Superiority of Closed Suction for Pancreatic Trauma
Drainage
A Randomized, Prospective Study
TIMOTHY C. FABIAN, M.D., KENNETH A. KUDSK, M.D., MARTIN A. CROCE, M.D., LYNDA W. PAYNE, R.N., EUGENE C. MANGIANTE, M.D., GUY R. VOELLER, M.D., and LOUIS G. BRITT, M.D.
During a 42-month period, 65 patients sustaining pancreatic injuries were treated. They were randomized on alternate days (two separate trauma teams) to receive sump (S) or closed suction (CS) drainage. Twenty-eight patients were randomized to S and 37 to CS; there were six early deaths, which precluded drainage analysis, leaving 24 evaluable S patients and 35 CS patients. Penetrating wounds occurred in 71% and blunt in 29%. No significant differences appeared between the groups with respect to age, Penetrating Abdominal Trauma Index (PATI), Injury Severity Score (ISS), or grade of pancreatic injury. Twelve patients in each group required resection and drainage for grade III injuries, with the remaining patients receiving external drainage alone. Five of twenty-four S patients versus one of thirtyfive CS patients developed intra-abdominal abscesses (p < 0.04). We conclude that septic complications after pancreatic injury are significantly reduced by CS drainage. Bacterial contamination via sump catheters is a major source for intra-abdominal infections after pancreatic trauma.
From the Department of Surgery, University of Tennessee, Memphis, Tennessee
IGNIFICANT MORBIDITY AND mortality are associated with injuries to the pancreas. Early mortality is usually due to hemorrhagic shock resulting from associated injuries. In those patients who survive the initial period following injury, pancreatic injury is commonly followed by fistula, abscess, or pancreatitis. The late mortality rate resulting from pancreatic complications is approximately 30%. 1-3 Currently accepted management dictates suction drainage alone for pancreatic contusion, minor capsular and parenchymal disruption without ductal injuries, and injuries of the head of the pancreas (unless uncontrolled hemorrhage or excessive pancreatic or duodenal destruction dictate resection). Distal pancreatectomy, usually with splenectomy, and suction drainage are reserved for major ductal and severe crush injuries of the body and tail of the pancreas. S
Presented at the 101st Annual Meeting of the Southern Surgical Association, Hot Springs, Virginia, December 3-6, 1989. Address reprint requests to Timothy C. Fabian, M.D., Director of Trauma, University of Tennessee, 956 Court Avenue, Room G210, Memphis, TN 38163.
Although sump drainage is generally recommended after pancreatic trauma, the safest form of pancreatic drainage has not been determined. Previous work demonstrated that routine sump drainage reduced pancreatic complications compared to Penrose drains.4 5 Because the tract of the sump drain is rapidly colonized, it provides a portal of entry for contamination of injured retroperitoneal tissues. Closed suction drains minimize the risk of colonization, but the efficacy of closed suction versus sump drainage has not been determined. This randomized, prospective study evaluates the effects of sump (S) versus closed suction (CS) drainage on the postoperative course of patients sustaining pancreatic trauma. Materials This study was performed during the 42-month period from December 1985 to May 1989. All patients admitted to the Presley Regional Trauma Center with injuries to the pancreas were randomized to either sump (S) or closed suction (CS) drainage of the pancreas on alternate days. Pancreatic injuries were diagnosed at exploratory laparotomy soon after admission to the trauma center. After mobilization of the pancreas, injuries were classified by severity3 (Table 1). Grades I and II injuries were treated with drainage alone, while most grades III and IV injuries were treated with distal pancreatectomy. No combined crush injuries to the duodenum and pancreas necessitating pancreaticoduodenectomy occurred during the study period. Drainage was accomplished by placing either a sump suction tube (Davol, Cranston, RI) or closed suction tube (Jackson-Pratt, Anasco, Puerto Rico) near the location of pancreatic injury or resection. No Penrose drains were
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CLOSED SUCTION IN PANCREATIC TRAUMA
TABLE 3. Associated Intra-abdominal Injuries
TABLE 1. Injury Classification and Treatment Drainage
Grade
Type of Injury
S
CS
I II III IV
Contusion/hematoma Minor capsular and parenchymal disruption Major ductal injury Severe crush
2 9 12 1 24
2 20 12 1 35
used. In cases of distal resection, management of the proximal pancreatic segment consisted of oversewing the gland with interrupted 3-0 polypropylene U-sutures. The pancreatic duct was separately suture ligated with 4-0 or 5-0 polypropylene. An apron of omentum was placed beneath the pancreas after resections. Drains exited near the tip of the 12th rib posteriorly through a stab wound and were left in place for a minimum of 7 days. When sump suction tubes were removed, a large red Robinson catheter was placed inside the tract to the gland and gradually withdrawn during the succeeding 3 to 4 days to allow the tract to seal from within. A Penetrating Abdominal Trauma Index (PATI) or Injury Severity Score (ISS) was calculated for patients sustaining penetrating or blunt injury, respectively. Drainage from the pancreatic gland and septic and nonseptic pancreatic complications were evaluated on an ongoing basis. Statistical analyses included chi square and Fisher's exact test for discrete variables. Student's t test was applied to continuous variables. Wilcoxon rank sums test was used to compare drainage volumes. Results Sixty-five patients were admitted with pancreatic injuries during the study period. Twenty-eight were randomized to sump drainage and 37 to closed suction drainage. Effectiveness of drainage could not be determined in 6 patients: 5 died within 24 hours of injury from TABLE 2. Pancreatic Drainage-Patient Profile
Characteristics
Male/female Age PATI ISS Mechanism of injury
Penetrating Gunshot Stab Shotgun Blunt
Sump
Closed Suction
20/4 35±13 34 ± 21 30± 13
25/10 28±10 32 ± 17 34± 8
14
28 13 13 2 7 5 1
8 5 1
10
MVA MCA Fall
7 2
Saddle
I
I
Organ
Sump
