Features of diagnosing battlefield pancreatic injuries during the war in Ukraine

Features of diagnosing battlefield pancreatic injuries during the war in Ukraine | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Features of diagnosing battlefield pancreatic injuries during the war in Ukraine Eduard Mykolaiovych Khoroshun, Ihor Petrovych Khomenko, Vitalii Volodymyrovych Makarov, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7462542/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The diagnosis of battlefield pancreatic injury (BPI) has specific features related to the stages of care and remains one of the most complex and resource-intensive problems in medical care. Methods Retrospective analyses of 1345 medical records of military personnel and civilian patients with battlefield abdominal injuries were performed. Biochemical blood analysis with determination of serum alpha-amylase, focused assessment with sonography in trauma (FAST), abdominal X-ray, multispiral computed tomography (MSCT) of the abdominal and pelvic organs, endoscopic retrograde cholangiopancreatography, intraoperative ultrasonography, indocyanine green fluorescent angiography and intraoperative revision of the pancreato‒duodenal complex were used. Results BPI was diagnosed in 117 (8.7%) patients. A total of 90 patients were included. Gunshot shrapnel pancreatic wounds were diagnosed in 81.1% of patients. Injury to the head of the pancreas was diagnosed in 18.9% of the patients, to the neck in 1.1%, to the body in 14.4%, and to the tail in 55.6%. Multiple injuries were detected in 10% of the patients. Intraoperative revision of the pancreato‒duodenal complex in hemodynamically unstable patients diagnosed with BPI in 78.2% of patients. BPI diagnosis in 85.7% of hemodynamically stable patients was based on preoperative serum alpha-amylase, FAST, and intraoperative X-ray. At the hospital stage of medical care, the sensitivity of the extended BPI diagnostic algorithm was 98.8%. Conclusions BPI diagnosis is difficult because of its rarity, anatomical and topographical features of the pancreas, polysymptomatic clinical presentation in combined and multiple injuries, manifestations of traumatic and hypovolemic shock, and peritonitis. The main examination methods for BPI are MSCT of the abdominal cavity and pelvis and detailed intraoperative revision of the pancreato‒duodenal complex. Trial registration Not applicable. This retrospective study did not require trial registration. Battlefield pancreatic injury battlefield abdominal injury advanced surgical team damage control surgery distal resection of the pancreas pancreatoduodenal resection focused assessment with sonography in trauma multispiral computed tomography with contrast enhancement intraoperative indocyanine green fluorescent angiography Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background The large-scale armed aggression of the Russian Federation against Ukraine has resulted in serious injuries among military personnel and civilians [ 1 – 3 ]. The severity of combat injuries is associated with the enemy's use of high-tech new types of weapons and the specific characteristics of wound ballistics [ 4 ]. Exploded and gunshot wounds to the abdomen are among the most complex types of combat trauma in military surgery [ 4 , 5 ]. According to our clinical observations, the number of gunshot wounds to the abdomen in the overall structure of combat injuries during the Russian‒Ukrainian war of 2022–2024 was 7.6–8.5%. Pancreatic injury is rare as it has been reported to occur as low as 0.2% to 1.1% of all trauma. Sixty-three percent are from penetrating gunshot and stab wounds while the remaining 37% are consequences of blunt abdominal trauma. The incidence of pancreatic injury in abdominal trauma is cited as low as 3% to 12% and 0.2% to 2% in all trauma [ 6 ]. A special group of patients with battlefield abdominal trauma consists of military personnel and civilians with battlefield pancreatic injuries (BPIs). Analysing the experience of treating gunshot wounds in the pancreas, it is not known exactly which therapeutic and diagnostic algorithm for the treatment of this type of injury leads to the most favourable results. According to a series of published articles on BPIs, most focus on blunt trauma and stab wounds during peacetime. A small number of articles have specifically valuated the results of treatment for gunshot wounds to the pancreas [ 7 – 18 ]. On the bases of the experience of combat operations OIF (Operation Iraqi Freedom) and OEF (Operation Enduring Freedom), there is a general analysis of the