical bed packed, the abdomen drained, the skin closed and the patient transferred to the ICU (damage control surgery, DCS). Unfortunately, this patient died hours later due to consumption coagulopathy and uncontrollable bleeding. A flow chart illustrating patients management is shown in Figure 6. Postoperative course Eleven patients (%) needed ICU admission post-operatively (PO) for periods ranging from to 7 days (median days) and patient (%) required total parenteral nutrition. Overall, PO complications were recorded in (7.%) patients. Five patients (.7%) had chest-related complications (basal atelectasis, chest infection and pleural effusion) and all were treated conservatively. Three patients (%) developed temporary endocrine insufficiency requiring insulin for a median period of 0 weeks (- weeks). Abdominal complications included subphrenic bile collection in patient (.%), colocutanous fistula requiring colectomy in patient (.%) and incisional hernia in patient (.%). One patient (.%) died after damage control laparotomy. The postoperative hospital stay ranged between and days with a median of 9 days. The patients with isolated pancreatic injury stayed in hospital, and 6 days PO (Table ). Discussion Pancreatic trauma is uncommon and it occurs in around % of all patients sustaining abdominal injuries [7]. Owing to its intimate relationship with major upper abdominal vessels, severe pancreatic injury is commonly attended with significant morbidity and mortality []. Table. PO complications. Figure. Surgical specimen of distal pancreatectomy and splenectomy after a stab wound causing grade III injury. PO complications No of patients Chest complications Insulin insufficiency Intra-abdominal collection Colo-cutaneous fistula Incisional hernia Variable No % PO mortality PO hospital stay (days) Range Median J Trauma Crit Care 0 Volume Issue 6

5 Abdallah/Saber Figure 6. Flow chart showing patients management. Outside of the United States, blunt trauma is the cause of the majority of pancreatic injuries [9] while in the United States; penetrating trauma is responsible for % [0]. Motor vehicle accident was the most common mechanism of injury (9.%) in a report by Duchesne et al. []. Blunt trauma was responsible for 9% of pancreatic injuries in our report with road traffic accidents (RTA) being the most common mechanism of injury accounting for %. The World Health Organization reported that Egypt comes among the top 0 countries globally for the number of fatal RTA. According to the Central Agency for Public Mobilization and Statistics in Egypt, the total number of RTA recorded in 06 was,70 accidents resulting in deaths and 66 injuries []. Close proximity of the pancreas to multiple vital structures accounts for the fact that isolated pancreatic trauma is extremely rare. Associated intra-abdominal injuries occur in over 90% of cases [] and the most commonly injured organs are the stomach, the liver, the small bowel, the duodenum, major vessels and the diaphragm []. In our study, patients (%) had concomitant intra-abdominal injuries with the liver (7.%), duodenum (7.%), spleen (%) and retroperitoneal hematomas (%) being the most commonly injured in blunt trauma while hollow viscus injury was the most common in penetrating trauma (/, 00%). In the study of Duchesne et al. [], the most commonly injured solid organs were the liver (66%) followed by spleen (0%) while in the study of Feliciano et al. [], hollow viscus injuries were the most common injuries due to gunshot. Three patients (%) in the current study had isolated pancreatic injury while Akhrass et al. [6] and Bradley et al. [] reported % and.% incidence of isolated pancreatic injury respectively. Pancreatic trauma is difficult to recognize because coexisting injuries to other intra-abdominal organs and its retroperitoneal location make signs and symptoms less marked [,9]. In the current report, most of the clinical manifestations were quite insensitive; hypovolemic shock was present in patients (%), vomiting in 6 patients (%), abdominal distension in patients (0%) and peritoneal signs in 9 patients (6%). Epigastric pain, on the other hand, had the highest sensitivity (7%). This insensitivity resulted in pancreatic injuries being overlooked for days in patients (%). Similarly, in the current study, laboratory investigations lacked sensitivity since only 7 patients (7%) had raised pancreatic enzymes and patients (%) had raised WBC count. Takishima et al. [7] reported a higher