Stomach Liver Spleen Colon Duodenum Small intestine Vascular
9 (37%) 7 (29%) 4 (17%) 4 (17%) 3 (12%) 3 (12%) 2 (8%)
Closed Suction 12 (34%) 12 (34%) 8 (24%)
5(14%) 4 (12%) 3 (9%) 9 (26%)
refractory shock, and 1 died from multiple-organ failure shortly after diagnosis of a pancreatic injury missed at the initial operation. Effectiveness of drainage was evaluable in 59 patients: 24 received sump drainage, and 35 closed suction drainage. The patient profile is described in Table 2. Analysis showed no significant differences in age, PATI, or ISS between the two groups. Fifty per cent of S patients and 60% of CS patients had a PATI of 25 or more. A larger percentage of patients sustaining penetrating wounds appeared in the closed suction group than in the sump group. As shown in Table 1, equal numbers of grades III and IV injuries were present in each group. The difference in the population sizes was accounted for by the greater number of CS patients with grade II injuries. Associated injuries are listed in Table 3. These were fairly evenly distributed between the S and CS groups, although more intra-abdominal vascular injuries occurred in the CS group. Penetrating colon injuries were evenly distributed and were managed by primary repair. Table 4 demonstrates the surgical procedures performed on patients randomized to the two groups. More patients in the CS group underwent drainage only; however 12 patients in each group had a distal pancreatic resection. The need for splenectomy with the pancreatic resection was similar in the two groups. One patient with pancreatic transection had suture closure of proximal and distal segments without resection. Table 5 delineates the postoperative course of patients sustaining pancreatic injuries. The drainage volumes are highly variable. No significant difference was noted between the groups. Mild pancreatitis occurred in 1 CS patient, while fistulas occurred in 1 S patient and 2 CS patients. All three fistulas closed spontaneously within 4 weeks. Five of the six patients developing intra-abdominal TABLE 4. Pancreatic Injuries-Surgical Procedures
Procedure
Drainage only Distal resection
Splenectomy No splenectomy Other
Sump
Closed Suction
11 (46%)
23 (66%) 12 (34%) 8 4
12 (50%) 9 3 I
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FABIAN AND OTHERS
TABLE 5. Pancreatic Injuries-Postoperative Course Postoperative Outcome
Sump
Closed Suction
Drainage volumes Drain only Resection With complications Without complications Wound infections Pancreatitis Fistula Abdominal abscess Pseudocyst
447 ± 671 1034 ± 1253 1812 ± 1699 505 ± 644 2 0 1 5 (1 death)* 1
626 ± 579 750 ± 808 400 674 ± 660 2 1 2 1 0
*
p < 0.04, sump compared to closed suction.
abscesses were in the S group (p < 0.05), and all S abscesses occurred after distal resections. The one intra-abdominal abscess in a CS patient (lesser sac and subhepatic abscess) developed after a grade IV injury of the head and uncinate process. The following organisms were isolated from these abscesses: Streptococcus viridans, Staphylococcus epidermidis (2), Staphylococcus aureus, Enterococcus (2), Escherichia coli, Enterobacter aerogenes, and Bacteroides sp. Thus 5 of 12 patients undergoing pancreatic resection in association with sump drainage developed intra-abdominal abscess, in contrast to 0 of 12 CS patients undergoing resection (p < 0.04). An overview of the patients with significant pancreatic complications is found in Table 6. Two of the twentyfour S patients had delayed deaths. One 67-year-old patient with known atherosclerosis died on day 7 after injury from a myocardial infarction. The second patient died on day 11 after injury from sepsis and multiple-organ failure, secondary to a lesser sac abscess and necrotizing pancreatitis. None of the 35 CS patients died. Adding the six early deaths in nonevaluable patients to the two deaths in the S group yields a mortality rate of 12% for this series.
Discussion Recent reports of pancreatic trauma have demonstrated mortality rates ranging from 15% to 35%.1,3,6 Certainly
Ann. Surg. * June 1990
most deaths follow hemorrhagic shock from associated major vascular injuries, due to the precarious position of the pancreas amid the aorta, vena cava, and mesenteric
vessels. Indeed major vascular injuries occurred in 25% of the 65 patients in this series, and six ofthe eight deaths were due to hemorrhagic shock. The two remaining deaths also illustrate important points in pancreatic trauma management: first missed injuries can be lethal, and second death can result from pancreatic complications. One death resulted from a blunt pancreatic injury that was missed at initial laparotomy and discovered 4 days later. The patient developed sepsis, coagulopathy, and multiple-organ failure. Smego et al.3 reported two deaths from delayed recognition of pancreatic injuries in a series of 57 patients. These results demonstrate that all peripancreatic hematomas, whether from penetrating or blunt trauma, must be explored, with mobilization ofthe entire pancreas if necessary. Division ofthe gastrocolic ligament exposes the body and tail, and a combination of Kocher and Cattell maneuvers7 permits thorough inspection of the head and neck. Sometimes hematomas over the pancreas, as in the missed injury in this report, can mask significant parenchymal disruption and might require incision of the visceral peritoneum over the inferior border of the gland for accurate inspection. Irrigation of the tissues will reduce the blood staining, improving parenchymal visualization. Although generally low, most series report some deaths attributed directly to complications of the pancreatic injury. The second late death in this series was associated with complications from the pancreatic injury: lesser sac abscess and necrotizing pancreatitis. Jones2 reported that pancreatic complications contributed to 11 of the 36 deaths (30%) in that series. Cogbill et al.' reported two deaths due to the pancreatic injury in 34 patients, one of which was secondary to abscess. Stone et al.5 reported a 22% mortality rate associated with 36 pancreatic complications in a series of 275 patients. These figures demonstrate the gravity of pancreatic injury and the need for optimal surgical management.
