Do advances in CT technology have an impact on identifying traumatic pancreatic injury?

Matthew Vasquez, MD1, Cassandra Cardarelli, MD1, Jacob Glaser, MD2, Thomas Scalea, MD2, Deborah Stein, MD2, Sarah Murthi, MD2. 1Walter Reed National Military Medical Center, Bethesda, Maryland, 2Department of Surgery and Surgical Critical Care, UMMS, Baltimore, Maryland

OBJECTIVES: Missed pancreatic injury in trauma carries significant morbidity. CT imaging is relied upon for initial triage of the stable trauma patient. Previous studies indicate that CT imaging may lack the sensitivity to identify all pancreatic injury, particularly pancreatic ductal injury. It has been proposed that new generation CT scanners would improve sensitivity, but this has not been validated in practice. We aim to review the accuracy of CT for pancreatic injury, and review the role of injury grading based off of CT scan.

METHODS: All trauma admissions in our trauma database from 2007 and 2012 were retrospectively reviewed.  Patients with a documented pancreatic injury, either on CT or intra-operatively, were included (n=107). Data extracted included age, injury severity, injury mechanism, CT and operative findings. Pancreatic injuries were graded based on the standard AAST grading scale. Sensitivity and specificity were calculated using Students T test.

RESULTS: Over the study period, all patients with pancreatic trauma were reviewed. 107 patients had a pancreatic injury on CT or identified intra-operatively (n=107). The average age was 41, average ISS was 33, and the majority (68%) were a blunt mechanism. 36 patients underwent an operation without a preoperative CT. 18 had an injury noted on CT but did not undergo operative intervention. 53 patients had injuries noted on CT and in the OR, which comprised our study group. In this group, 62.3% (n=33) had CT findings which did not correlate with operative findings. 78.8% (n=26) of these had no injury noted on CT, and almost 1/3 of these (26.9%) required a pancreatic resection (6 distal pancreatectomy, 1 pancreatic head resection, 15 had drains placed, 4 managed without drains). Seven patients (13.2%) had injury noted on initial CT but none identified in the OR. Based on these results, the sensitivity for CT imaging to identify an injury is 39.5% (95% CI: 24.9% to 55.6%) and specificity 30.0% (95% CI: 7.03% to 65.2%).

CONCLUSION: The rate of complications from pancreatic injuries can range from 24 to 50%. Our results indicate that despite advances in CT technology, the sensitivity and specificity for identifying pancreatic injury remains low.  Relying on CT imaging exclusively to identify pancreatic injury may expose the trauma patient increased morbidity. While CT scans remain a critical component of initial trauma evaluations, awareness of this diagnostic gap is important and consideration for more sensitive imaging regarding the pancreas may be justified. Further analysis is required to determine any impact on patient outcomes.

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