characteristics of BPIS treatment wartime without a clear treatment and diagnostic algorithm [ 19 ]. Current recommendations for BPIs in emergency war surgery are limited and focus on the treatment of long-term complications [ 20 ]. The most important determinant of the outcome of treatment for pancreatic trauma is the time from injury to final diagnosis. [ 21 , 22 ]. The diagnostic algorithm in accordance with the level of care for BPIs has not been described in the available literature. The aim of this study is to demonstrate the experience of diagnosing BPIs during Russia's large-scale invasion of Ukraine (2022–2024) under the conditions of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, Kharkiv (MMCCNRAFU). Methods This article presents a retrospective analysis of the use of various methods for diagnosing battlefield abdominal trauma in patients with abdominal injuries at the MMCCNRAFU from 2022–2024. The inclusion criteria were military personnel and civilians who had suffered combat abdominal trauma, which was confirmed intraoperatively or via special imaging methods. Battlefield abdominal trauma during combat operations with a treatment duration at the MMCCNRAFU of more than 5 days until discharge or evacuation to the next level of medical care (Regional Medical Centre). The exclusion criteria were patients with BPIs with a treatment period of up to 5 days, and incomplete data in the accompanying documentation or medical records of the hospitalized patient, which made it impossible to analyse the data under study. Data on the diagnosis and treatment of patients with BPIs, including surgical, resuscitation, radiological, endoscopic, and multidisciplinary clinic reports, were collected retrospectively from inpatient medical records. These included demographic indicators (age, sex), distribution by mechanism and damaging factors of injury, severity of general status according to the Abbreviated Injury Scale (AIS), overall severity of injury according to the Injury Severity Score (ISS), number and location of combined intra- or extraperitoneal injuries, injuries to the pancreas (amylase peak, location of injury, World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) severity assessment), diagnostic methods (general clinical blood tests, biochemical blood analysis with determination of serum alpha-amylase, ultrasonography of the abdominal organs according to the Focused Assessment with Sonography in Trauma (FAST) protocol, X-ray of the chest, abdomen and pelvis, endoscopic retrograde cholangiopancreatography (ERCP), indocyanine green fluorescent angiography (ICG-FA), intraoperative revision of the pancreato-duodenal complex), treatment (conservative, endoscopy, surgical intervention) and treatment outcomes (mortality, duration of hospital stay). The diagnosis of BPI was performed via multispiral computed tomography (MSCT) of the abdominal cavity or intraoperatively (in the case of initial surgery in the intensive care unit). The decision to perform primary laparotomy depended on the hemodynamic status at the time of admission and/or the presence of concomitant injuries requiring surgical examination. Intraoperative examination of the pancreas was performed only in stable patients. Damage to the main pancreatic duct was diagnosed on a routine basis. In cases of severe physiological disorders (hemodynamic instability, hypothermia, acidosis), a limited laparotomy was performed via the ‘damage control surgery’ (DCS) approach. Contrast-enhanced MSCT was routinely performed for all patients who were stable at the time of admission to the MMCCNRAFU. When deciding on selective nonoperative management (SNOM), patients with pancreatic trauma are cured according to the acute pancreatitis protocol. The severity of pancreatic injury was assessed via the AAST Organ Injury Scale (OIS). Complications, both general and organ-specific, which directly related to pancreatic injury were analysed separately. The organ-specific complications observed were bleeding, posttraumatic acute pancreatitis (PTAP), peritonitis, external pancreatic fistula (EPF), and pancreatic pseudocyst (PPC). Complications were considered serious when they required surgical or interventional treatment or intensive care, corresponding to Dindo-Clavien grade III or higher. PTAP was defined as a plasma amylase level above three times the normal value for three or more consecutive days in combination with characteristic clinical symptoms. Peritonitis was defined as a generalized complication associated with systemic inflammatory response syndrome (SIRS). Postoperative EPF was defined as drainage