TABLE 6. Pancreatic Injuries-Overview of Septic Complications
Age
Associated Injuries
Mechanism
Complication
Grade
Closed Suction
25
MVA
Liver
28 26 60 49* 46
Shotgun MCA
Small bowel
IV
Abscess
III III III III IV
Abscess Abscess Abscess Abscess, necrotizing pancreatitis Abscess
Sump MVA Gunshot MVA
Kidney, spleen Pulmonary contusion Colon, diaphragm Colon, spleen, kidney, liver, duodenum
* Death-pancreatic complication contributed significantly.
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CLOSED SUCTION IN PANCREATIC TRAUMA
External drainage has been the mainstay of pancreatic wound management. We could find no reports advocating no drainage. Graham et al.8 managed 78% of 448 patients with external drainage alone. Stone et al.5 externally drained 84% of 275 patients. Jones2 externally drained 76% of 450 patients. In the last decade there has been a trend away from drainage alone for most injuries toward a more aggressive approach to pancreatic resection combined with external drainage. Our resection rate was 41%, compared to recent reports of 30% to 52%.3,69 Significant pancreatic fistulas are less likely to occur when the gland is resected in the presence of major duct injury.3 Generally we support an approach of external drainage alone for grades I and II injuries and resection for grades III and IV injuries. Exceptions to resectional management include nondevitalizing pancreatic head injuries in which resection would entail near-total pancreatectomy or pancreaticoduodenectomy. We use external drainage in these cases. One grade IV injury in this series involved the head and uncinate process and was drained by closed suction without resection; a lesser sac abscess developed that was the sole major pancreatic complication in the CS group. This patient survived without major sequelae. When the main pancreatic duct is involved, the surgeon has only two options other than resection for managing the distal gland: Roux-en-Y drainage or oversewing the distal gland. This second option was chosen in one patient in our series (S group). That patient developed a large pseudocyst that was internally drained without complication 2 weeks later. This has not been considered a failure of sump drainage for statistical analysis of complications between the S and CS groups, but was rather a failure due to an unsatisfactory operative approach. Roux-en-Y drainage is seldom used now because of associated complications and was not used in this series. Stone et al.5 noted five pancreatic fistulas and three abscesses in seven patients managed with this technique. Similarly Jones reported that 7 of 11 Roux-en-Y patients developed lesser sac or intra-abdominal abscesses.2 Although external drainage is widely acknowledged as a major component of management, little attention has been directed toward the most appropriate drainage technique. What has been reported is retrospective and largely testimonial in nature. The three choices for external drains are Penrose, sump, or closed suction. Penrose drains were used for many years before the other drains became available. In 1974 Anderson et al.4 observed 22 complications in 17 patients drained by Penrose alone but significantly reduced complications to 8 of 31 patients when a sump drain was added. Subsequently Stone et al.5 reported a 39% complication rate with Penrose drainage compared to 2% with sump drainage. Since those reports most of the literature has supported active sump drainage. 1-3'9 One
727
report suggested that closed suction drainage might be superior but provided no supporting data.2 Before this study there have been no prospective analyses of pancreatic drainage, and closed suction has not been evaluated. Potential concerns with sump drainage include inadequate evacuation of pancreatic secretions and contamination of the lesser sac with bacteria drawn through the sump. The major concern with closed suction would be adequacy of secretion evacuation, but contamination would appear to be a minor problem. The drainage volumes (Table 5) were approximately the same between the S and CS groups, although there were large fluctuations among patients. Three patients (one S, two CS) developed pancreatic fistulas, which spontaneously closed, and were not considered major complications of drainage. On the contrary major complications would be likely if these secretions were not successfully externally drained. The major pancreatic complications in this series were intraabdominal abscesses located in the lesser sac and subphrenic space. Abscesses occurred in 21% of S patients and 3% of CS patients, a significant difference. Furthermore all 5 of the S abscesses occurred among the 12 sumpdrained resections and none occurred in the 12 closed suction-drained resections. Patients with grades I and II injuries appear at low risk for abscess, and the type of drain in these patients is probably of little consequence. Patients requiring resection are more likely to have high concentrations of pancreatic juice in the drainage area compared to lesser injuries. This probably causes enough autodigestion to provide a medium for bacteria. Bacterial colonization most likely results from contamination via the drain tract, which is more open with sump drains. Five of the twelve distal resections in each drainage group had colon or gastric injuries, which eliminates that as a bias for contamination. The microbiology of the abscesses demonstrated aerobic gram-positive cocci and aerobic gram-negative rods (except one Bacteroides sp.) compatible with nosocomial contamination. Splenic salvage was accomplished in 7 (3 S, 4 CS) of the 24 resections (29%). All five S group abscesses occurred in splenectomized patients. Past studies have reported minimal splenic salvage with distal pancreatic resection.`3 Certainly unstable patients should not be subjected to the extra 30 to 45 minutes of operative time required for splenic salvage, but we believe it is practical and beneficial in stable patients. Our current institutional approach is as follows: if grade I or grade II injury of the pancreas is found, simple drainage with closed suction and placement of a jejunostomy for subsequent feeding is indicated. For most grade III and grade IV injuries, a distal pancreatectomy is performed, with or without a splenectomy, depending on the gravity of the situation and the ease of splenic salvage.
728
FABIAN
AND
Drainage with a closed suction catheter is performed with jejunostomy to assure enteral access for postoperative feeding should complications arise.
Acknowledgments The authors thank Carrie Mook for her expertise in the preparation of this manuscript and Dr. Elizabeth Tolley for her statistical expertise.
