Tompa pancreastrauma diagnózisa és kezelése = Diagnosis and management of blunt pancreatic trauma

Absztrakt: A torzo szerveinek seruleseiről, ezek kezeleseről mostanra kiterjedt irodalom es letisztult protokollok allnak rendelkezesre. A hasnyalmirigy ez alol kivetelt kepez. A pancreas tompa vagy athatolo serulesei meglehetősen ritkak, reszben emiatt ez idaig nem szuletett a temaban magas szintű evidencian alapulo kezelesi ajanlas. Attekintest adunk az utobbi evtizedek relevans kozlemenyeinek kovetkezteteseiről mind a felnőttkori, mind a gyermekkori pancreasserulesek kapcsan. Rendszerezzuk az eddigi osztalyozasokat es ezek megbizhatosagat. A konzervativ vagy operativ kezelesi terv adekvat felallitasahoz alkalmazott klasszifikaciokat sorra vesszuk a betegvizsgalattol a diagnosztikai leleteken at a szovődmenyekig. A pancreasserulesek kezelesi elvei egyelőre nem alapulnak sem prospektiv, sem randomizalt vizsgalatokon. A fellelhető tanulmanyok csak retrospektiv, alacsony esetszamu betegcsoportokat dolgoznak fel, vagy esetismertetesek, illetve ezek attekintesei (4. vagy 5. szintű evidencia). Ennek ellenere konszenzus alakult ki arrol, hogy a Wirsung-vezetek erintettsegen mulik, hogy alacsony vagy magas rizikoju serulesről van-e szo; a klasszifikaciok is ezt a logikat kovetik. Intakt fő pancreasvezetek eseten stabil betegnel konzervativ kezeles javasolt. Amennyiben ductusserules kimutathato, felnőttkorban javasolt a perkutan, endoszkopos vagy laparotomias megkozelites ennek ellatasara. A gyermekkori serulesek kezeleseről sokkal ellentmondasosabb ajanlasok lattak napvilagot. Szamos erv hozhato fel a nem operativ es az operativ kezeles oldalan es ellene is, ennek feloldasa meg varat magara. Orv Hetil. 2018; 159(2): 43–52. | Abstract: The management of thoracic and abdominal organ injuries has very thorough and extensive literature, including evidence-based protocols. Pancreatic trauma stands as an exception. Blunt or penetrating trauma of the pancreas is rather rare (less than 2% of all trauma cases, approximately 3–12% of all abdominal trauma), leading to the lack of high-level evidences regarding its treatment. Damage of the pancreas parenchyma can cause substantial morbidity and mortality, therefore it is essential to separate cases where conservative treatment suffices from those that need surgical approach. This study aims to review the conclusions of relevant articles of the past decades concerning the management of both adult and childhood pancreatic trauma. Classifications and their reliability are revised. We enlist scaling systems that can help in making decision whether to operate or to treat conservatively, from physical examination to diagnostic measures and complications. To date, the treatment principles of pancreatic trauma are not based either on prospective or on randomised trials. The database search of studies retrieved only retrospective and/or small case cohorts, case reports and expert opinions (levels 4 and 5 of evidence). However, it is a generally accepted conviction that the damage of the main pancreatic duct determines if the pancreatic injury is of low or high grade. Available classifications are based on the same principle. Conservative treatment is feasible given that the patient is hemodinamically stable and the pancreatic duct is unimpaired. If duct lesion is discovered, adult cases are to be treated with minimally invasive (percutaneous or endoscopic) measures or surgically (including reconstruction, resection and drainage). The management of childhood injuries has controversial literature. Many arguments can be enumerated on the operative as also on the non-operative approach, this confusion is to be clarified in the future. The highest morbidity rates are derived from the late diagnosis of the pancreatic duct, while increased mortality is seen in the polytrauma patient groups. Levels 1–2 evidence-based recommendations are needed, but planning of strong trials is critically limited due to the small number of cases and the heterogeneity of the relevant patient groups. Orv Hetil. 2018; 159(2): 43–52.