fluid with amylase levels at least three times greater than normal. The surgical technique included a complete examination of the pancreas and assessment of the integrity of the main pancreatic duct (MPD), especially if there were signs of pancreatic trauma, including fluid accumulation in the omental bursa, the presence of bile in the retroperitoneal space, steatonecrotic spots on the peritoneum, and hematoma located in the pancreas area. Length of hospital stay and length of stay in the intensive care unit (ICU) were expressed in calendar days. Results Among all patients with penetrating combat abdominal trauma, BPIS was diagnosed in 117 (8.7%) patients. Ninety patients were included for further analysis. Due to incomplete data and short treatment durations, 27 patients were excluded. All patients were male. The average age of the patients was 39.1±3.4 years. The average time from injury to evacuation to the appropriate level of medical care (R2-4) was 11.6 hours (range 2-48). The diagnostic algorithm corresponded to the patient's haemodynamic status and the material, technical and personnel capabilities of individual levels of medical care (R2-4). According to the international AIS scale, 80 (88.9%) victims were hospitalized in severe and profound conditions. The overall severity of injuries was determined via the ISS scale, with an average ISS of 28.8 (Table 1). Table 1. Severity of injuries according to the ISS. Severity according to the ISS scale n % 9 – 15 Moderate 4 4,4 16 – 24 Severe 35 38,9 >/=25 Profound 51 56,7 Total 90 100 The associated injuries to the abdominal organs and structures of the combined injuries are presented in Table 2. The distributions by location of pancreatic injury and severity according to the AAST-OIS are presented in Table 3. Table 3. Location of pancreatic injury and severity according to the AAST-OIS Location of pancreatic injury n % Head 17 18,9 Head and tail 2 2,2 Body 13 14,4 Body and tail 7 7,8 Tail 50 55,6 Isthmus and Body 1 1,1 Grade by AAST-OIS n % Grade I 26 28,9 Grade II 35 38,9 Grade III 21 23,3 Grade IV 5 5,6 Grade V 3 3,3 Total 90 100,0 FAST of the abdominal cavity in BPIs was determined to be positive in 79 (87.7%) victims. On the basis of the results of preoperative ultrasound examination of the abdominal organs, BPIS was diagnosed in 57 (63.3%) patients. According to the results of X-ray examination of the abdominal organs, 57 (63.3%) patients had foreign bodies detected in the projection of the pancreas. Elevated serum amylase levels in patients with BPIs were detected in 46 (51.5%) patients with an average value of 183 U/L. MSCT was performed in all 90 (100%) patients with BPIS. Direct signs of BPIS were the presence of foreign bodies (fragments, bullets, and other wounding projectiles) in the pancreatic parenchyma, which was detected in 57 (63.3%) patients (Fig.1). Direct signs of pancreatic damage also included rupture, focal enlargement, or hematoma of the pancreas coinciding with the trajectory of the wound channel (Fig. 1a, b, c). In the case of pancreatic rupture, complete or partial loss of pancreatic structure can be identified (Fig. 1d, e, f). Indirect MSCT signs of pancreatic damage included nonspecific peripancreatic fluid (Fig. 1f) in the right pararenal space or in the omental bursa cavity, peripancreatic fat consolidation, and thickening of the left anterior renal fascia. To assess the condition of the MPD at BPI 43 (47.7%), patients underwent ERCP (Fig. 2). During laparotomy to diagnose parenchymal damage or the condition of the MPD in cases of small wounds of the pancreas located in the projection of the MPD, intraoperative ultrasonography of the pancreas was performed in 26 (28.8%) patients (Fig. 2c). To determine the viability of the parenchyma of the pancreas, visualize fluorescent structures in real time with the determination of optimal tissue perfusion for penetrating abdominal wounds with BPI and develop a surgical strategy, ICG-FA was used in 8 (8.8%) patients (Fig. 3). According to the SNOM acute pancreatitis treatment protocol, 1 (1.2%) patient with explosive trauma with liver contusion and OIS I and severe skeletal trauma was cured. The patient was transferred on the third day in a moderate condition to the next stage of medical care. For 89 (98.8%) patients with penetrating abdominal trauma, intraoperative revision of the pancreato-duodenal complex was performed. The number of undiagnosed cases of BPIS after preoperative examination was 25 (27.7%) (Fig. 4). A total of 89 (98.8%) patients underwent 248 surgical interventions for concomitant pancreatic injuries, which