References 1. Cogbill TH, Moore EE, Kashuk JL. Changing trends in the management of pancreatic trauma. Arch Surg 1982; 117:722-728. 2. Jones RC. Management of pancreatic trauma. Am J Surg 1985; 150:
698-704.
DiSCUSSION DR. DAVID V. FELICIANO (Rochester, New York): Dr. Fabian and his colleagues have compared Jackson-Pratt closed suction drains and Davol sump drains in a series of 59 patients with a mixed bag of pancreatic injuries. Based on the results of five abscesses in the sump drain group as compared to one abscess in the JP group they have concluded that closed suction drains are a better choice. This is an interesting study in which the results confirm the biases of many trauma surgeons. However, I have some concerns and questions about the design of the study and the methods used in the analysis. My first concern is with the method of randomization used. While alternating forms of therapy is a time-honored technique in trauma centers, and I have used it frequently, it only satisfies classical statistical randomization requirements when many patients are entered into a study. The single greatest problem with the design of this study is that the two patient groups that resulted are not truly equal. In the sump group, 12 of 24 patients (or 50%) had major pancreatic injuries requiring resection; however, in the closed suction group, only 13 of 35 (or 37%) underwent resection. Despite the matched ISS scores and associated injuries, there is little question in my mind that the overall sump group had more severe pancreatic injuries. I have several questions. First, is the statistical comparison based on class III injuries alone as you implied, or on all injuries, including grades I, II, III and IV? My second concern is with the management of the drains. You removed closed suction drains directly but manipulated the tract of sump drains by inserting a Robinson catheter for several days. Can you justify this manipulation based on historical data? Can you prove that the insertion of the Robinson catheter into a contaminated tract from outside in is not the cause of peripancreatic contamination and subsequent abscess formation? I believe that this study is a preliminary one and would like to see it extended with the following changes: formal techniques of randomization, elimination of patients not requiring suture or resection, and direct removal of the sump drains without late postoperative manipulation of the tract. DR. H. LEON PACHTER (New York, New York): For those of us dealing with pancreatic trauma, we are certainly indebted to Dr. Fabian for his work along with Harlan Stone that definitively showed the superiority of suction sump drains over the passive Penrose drains when managing serious pancreatic injuries. This particular study 8 years later suggests that closed suction drains with Jackson-Pratt drains rather than sump drains are now preferred. The pertinent question, however, I believe should be: When is it appropriate to use what type of drain? In the present study 23 of the 24 sump drains were used in patients who had contusions, hematomas, minor capsular or parenchymal disruption, and major ductal injuries
OTHERS
Ann. Surg. June
1990
3. Smego DR, Richardson JD, Flint LM. Determinants of outcome in pancreatic trauma. J Trauma 1985; 25:771-776. 4. Anderson CB, Connors JP, Mejia DC, et al. Drainage methods in the treatment of pancreatic injuries. Surg Gynecol Obstet 1974; 138:587-590. 5. Stone HH, Fabian TC, Satiani B, et al. Experiences in the management of pancreatic trauma. J Trauma 1981; 21:257-262. 6. Sorenson VJ, Obeid FN, Horst HM, et al. Penetrating pancreatic injuries, 1978-1983. Am Surg 1986; 52:354-358. 7. Cattell RB, Braasch JW. Technique for exposure of the third and fourth portion of the duodenum. Surg Gynecol Obstet 1960; 111: 378-379. 8. Graham JM, Mattox KL, Jordan GL. Traumatic injuries of the pancreas. Am J Surg 1978; 136:744-748. 9. Sims EH, Mandal AK, Schlater T, et al. Factors affecting outcome in pancreatic trauma. J Trauma 1984; 24:125-128.
requiring resection, and I would submit that in these instances the closed suction drain such as the Jackson-Pratt is all that is needed. For crush injuries or when a clean resection line cannot be accomplished, however, then a soft sump drain is warranted. In my experience, a Jackson-Pratt drain is inadequate to deal with the particulate pancreatic matter that frequently accumulates. This leaves us with two patients in the crush group, and each patient developed an abscess regardless of the type method used for drainage. In addition all five patients in the sump group who developed subsequent abscesses had their spleens removed and, although the number of patients undergoing splenectomy and those undergoing splenic salvage procedures were comparable in both of the groups, I believe that great consideration should be given to distal pancreatectomy with splenic preservation. The authors raise concern that doing this sort of procedure is more time consuming. Dr. Carol Scott-Conner of Jackson, Mississippi addressed this issue in the January 1989 issue of the American Surgeon, and she clearly documented that there was no difference in the time required to perform distal pancreatectomy with splenectomy or distal pancreatectomy with splenic preservation. I wish to echo Dr. Feliciano's words. I think that there is a need for further investigation in this area before any specific drains are adopted routinely. DR. EUGENE H. SHIVELY (Campbellsville, Kentucky): Dr. Fabian and his colleagues at the Elvis Presley Trauma Center have presented an excellent paper. It compares the outcome of pancreatic injuries treated by sump drainage and closed drainage of the Jackson-Pratt variety. The groups appear to be comparable, and the closed suction group had fewer infections based on the premise that bacterial contamination occur via the sump drains. The results achieved by these authors are similar to a group of patients reported at the University of Louisville several years ago where it was stressed that distal pancreatectomy was important in patients with major pancreatic disruption. I have three questions. You removed your drains after a minimum of 7 days. Why is this important? Why not just remove the drain when it stops draining? When patients develop pancreatic distulas, how long do you wait to let them heal? When do you operate and when do you feed your patients? In patients with grades I and II injuries, why drain them at all? Perhaps the next part of your study should include a group with no drainage versus closed drainage for grades I and II injuries.
DR. GEORGE F. SHELDON (Chapel Hill, North Carolina): I think it has been known from the studies on splenectomy and drains that it is ofvalue not to have a two-way street for bacteria into a cavity previously occupied by a large organ such as the spleen.
