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A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCONECT)

George C. Velmahos, MD; Malek Tabbara, MD; Ronald Gross, MD; Paul Willette, MD; Erwin Hirsch, MD; Peter Burke, MD; Timothy Emhoff, MD; Rajan Gupta, MD; Robert J. Winchell, MD; Lisa A. Patterson, MD; Yorrell Manon-Matos, MD; Hasan B. Alam, MD; Michael Rosenblatt, MD; James Hurst, MD; Sheldon Brotman, MD; Bruce Crookes, MD; Kennith Sartorelli, MD; Yuchiao Chang, PhD

Arch Surg. 2009;144(5):413-419.

Objectives  To evaluate the safety of nonoperative management (NOM), to examine the diagnostic sensitivity of computed tomography (CT), and to identify missed diagnoses and related outcomes in patients with blunt pancreatoduodenal injury (BPDI).

Design  Retrospective multicenter study.

Setting  Eleven New England trauma centers (7 academic and 4 nonacademic).

Patients  Two hundred thirty patients (>15 years old) with BPDI admitted to the hospital during 11 years. Each BPDI was graded from 1 (lowest) to 5 (highest) according to the American Association for the Surgery of Trauma grading system.

Main Outcome Measures  Success of NOM, sensitivity of CT, BPDI-related complications, length of hospital stay, and mortality.

Results  Ninety-seven patients (42.2%) with mostly grades 1 and 2 BPDI were selected for NOM: NOM failed in 10 (10.3%), 10 (10.3%) developed BPDI-related complications (3 in patients in whom NOM failed), and 7 (7.2%) died (none related to failure of NOM). The remaining 133 patients were operated on urgently: 34 (25.6%) developed BPDI-related complications and 20 (15.0%) died. The initial CT missed BPDI in 30 patients (13.0%); 4 of them (13.3%) died but not because of the BPDI. The mortality rate in patients without a missed diagnosis was 8.8% (P = .50). There was no correlation between time to diagnosis and length of hospital stay (Spearman r = 0.06; P = .43). The sensitivity of CT for BPDI was 75.7% (76% for pancreatic and 70% for duodenal injuries).

Conclusions  The NOM of low-grade BPDI is safe despite occasional failures. Missed diagnosis of BPDI continues to occur despite advances in CT but does not seem to cause adverse outcomes in most patients.

Author Affiliations: Departments of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston (Drs Velmahos, Tabbara, and Alam); Hartford Hospital and University of Connecticut, Hartford (Drs Gross and Willette); Boston Medical Center and Boston University (Drs Hirsch and Burke); University of Massachusetts Memorial Hospital, Worchester (Dr Emhoff); Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire (Dr Gupta); Maine Medical Center, Portland (Dr Winchell); Baystate Medical Center, Springfield, Massachusetts (Drs Patterson and Manon-Matos); Lahey Clinic Medical Center, Burlington, Massachusetts (Dr Rosenblatt); Beth Israel Deaconess Medical Center and Harvard Medical School (Dr Hurst); Berkshires Medical Center, Pittsfield, Massachusetts (Dr Brotman); Fletcher Allen Healthcare and University of Vermont, Burlington (Drs Crookes and Sartorelli); and Clinical Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School (Dr Chang). Dr Tabbara is currently with Brigham and Women's Hospital, Boston. Dr Gross is currently with Baystate Medical Center.
Deceased.

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Blunt Pancreatoduodenal Injury—Invited Critique
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Arch Surg. 2009;144(5):419-420.
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