amounted to 2.8 operations per case, and 179 surgeries for the treatment of pancreatic injuries (Table 4). Table 4. Surgery performed for patients with BPIs Type of surgery DCS I DCS III Total Tamponade/drainage 82 64 146 Suturing of the pancreas 4 1 5 Removal of pancreatic fragments 5 2 7 Distal resection with splenectomy - 11 11 Distal resection with spleen preservation - 3 3 Central resection of the pancreas - 1 1 Pancreatoduodenal resection 2 3 5 Pancreatectomy - 1 1 Total 93 86 179 Twenty (22.4%) patients had no general postoperative complications and had an average hospital stay of 7 days before discharge or transfer to the next stage of evacuation (Table 5). The remaining 70 (77.6%) patients had a total of 138 general complications, with a median of 2.6 complications per patient in this subgroup (range 1–7) (Table 5). On the basis of the available study results, we propose a diagnostic algorithm for BPIs in accordance with the level of medical care (Fig. 5). Role 2-3: In the case of a hemodynamically unstable patient with penetrating abdominal injury, an emergency laparotomy with revision of the omental bursa is performed to diagnose BPIS and other associated injuries. Such surgery is completed with a hemostatic manoeuver, tamponade of the damaged area of the pancreas and the formation of a closed laparostomy. The sensitivity of intraoperative revision of the abdominal organs for the diagnosis of BPIS during emergency laparotomy in hemodynamically unstable patients with penetrating abdominal wounds was 14 (60.8%). In hemodynamically stable patients, preoperative examination is available in the form of clinical and laboratory tests with determination of serum alpha-amylase, abdominal FAST, X-ray of the abdominal organs and diagnostic laparotomy as indicated. The sensitivity of the abbreviated diagnostic algorithm for diagnosing BPIs during emergency laparotomy in hemodynamically stable patients with penetrating abdominal wounds was 44 (77.2%). Role 4: In the case of a hemodynamically unstable patient with penetrating abdominal injury, an emergency laparotomy with revision of the omental bursa is performed to diagnose BPIS and other associated injuries. All hemodynamically stable patients and all stabilized patients after preliminary treatment by the advanced surgical team (AST) underwent a complete clinical and instrumental examination. The priority is a clinical and laboratory examination and MSCT of the abdominal cavity and pelvis. If the injury was sustained within 12–24 hours prior to hospitalization, MSCT with intravenous contrast was performed. On the basis of the results of the examination, ERCP is indicated if damage to the MPD is suspected. The most diagnostically valuable is a detailed (complete) intraoperative examination of the pancreato-duodenal complex in hemodynamically stable or stabilized patients during phase 3 of DCS. During emergency laparotomy with visual signs of acute pancreatitis, intraoperative ultrasonography and ICG-FA can be used for additional intraoperative examination of the pancreas. The sensitivity of the extended diagnostic algorithm for the diagnosis of severe acute pancreatitis was 89.98.8%. Discussion A special group of wounded patients during combat operations are those with penetrating abdominal wounds with BPIs. The diagnosis and treatment of patients with BPIs remains one of the most difficult and resource-intensive problems of medical care in combat conditions [ 7 ]. The current guidelines for diagnosing abdominal trauma are based on the examination of patients in medical institutions of various levels at the peacetime [ 23 – 25 ]. There is insufficient information on the analysis of BPIs in the available literature. In this study, which was conducted at the MMCCNRAFU during Russia's large-scale invasion of Ukraine from 2022–2024, we confirmed that BPI was diagnosed in 8.7% of combat abdominal injuries. This differs sharply from a series of studies reporting that pancreatic injury occurs in 0.21–5.37% of patients with penetrating abdominal trauma [ 14 ]. This may be due to the specific characteristics of wound ballistics, when the wound element crosses the abdominal cavity and/or retroperitoneal space, causing damage to the pancreas. Patients with BPIs constitute a relatively homogeneous group of predominantly young adult males (the average age of patients was 39.1 ± 3.4 years), with minor or no concomitant pathology. Patients with BPIs are hospitalized at the MMCCNRAFU from the AST area of responsibility and directly from the battlefield or the site of injury by medical transport accompanied by a