Drainage
A Randomized, Prospective Study
TIMOTHY C. FABIAN, M.D., KENNETH A. KUDSK, M.D., MARTIN A. CROCE, M.D., LYNDA W. PAYNE, R.N., EUGENE C. MANGIANTE, M.D., GUY R. VOELLER, M.D., and LOUIS G. BRITT, M.D.
During a 42-month period, 65 patients sustaining pancreatic injuries were treated. They were randomized on alternate days (two separate trauma teams) to receive sump (S) or closed suction (CS) drainage. Twenty-eight patients were randomized to S and 37 to CS; there were six early deaths, which precluded drainage analysis, leaving 24 evaluable S patients and 35 CS patients. Penetrating wounds occurred in 71% and blunt in 29%. No significant differences appeared between the groups with respect to age, Penetrating Abdominal Trauma Index (PATI), Injury Severity Score (ISS), or grade of pancreatic injury. Twelve patients in each group required resection and drainage for grade III injuries, with the remaining patients receiving external drainage alone. Five of twenty-four S patients versus one of thirtyfive CS patients developed intra-abdominal abscesses (p < 0.04). We conclude that septic complications after pancreatic injury are significantly reduced by CS drainage. Bacterial contamination via sump catheters is a major source for intra-abdominal infections after pancreatic trauma.
From the Department of Surgery, University of Tennessee, Memphis, Tennessee
IGNIFICANT MORBIDITY AND mortality are associated with injuries to the pancreas. Early mortality is usually due to hemorrhagic shock resulting from associated injuries. In those patients who survive the initial period following injury, pancreatic injury is commonly followed by fistula, abscess, or pancreatitis. The late mortality rate resulting from pancreatic complications is approximately 30%. 1-3 Currently accepted management dictates suction drainage alone for pancreatic contusion, minor capsular and parenchymal disruption without ductal injuries, and injuries of the head of the pancreas (unless uncontrolled hemorrhage or excessive pancreatic or duodenal destruction dictate resection). Distal pancreatectomy, usually with splenectomy, and suction drainage are reserved for major ductal and severe crush injuries of the body and tail of the pancreas. S
Presented at the 101st Annual Meeting of the Southern Surgical Association, Hot Springs, Virginia, December 3-6, 1989. Address reprint requests to Timothy C. Fabian, M.D., Director of Trauma, University of Tennessee, 956 Court Avenue, Room G210, Memphis, TN 38163.
Although sump drainage is generally recommended after pancreatic trauma, the safest form of pancreatic drainage has not been determined. Previous work demonstrated that routine sump drainage reduced pancreatic complications compared to Penrose drains.4 5 Because the tract of the sump drain is rapidly colonized, it provides a portal of entry for contamination of injured retroperitoneal tissues. Closed suction drains minimize the risk of colonization, but the efficacy of closed suction versus sump drainage has not been determined. This randomized, prospective study evaluates the effects of sump (S) versus closed suction (CS) drainage on the postoperative course of patients sustaining pancreatic trauma. Materials This study was performed during the 42-month period from December 1985 to May 1989. All patients admitted to the Presley Regional Trauma Center with injuries to the pancreas were randomized to either sump (S) or closed suction (CS) drainage of the pancreas on alternate days. Pancreatic injuries were diagnosed at exploratory laparotomy soon after admission to the trauma center. After mobilization of the pancreas, injuries were classified by severity3 (Table 1). Grades I and II injuries were treated with drainage alone, while most grades III and IV injuries were treated with distal pancreatectomy. No combined crush injuries to the duodenum and pancreas necessitating pancreaticoduodenectomy occurred during the study period. Drainage was accomplished by placing either a sump suction tube (Davol, Cranston, RI) or closed suction tube (Jackson-Pratt, Anasco, Puerto Rico) near the location of pancreatic injury or resection. No Penrose drains were
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CLOSED SUCTION IN PANCREATIC TRAUMA
TABLE 3. Associated Intra-abdominal Injuries
TABLE 1. Injury Classification and Treatment Drainage
Grade
Type of Injury
S
CS
I II III IV
Contusion/hematoma Minor capsular and parenchymal disruption Major ductal injury Severe crush
2 9 12 1 24
2 20 12 1 35
used. In cases of distal resection, management of the proximal pancreatic segment consisted of oversewing the gland with interrupted 3-0 polypropylene U-sutures. The pancreatic duct was separately suture ligated with 4-0 or 5-0 polypropylene. An apron of omentum was placed beneath the pancreas after resections. Drains exited near the tip of the 12th rib posteriorly through a stab wound and were left in place for a minimum of 7 days. When sump suction tubes were removed, a large red Robinson catheter was placed inside the tract to the gland and gradually withdrawn during the succeeding 3 to 4 days to allow the tract to seal from within. A Penetrating Abdominal Trauma Index (PATI) or Injury Severity Score (ISS) was calculated for patients sustaining penetrating or blunt injury, respectively. Drainage from the pancreatic gland and septic and nonseptic pancreatic complications were evaluated on an ongoing basis. Statistical analyses included chi square and Fisher's exact test for discrete variables. Student's t test was applied to continuous variables. Wilcoxon rank sums test was used to compare drainage volumes. Results Sixty-five patients were admitted with pancreatic injuries during the study period. Twenty-eight were randomized to sump drainage and 37 to closed suction drainage. Effectiveness of drainage could not be determined in 6 patients: 5 died within 24 hours of injury from TABLE 2. Pancreatic Drainage-Patient Profile
Characteristics
Male/female Age PATI ISS Mechanism of injury
Penetrating Gunshot Stab Shotgun Blunt
Sump
Closed Suction
20/4 35±13 34 ± 21 30± 13
25/10 28±10 32 ± 17 34± 8
14
28 13 13 2 7 5 1
8 5 1
10
MVA MCA Fall
7 2
Saddle
I
I
Organ
Sump
Stomach Liver Spleen Colon Duodenum Small intestine Vascular