sensitivity of pancreatic enzymes than in our study. He also found that hyperamylasemia after blunt pancreatic trauma was time dependent and it was elevated in all cases tested > hours post-injury versus.6% of patients tested on admission. Therefore, the axiom that epigastric pain, leukocytosis and raised pancreatic enzymes typical of pancreatic injury is, thus, inaccurate as these features are frequently missing in patients with pancreatic injuries [0-]. However, hyperamylasemia, though insensitive for pancreatic injury, if present in blunt abdominal trauma, patients should be carefully investigated to detect pancreatic injury []. As a result, a high index of suspicion is required for early diagnosis and for preventing overlooking pancreatic injuries. In a report by Lin et al. grade III injuries treated within h had a complication rate of % compared to 0% for those treated > h after injury. In addition, all mortalities occurred in patients operated on > h after injury [9]. Management of patients in our series followed the guidelines of the Advanced Trauma Life Support (ATLS) of the American College of Surgeons Committee on Trauma [0]. The decision making in patients with haemodynamic instability due to intra-abdominal bleeding and in those patients with pneumoperitoneum was straightforward; abdominal exploration to control bleeding or to repair the injured bowel. On the other hand, patients with blunt trauma without an immediate indication for laparotomy were further evaluated by abdominal CECT. The reported sensitivity of CT in detection of pancreatic injury ranges from to % and from.9 to 70% in detection of pancreatic ductal injury [,,]. On the other hand, Ilahi et al. [] reported a positive predictive value of 00%. In our study, 7 patients were explored after CECT diagnosis of grade III/IV pancreatic injury. In this subset of patients, CECT showed 00% sensitivity and 00% +ve predictive value of pancreatic injury. Since the major prognostic factor following pancreatic trauma is the integrity of the main pancreatic duct (MPD) [,], assessment of the duct is paramount in decision making. In 7 J Trauma Crit Care 0 Volume Issue

6 Citation: Abdallah HS, Saber SA. Surgical management of pancreatic trauma: a retrospective case series. J Trauma Crit Care. 0;():-9 patients explored immediately after admission (6 patients), the integrity of the pancreatic duct was evaluated intra-operatively by direct exploration of the site of injury. The remaining 7 patients had complete transection of the pancreatic neck (grade III/IV) on preoperative CECT and this was confirmed during exploration which inevitably means transection of the MPD. In the study of Gupta et al. [9], pancreatic injury and disruption of the MPD was diagnosed by operative exploration in % of patients. CECT was diagnostic of pancreatic injury in 0% of patients and intraoperative magnetic resonance cholangiopancreatography (MRCP) was needed in 0%. Wong et al. [6] have suggested that the presence of laceration > half of the parenchymal thickness on CECT imaging, should raise suspicion of major ductal injury. The most common injury in this report was grade III/IV disruption of the pancreatic neck (9/; 76%). In of them, the pancreas was injured after being crushed against the lumbar spine by an antero-posterior impact. All these patients had subtotal/distal pancreatectomy and splenectomy which was performed several hours to several days post-injury. Due to the presence of significant inflammatory reactions in the peripancreatic tissues and the presence of associated intra and extra-abdominal injuries, it was not possible or appropriate to try splenic preservation. In 6 of these patients, it was possible to control the proximal pancreatic stump by different techniques. In patients, significant pancreatitis precluded identification of the proximal pancreatic duct stump; in one of them Histoacryl was applied over the proximal pancreatic stump and in the other, nothing at all was done. Fortunately, these patients had a smooth PO course with no intra-abdominal collection or pancreatic fistula. For a penetrating trauma to reach the pancreas lying in the retroperitoneum and surrounded by several important structures, its trajectory should traverse these structures producing devastating injuries leading to significant morbidity and mortality. Two patients in this study sustained penetrating trauma; one of them had extensive visceral and vascular injuries after a gunshot and although