resuscitation team. Patients were delivered to the AST or the MMCCNRAFU with an average time from injury of 11.6 hours (range 2–48), which is associated with the operational and tactical situation on the front line and the complexity of evacuating the wounded. The severity of patients with abdominal trauma is associated with a high incidence of combined severe injuries to the abdominal organs and major visceral vessels in penetrating abdominal trauma [ 26 – 28 ]. Multivisceral injury of the abdominal organs in pancreatic injury is the rule rather than the exception [ 16 , 29 ]. This is due to the overall impact of the shock wave on the body and the damaging effect of primary and secondary wounding elements during an explosion, with the potential for not only multiple abdominal injuries, but also the development of blast trauma and combined injuries to other locations (head, chest, pelvis, limbs, etc.) Krige et al. [ 13 ] reported isolated lesions in only 11% of cases. In a study by Petrone P. et al. [ 15 ], 9110 intra-abdominal lesions were diagnosed in 4559 patients with blast injuries (1.9 per patient). The most common combined intra-abdominal injuries included liver (20.9%), stomach (17.2%), and vascular (14.3%) injuries. Among combined injuries, 8.5% were duodenal damage, with a tendency to increase to 12%-21% in cases of penetrating trauma. Among extra-abdominal injuries, chest injuries predominated (44.5%), followed by musculoskeletal injuries (26.2%) and head injuries (17.5%) [ 17 , 29 ]. In this study, isolated BPIS was diagnosed in only 1 (1.1%) of 90 patients. All other patients had combined injuries. Combined intra-abdominal injuries were found in 89 (98.8%) patients. The most common intra-abdominal injuries were stomach injuries (38 (17.2%)); spleen injuries (36 (16.3%)); colon injuries (32 (14.5%)); liver injuries (31 (14.0%)); small intestine injuries (25 (11.3%)); and duodenum injuries (10 (4.5%)). Among the 90 victims with BPIs, 14 (15.5%) had damage to one other abdominal organ, 29 (32.2%) had damage to two organs, 30 (33.3%) had damage to three organs, 23 (25.5%) had damage to four organs, 12 (13.3%) had damage to five organs, 6 (6.6%) had damage to six organs, and 7 (7.7%) had damage to seven organs. Combined injuries to major vessels were diagnosed in 10 (11.1%) patients, including damage to the inferior vena cava in 3 (3.6%) patients, the renal artery and renal vein in 2 (2.4%) patients, the superior mesenteric artery and vein in 5 (6.0%) patients, the aorta in 1 (1.2%) patient, the portal vein in 1 (1.2%) patient, the splenic vein in 2 (2.2%) patients, the left gastric artery in 1 (1.2%) patient, the femoral artery and vein in 2 (2.4%) patients. A total of 74 (82.2%) of the wounded had extra-abdominal combat injuries and required a multidisciplinary approach. According to the analysis, 23 (25.5%) patients had 1 extra-abdominal injury, 41 (45.5%) of patients had 2, 5 (5.5%) patients had 3, 2 (2.2%) had 4, and 3 (3.3%) had 5 combined injuries to organs in other anatomical areas. Most commonly (17 (18.9%)), the injured had a combination of chest, abdominal, and limb injuries. Isolated abdominal injuries were diagnosed in only 16 (17.8%) patients. A total of 90 patients had 336 combined injuries at various locations (3.7 injuries per patient), including 221 combined abdominal injuries (2.5 injuries per patient). Pancreatic injuries during combat operations have specific distribution patterns depending on the mechanism of injury. Gunshot wounds to the abdominal cavity predominated — 77 (85.5%), of which 73 (81.1%) were shrapnel wounds and 4 (4.4%) were bullet wounds. Injuries resulting from explosive trauma were diagnosed in 11 (12.2%) patients. Non firearm injuries were recorded in only 2.2% of the cases. This differs sharply from data recorded in the United States or South Africa [ 29 – 31 ], where the ratio of blunt to penetrating injuries is the opposite. In a review by Petrone P. et al. [ 15 ], among 1,236 patients, closed trauma accounted for 59.8%, and penetrating trauma accounted for 40.2%. Among patients with penetrating trauma, only 59% were injured by firearms. According to the results of the present study, mild BPI according to OIS I-II was diagnosed in 61 (67.8%) patients, and severe BPI with obstruction of MPD according to OIS III-V was diagnosed in 29 (32.2%) patients. Damage to the tail of the pancreas was more common (50 patients; 55.6%), and multiple injuries were detected in 10 (11.1%) patients. The distribution differs from the data reported by Laura L. et al. [ 32 ], where pancreatic trauma was accompanied by damage