9 (37%) 7 (29%) 4 (17%) 4 (17%) 3 (12%) 3 (12%) 2 (8%)
Closed Suction 12 (34%) 12 (34%) 8 (24%)
5(14%) 4 (12%) 3 (9%) 9 (26%)
refractory shock, and 1 died from multiple-organ failure shortly after diagnosis of a pancreatic injury missed at the initial operation. Effectiveness of drainage was evaluable in 59 patients: 24 received sump drainage, and 35 closed suction drainage. The patient profile is described in Table 2. Analysis showed no significant differences in age, PATI, or ISS between the two groups. Fifty per cent of S patients and 60% of CS patients had a PATI of 25 or more. A larger percentage of patients sustaining penetrating wounds appeared in the closed suction group than in the sump group. As shown in Table 1, equal numbers of grades III and IV injuries were present in each group. The difference in the population sizes was accounted for by the greater number of CS patients with grade II injuries. Associated injuries are listed in Table 3. These were fairly evenly distributed between the S and CS groups, although more intra-abdominal vascular injuries occurred in the CS group. Penetrating colon injuries were evenly distributed and were managed by primary repair. Table 4 demonstrates the surgical procedures performed on patients randomized to the two groups. More patients in the CS group underwent drainage only; however 12 patients in each group had a distal pancreatic resection. The need for splenectomy with the pancreatic resection was similar in the two groups. One patient with pancreatic transection had suture closure of proximal and distal segments without resection. Table 5 delineates the postoperative course of patients sustaining pancreatic injuries. The drainage volumes are highly variable. No significant difference was noted between the groups. Mild pancreatitis occurred in 1 CS patient, while fistulas occurred in 1 S patient and 2 CS patients. All three fistulas closed spontaneously within 4 weeks. Five of the six patients developing intra-abdominal TABLE 4. Pancreatic Injuries-Surgical Procedures
Procedure
Drainage only Distal resection
Splenectomy No splenectomy Other
Sump
Closed Suction
11 (46%)
23 (66%) 12 (34%) 8 4
12 (50%) 9 3 I
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FABIAN AND OTHERS
TABLE 5. Pancreatic Injuries-Postoperative Course Postoperative Outcome
Sump
Closed Suction
Drainage volumes Drain only Resection With complications Without complications Wound infections Pancreatitis Fistula Abdominal abscess Pseudocyst
447 ± 671 1034 ± 1253 1812 ± 1699 505 ± 644 2 0 1 5 (1 death)* 1
626 ± 579 750 ± 808 400 674 ± 660 2 1 2 1 0
*
p < 0.04, sump compared to closed suction.
abscesses were in the S group (p < 0.05), and all S abscesses occurred after distal resections. The one intra-abdominal abscess in a CS patient (lesser sac and subhepatic abscess) developed after a grade IV injury of the head and uncinate process. The following organisms were isolated from these abscesses: Streptococcus viridans, Staphylococcus epidermidis (2), Staphylococcus aureus, Enterococcus (2), Escherichia coli, Enterobacter aerogenes, and Bacteroides sp. Thus 5 of 12 patients undergoing pancreatic resection in association with sump drainage developed intra-abdominal abscess, in contrast to 0 of 12 CS patients undergoing resection (p < 0.04). An overview of the patients with significant pancreatic complications is found in Table 6. Two of the twentyfour S patients had delayed deaths. One 67-year-old patient with known atherosclerosis died on day 7 after injury from a myocardial infarction. The second patient died on day 11 after injury from sepsis and multiple-organ failure, secondary to a lesser sac abscess and necrotizing pancreatitis. None of the 35 CS patients died. Adding the six early deaths in nonevaluable patients to the two deaths in the S group yields a mortality rate of 12% for this series.
Discussion Recent reports of pancreatic trauma have demonstrated mortality rates ranging from 15% to 35%.1,3,6 Certainly
Ann. Surg. * June 1990
most deaths follow hemorrhagic shock from associated major vascular injuries, due to the precarious position of the pancreas amid the aorta, vena cava, and mesenteric
vessels. Indeed major vascular injuries occurred in 25% of the 65 patients in this series, and six ofthe eight deaths were due to hemorrhagic shock. The two remaining deaths also illustrate important points in pancreatic trauma management: first missed injuries can be lethal, and second death can result from pancreatic complications. One death resulted from a blunt pancreatic injury that was missed at initial laparotomy and discovered 4 days later. The patient developed sepsis, coagulopathy, and multiple-organ failure. Smego et al.3 reported two deaths from delayed recognition of pancreatic injuries in a series of 57 patients. These results demonstrate that all peripancreatic hematomas, whether from penetrating or blunt trauma, must be explored, with mobilization ofthe entire pancreas if necessary. Division ofthe gastrocolic ligament exposes the body and tail, and a combination of Kocher and Cattell maneuvers7 permits thorough inspection of the head and neck. Sometimes hematomas over the pancreas, as in the missed injury in this report, can mask significant parenchymal disruption and might require incision of the visceral peritoneum over the inferior border of the gland for accurate inspection. Irrigation of the tissues will reduce the blood staining, improving parenchymal visualization. Although generally low, most series report some deaths attributed directly to complications of the pancreatic injury. The second late death in this series was associated with complications from the pancreatic injury: lesser sac abscess and necrotizing pancreatitis. Jones2 reported that pancreatic complications contributed to 11 of the 36 deaths (30%) in that series. Cogbill et al.' reported two deaths due to the pancreatic injury in 34 patients, one of which was secondary to abscess. Stone et al.5 reported a 22% mortality rate associated with 36 pancreatic complications in a series of 275 patients. These figures demonstrate the gravity of pancreatic injury and the need for optimal surgical management.