it was possible to control the vascular injury, the patient died few hours PO due to consumption coagulopathy and ongoing uncontrollable bleeding. Low-grade blunt pancreatic injuries (LGBPI) occurred in 6% of the current study population. Two patients were treated nonoperatively and the other patients were explored for associated injuries. So, most of the patients with LGBPI with intact MPD can be managed non-operatively like in other solid organ injuries provided that there is no associated intra-abdominal injuries requiring surgery. The current evidence in the literature also supports the non-operative management of LGBPI. Duchesne et al. [] has shown that non-operative management of LGBPI diagnosed by CECT was successful in the majority of haemodynamically stable patients, with low morbidity and mortality. However, the authors have emphasized the role for early ductal injury detection with either endoscopic retrograde cholangiopancreatography or MRCP and select patient without ductal injury for non-operative management for better outcome. Moreover, when surgery is performed, Akhrass et al. [6] have shown that patients with LGBPI, confirmed by laparotomy, J Trauma Crit Care 0 Volume Issue had a higher morbidity with external drainage compared with exploration without drainage. Conclusion Pancreatic injuries are commonly associated with other intra-abdominal injuries. In the acute setting, both clinical manifestations and laboratory studies lack sensitivity. Most pancreatic injuries are due to direct blunt trauma to upper abdomen producing parenchymal transection. In this subset of patients, CECT is both highly sensitive and specific and subtotal/ distal pancreatectomy is well tolerated. Although postoperative morbidities are frequent, mortality is due to associated major vascular injuries especially after penetrating trauma. References. Craig MH, Talton DS, Hauser CJ, et al. Pancreatic injuries from blunt trauma. Am Surg. 99;6:-.. Bradley EL, Young PR, Chang MC, et al. Diagnosis and initial management of blunt pancreatic trauma: guidelines from a multiinstitutional review. Ann Surg. 99;7(6): Cirillo RL, Koniaris LG. Detecting blunt pancreatic injuries. J Gastrointest Surg. 00;6():7-9.. Schurink GW, Bode PJ, van Luijt PA, et al. The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study. Injury. 997;():6-6.. Iacono C, Zicari M, Conci S, et al. 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7 Abdallah/Saber duodenal injuries. Complex and lethal. Scand J Surg. 00;9():-6.. Feliciano DV, Burch JM, Sput-Patrinely V, et al. Abdominal gunshot wounds: an urban trauma centre s experience with 00 consecutive patients. Ann Surg. 9;0(): Akhrass R, Yaffe MB, Brandt CP, et al. Pancreatic trauma: a ten-year multi-institutional experience. Am Surg. 997;6(7): Takishima T, Sugimoto K, Hirata M, et al. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg. 997;6(): Gupta A, Kumar S, Yadav SK, et al. Magnitude, severity, and outcome of traumatic pancreatic injury at a level I trauma center in India. Indian J Surg. 07;79(6):-0 9. Lin BC, Chen RJ, Fang JF, et al. Management of blunt major pancreatic injury. J Trauma Acute Care Surg. 00;6(): ATLS Subcommittee; American College of Surgeons Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS ): the ninth edition. J Trauma Acute Care Surg. 0;7(): Thomason DA, Krige JEJ, Thomson SR, et al. The role of endoscopic retrograde pancreatography in pancreatic trauma: a critical appraisal of patients treated at a tertiary institution. J Trauma Acute Care Surg. 0;76(6): Smith DR, Stanley RJ, Rue LW. Delayed diagnosis of pancreatic transection after blunt abdominal trauma. J Trauma Acute Care Surg. 996;0: Ilahi O, Bochicchio GV, Scalea TM. Efficacy of computed tomography in the diagnosis of pancreatic injury in adult blunt trauma patients: a single-institutional study. Am Surg. 00;6(): Degiannis E, Levy RD, Velmahos GC, et al. Gunshot injuries of the head of the pancreas: conservative approach. World J Surg. 996;0():6-7.. Lewis G, Krige JE, Bornman PC, et al. Traumatic pancreatic pseudocysts. Br J Surg. 99;0(): Wong YC, Wang LJ, Lin BC, et al. CT grading of blunt pancreatic injuries: prediction of ductal disruption and surgical correlation. J Comput Assist Tomogr. 997;():6-0. *Correspondence to: Hamdy S Abdallah Gastrointestinal Surgery Unit General Surgery Department Tanta University Tanta Egypt Tel: , Hamdy.abdallah@med.tanta.edu.eg; hamdysedky@hotmail.com 9 J Trauma Crit Care 0 Volume Issue