to the MPD in 30.6% of cases. The high proportion of MPD damage among BPIs is associated with the characteristics of gunshot wounds with direct projectile impact, wounding, side impact and counterimpact. The formation of a wound channel with foci of contusion, destruction and deposition, and a zone of secondary molecular concussion with hypoxia and ischemia of the abdominal wall tissue contributes to damage to the MPD. Elevated amylase levels after abdominal trauma were previously considered indicators of pancreatic damage. However, upon hospitalization, normal blood amylase levels are found in 40% of patients with pancreatic trauma, and elevated levels are not specific to this type of trauma. Serum amylase may also be elevated in head, liver, and intestinal injuries, in alcohol abuse, and after pancreatic hypoperfusion [ 33 , 34 ]. An increase in amylase levels more than 3 times after trauma may indicate pancreatic damage, so a series of follow-up tests is recommended. According to the results of our study, the reference values for α-amylase at hospitalization were detected in 32 (35.6%) patients with BPI. Laboratory diagnosis with serum amylase measurement is neither sensitive nor specific for definitive screening or diagnosis of pancreatic injury, especially within the first 3–6 hours after trauma. FAST of the abdomen is a quick and effective method for diagnosing free fluid and damage to parenchymal organs. However, it is nonspecific and therefore not useful for assessing BPIs. Ultrasonography is not recommended for the routine diagnosis of duodenopancreatic trauma according to WSES-AAST guidelines [ 23 ]. According to our data, in 33 (36.7%) patients, it is impossible to visualize the pancreas clearly on the basis of ultrasonography results because of gas accumulation in the transverse colon in cases of penetrating abdominal injury. The two most important determinants of the outcome of pancreatic trauma treatment are the time from injury to final diagnosis and the condition of the MPD [ 21 ]. MSCT is the diagnostic method of choice in patients with hemodynamically stable abdominal trauma for the diagnosis of pancreatic injury. The sensitivity for detecting pancreatic injury varies widely, ranging from 47% to 79% [ 35 – 37 ]. The detection of MPD damage via MSCT is sensitive, ranging from 52% to 54% with a specificity ranging from 90% to 95%. [ 35 ] A disadvantage of this method is the need to determine the ideal moment, since immediately after injury, the pancreas may appear normal in 20% to 40% of cases, which is performed within the first 12 hours [ 38 , 39 ]. Pancreatic injuries become more pronounced 12 to 24 hours after injury [ 40 ]. Repeated MSCT with a specific pancreatic phase of the pancreas (35–40 seconds after iodine injection) helps in the diagnosis of MPD damage [ 41 ]. In our study, MSCT provided the most reliable information about the extent of pancreatic damage. However, in 30–33.3% of patients with BPIS without foreign bodies in the parenchyma, mild BPI OIS I-II may be misdiagnosed by MSCT of the abdomen due to the absence of significant morphological changes, which is performed within the first 12 hours after combat trauma. If it is impossible to determine the severity of the injury via MSCT results or if there is marginal damage to the parenchyma, ERCP is useful and more sensitive for assessing the condition of the MPD. However, its widespread use is limited, among other things, owing to the risk of developing PTAP, which reaches 3–14%, and mortality of 0.2–1%. [ 42 , 43 ]. The sensitivity and specificity of ERCP in our study were 81.4%. Finally, the most invasive diagnostic option, which is mandatory in unstable patients, is surgery [ 44 ]. During laparotomy, confirming the status of the MPD is important, as the lesion may be small and undetected. The use of intraoperative ultrasonography may help in the diagnosis of parenchymal or even ductal lesions. However, there is a lack of conclusive evidence on the value of the procedure, and the need for trained surgeons makes this technique unrecommended for routine investigations in trauma [ 45 ]. In our study, we used intraoperative ultrasonography of the pancreas in cases of small pancreatic wounds located in the projection of the MPD. In 15 (53.8%) patients, signs of MPD deformity were detected: narrowing of the lumen, and edema around the wound channel. ICG-FA is a promising method for real-time visualization of fluorescent structures and determination of optimal tissue perfusion for penetrating abdominal wounds with BPIs. Intraoperative ICG-FA can help surgeons diagnose lesions