TABLE 6. Pancreatic Injuries-Overview of Septic Complications
Age
Associated Injuries
Mechanism
Complication
Grade
Closed Suction
25
MVA
Liver
28 26 60 49* 46
Shotgun MCA
Small bowel
IV
Abscess
III III III III IV
Abscess Abscess Abscess Abscess, necrotizing pancreatitis Abscess
Sump MVA Gunshot MVA
Kidney, spleen Pulmonary contusion Colon, diaphragm Colon, spleen, kidney, liver, duodenum
* Death-pancreatic complication contributed significantly.
Vol. 211 * No. 6
CLOSED SUCTION IN PANCREATIC TRAUMA
External drainage has been the mainstay of pancreatic wound management. We could find no reports advocating no drainage. Graham et al.8 managed 78% of 448 patients with external drainage alone. Stone et al.5 externally drained 84% of 275 patients. Jones2 externally drained 76% of 450 patients. In the last decade there has been a trend away from drainage alone for most injuries toward a more aggressive approach to pancreatic resection combined with external drainage. Our resection rate was 41%, compared to recent reports of 30% to 52%.3,69 Significant pancreatic fistulas are less likely to occur when the gland is resected in the presence of major duct injury.3 Generally we support an approach of external drainage alone for grades I and II injuries and resection for grades III and IV injuries. Exceptions to resectional management include nondevitalizing pancreatic head injuries in which resection would entail near-total pancreatectomy or pancreaticoduodenectomy. We use external drainage in these cases. One grade IV injury in this series involved the head and uncinate process and was drained by closed suction without resection; a lesser sac abscess developed that was the sole major pancreatic complication in the CS group. This patient survived without major sequelae. When the main pancreatic duct is involved, the surgeon has only two options other than resection for managing the distal gland: Roux-en-Y drainage or oversewing the distal gland. This second option was chosen in one patient in our series (S group). That patient developed a large pseudocyst that was internally drained without complication 2 weeks later. This has not been considered a failure of sump drainage for statistical analysis of complications between the S and CS groups, but was rather a failure due to an unsatisfactory operative approach. Roux-en-Y drainage is seldom used now because of associated complications and was not used in this series. Stone et al.5 noted five pancreatic fistulas and three abscesses in seven patients managed with this technique. Similarly Jones reported that 7 of 11 Roux-en-Y patients developed lesser sac or intra-abdominal abscesses.2 Although external drainage is widely acknowledged as a major component of management, little attention has been directed toward the most appropriate drainage technique. What has been reported is retrospective and largely testimonial in nature. The three choices for external drains are Penrose, sump, or closed suction. Penrose drains were used for many years before the other drains became available. In 1974 Anderson et al.4 observed 22 complications in 17 patients drained by Penrose alone but significantly reduced complications to 8 of 31 patients when a sump drain was added. Subsequently Stone et al.5 reported a 39% complication rate with Penrose drainage compared to 2% with sump drainage. Since those reports most of the literature has supported active sump drainage. 1-3'9 One
727
report suggested that closed suction drainage might be superior but provided no supporting data.2 Before this study there have been no prospective analyses of pancreatic drainage, and closed suction has not been evaluated. Potential concerns with sump drainage include inadequate evacuation of pancreatic secretions and contamination of the lesser sac with bacteria drawn through the sump. The major concern with closed suction would be adequacy of secretion evacuation, but contamination would appear to be a minor problem. The drainage volumes (Table 5) were approximately the same between the S and CS groups, although there were large fluctuations among patients. Three patients (one S, two CS) developed pancreatic fistulas, which spontaneously closed, and were not considered major complications of drainage. On the contrary major complications would be likely if these secretions were not successfully externally drained. The major pancreatic complications in this series were intraabdominal abscesses located in the lesser sac and subphrenic space. Abscesses occurred in 21% of S patients and 3% of CS patients, a significant difference. Furthermore all 5 of the S abscesses occurred among the 12 sumpdrained resections and none occurred in the 12 closed suction-drained resections. Patients with grades I and II injuries appear at low risk for abscess, and the type of drain in these patients is probably of little consequence. Patients requiring resection are more likely to have high concentrations of pancreatic juice in the drainage area compared to lesser injuries. This probably causes enough autodigestion to provide a medium for bacteria. Bacterial colonization most likely results from contamination via the drain tract, which is more open with sump drains. Five of the twelve distal resections in each drainage group had colon or gastric injuries, which eliminates that as a bias for contamination. The microbiology of the abscesses demonstrated aerobic gram-positive cocci and aerobic gram-negative rods (except one Bacteroides sp.) compatible with nosocomial contamination. Splenic salvage was accomplished in 7 (3 S, 4 CS) of the 24 resections (29%). All five S group abscesses occurred in splenectomized patients. Past studies have reported minimal splenic salvage with distal pancreatic resection.`3 Certainly unstable patients should not be subjected to the extra 30 to 45 minutes of operative time required for splenic salvage, but we believe it is practical and beneficial in stable patients. Our current institutional approach is as follows: if grade I or grade II injury of the pancreas is found, simple drainage with closed suction and placement of a jejunostomy for subsequent feeding is indicated. For most grade III and grade IV injuries, a distal pancreatectomy is performed, with or without a splenectomy, depending on the gravity of the situation and the ease of splenic salvage.
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Drainage with a closed suction catheter is performed with jejunostomy to assure enteral access for postoperative feeding should complications arise.
Acknowledgments The authors thank Carrie Mook for her expertise in the preparation of this manuscript and Dr. Elizabeth Tolley for her statistical expertise.
References 1. Cogbill TH, Moore EE, Kashuk JL. Changing trends in the management of pancreatic trauma. Arch Surg 1982; 117:722-728. 2. Jones RC. Management of pancreatic trauma. Am J Surg 1985; 150:
698-704.
DiSCUSSION DR. DAVID V. FELICIANO (Rochester, New York): Dr. Fabian and his colleagues have compared Jackson-Pratt closed suction drains and Davol sump drains in a series of 59 patients with a mixed bag of pancreatic injuries. Based on the results of five abscesses in the sump drain group as compared to one abscess in the JP group they have concluded that closed suction drains are a better choice. This is an interesting study in which the results confirm the biases of many trauma surgeons. However, I have some concerns and questions about the design of the study and the methods used in the analysis. My first concern is with the method of randomization used. While alternating forms of therapy is a time-honored technique in trauma centers, and I have used it frequently, it only satisfies classical statistical randomization requirements when many patients are entered into a study. The single greatest problem with the design of this study is that the two patient groups that resulted are not truly equal. In the sump group, 12 of 24 patients (or 50%) had major pancreatic injuries requiring resection; however, in the closed suction group, only 13 of 35 (or 37%) underwent resection. Despite the matched ISS scores and associated injuries, there is little question in my mind that the overall sump group had more severe pancreatic injuries. I have several questions. First, is the statistical comparison based on class III injuries alone as you implied, or on all injuries, including grades I, II, III and IV? My second concern is with the management of the drains. You removed closed suction drains directly but manipulated the tract of sump drains by inserting a Robinson catheter for several days. Can you justify this manipulation based on historical data? Can you prove that the insertion of the Robinson catheter into a contaminated tract from outside in is not the cause of peripancreatic contamination and subsequent abscess formation? I believe that this study is a preliminary one and would like to see it extended with the following changes: formal techniques of randomization, elimination of patients not requiring suture or resection, and direct removal of the sump drains without late postoperative manipulation of the tract. DR. H. LEON PACHTER (New York, New York): For those of us dealing with pancreatic trauma, we are certainly indebted to Dr. Fabian for his work along with Harlan Stone that definitively showed the superiority of suction sump drains over the passive Penrose drains when managing serious pancreatic injuries. This particular study 8 years later suggests that closed suction drains with Jackson-Pratt drains rather than sump drains are now preferred. The pertinent question, however, I believe should be: When is it appropriate to use what type of drain? In the present study 23 of the 24 sump drains were used in patients who had contusions, hematomas, minor capsular or parenchymal disruption, and major ductal injuries
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1990
3. Smego DR, Richardson JD, Flint LM. Determinants of outcome in pancreatic trauma. J Trauma 1985; 25:771-776. 4. Anderson CB, Connors JP, Mejia DC, et al. Drainage methods in the treatment of pancreatic injuries. Surg Gynecol Obstet 1974; 138:587-590. 5. Stone HH, Fabian TC, Satiani B, et al. Experiences in the management of pancreatic trauma. J Trauma 1981; 21:257-262. 6. Sorenson VJ, Obeid FN, Horst HM, et al. Penetrating pancreatic injuries, 1978-1983. Am Surg 1986; 52:354-358. 7. Cattell RB, Braasch JW. Technique for exposure of the third and fourth portion of the duodenum. Surg Gynecol Obstet 1960; 111: 378-379. 8. Graham JM, Mattox KL, Jordan GL. Traumatic injuries of the pancreas. Am J Surg 1978; 136:744-748. 9. Sims EH, Mandal AK, Schlater T, et al. Factors affecting outcome in pancreatic trauma. J Trauma 1984; 24:125-128.
requiring resection, and I would submit that in these instances the closed suction drain such as the Jackson-Pratt is all that is needed. For crush injuries or when a clean resection line cannot be accomplished, however, then a soft sump drain is warranted. In my experience, a Jackson-Pratt drain is inadequate to deal with the particulate pancreatic matter that frequently accumulates. This leaves us with two patients in the crush group, and each patient developed an abscess regardless of the type method used for drainage. In addition all five patients in the sump group who developed subsequent abscesses had their spleens removed and, although the number of patients undergoing splenectomy and those undergoing splenic salvage procedures were comparable in both of the groups, I believe that great consideration should be given to distal pancreatectomy with splenic preservation. The authors raise concern that doing this sort of procedure is more time consuming. Dr. Carol Scott-Conner of Jackson, Mississippi addressed this issue in the January 1989 issue of the American Surgeon, and she clearly documented that there was no difference in the time required to perform distal pancreatectomy with splenectomy or distal pancreatectomy with splenic preservation. I wish to echo Dr. Feliciano's words. I think that there is a need for further investigation in this area before any specific drains are adopted routinely. DR. EUGENE H. SHIVELY (Campbellsville, Kentucky): Dr. Fabian and his colleagues at the Elvis Presley Trauma Center have presented an excellent paper. It compares the outcome of pancreatic injuries treated by sump drainage and closed drainage of the Jackson-Pratt variety. The groups appear to be comparable, and the closed suction group had fewer infections based on the premise that bacterial contamination occur via the sump drains. The results achieved by these authors are similar to a group of patients reported at the University of Louisville several years ago where it was stressed that distal pancreatectomy was important in patients with major pancreatic disruption. I have three questions. You removed your drains after a minimum of 7 days. Why is this important? Why not just remove the drain when it stops draining? When patients develop pancreatic distulas, how long do you wait to let them heal? When do you operate and when do you feed your patients? In patients with grades I and II injuries, why drain them at all? Perhaps the next part of your study should include a group with no drainage versus closed drainage for grades I and II injuries.
DR. GEORGE F. SHELDON (Chapel Hill, North Carolina): I think it has been known from the studies on splenectomy and drains that it is ofvalue not to have a two-way street for bacteria into a cavity previously occupied by a large organ such as the spleen.