and modify the surgical plan, resulting in fewer postoperative complications [ 46 ]. In our study, 2 (2.2%) patients underwent increased resection of the pancreatic parenchyma due to irreversible changes in the blood supply of the organ. However, the small sample size makes it difficult to determine specific conclusions. The application of this technique requires further research. Ultimately, in patients with hemodynamic instability, diagnostic uncertainty or worsening clinical presentation, negative radiological and/or laboratory changes due to penetrating abdominal wounds and laparotomy without prior MSCT imaging should be performed. In these cases, pancreatic injuries are assessed intraoperatively. [ 47 – 49 ]. Penetrating abdominal trauma requires a meticulous examination with revision of the retroperitoneal space to identify pancreatic injuries [ 50 ]. After fluid resuscitation, the patient was prepared for repeat surgical intervention. In our study, initial resuscitation was performed according to ATLS quidelines. Surgical treatment of BPIS was performed according to a specific surgical strategy: emergency control of intra-abdominal bleeding, closure of visceral lesions to prevent abdominal cavity contamination and rapid volume replacement to correct acidosis, coagulopathy and hypothermia. In our study, 79 (87.8%) patients with injuries to the pancreas and associated organs complicated by significant blood loss, acidosis, coagulopathy and hypothermia were cured by DCS tactics and received an average of 11 (range 2–35) units of blood. Tamponade of the pancreatic area for hemostatic purposes, such as DCS I was performed in 82 (91.1%) patients, and drainage of the omental bursa completed treatment in 64 (71.1%) patients. In the case of severe OIS IIІ damage to the pancreas, distal resection of the pancreas was performed in 14 (15,5%) patients. Central resection at the penetrating wound of the proximal part of the pancreatic body with MPD damage was performed in 1 (1,1%) patient. Five (5,5%) patients with severe combined trauma to the pancreas and duodenum OIS V underwent pancreaticoduodenal resection (PDR). Pancreatectomy was performed in 1 (1.1%) patient with severe postoperative portal vein hemorrhage after PDR. The most common organ-specific complication of BPI in 43 (47.7%) patients in our study was PTAP. Most pancreas-related complications occurred in patients with OIS grade III injuries. The average length of hospital stay was 10.4 (1–56) days. Forty (44.5%) patients were discharged from the hospital with a definite outcome. Twenty five (27.8%) patients died, while 50 (55.5%) stable patients were transferred to the next stage of medical evacuation. All 25 patients who died were cured with DCS with a median ISS of 28.8 (range 16–50). Six (6.6%) patients died in the first 3 days after severe injury from irreversible hemorrhagic shock. Twenty-four (26.6%) patients died after multiple reoperative interventions from progressive multiple organ failure with a background of severe distributive shock, 1 (1.1%) – died from ischemic necrosis of the small intestine with a background of thrombosis of the superior mesenteric vein. Fifty-four (60.0%) patients who survived in the DCS group underwent 2 to 7 relaparotomies. In our study, 7 (28%) patients who died had combined injury to the major vessels, with superior mesenteric vein and inferior vena cava injuries being the most commonly diagnosed. Patients who died had an average of 3 (range 1–6) complications, and 7 (28%) had four or more complications. Fifteen (60.0%) of the 25 patients who died were in shock at the time of admission. Among the 21 (23.3%) patients with proximal pancreatic injury, 6 (28.6%) died. Conclusions BPI during combat operations occurs mainly as a result of explosive devices with significant accompanying anatomical damage. The complexity of diagnosing BPI is associated with its rarity, the anatomical and topographical features of the organ, the absence of pathognomonic signs and the polysymptomatic clinical presentation in cases of combined and multiple injuries, manifestations of traumatic and hypovolemic shock, and the development of peritonitis. The leading diagnostic methods for BPIs are MSCT of the abdominal cavity and pelvis within 12–24 hours with intravenous contrast and detailed (complete) intraoperative revision of the pancreato-duodenal complex, which increases the diagnostic accuracy of BPIs to 98.8%. Further research is needed on the characteristics of the diagnosis and treatment of acute pancreatitis in combat conditions. Table 2 Associated injuries to the abdominal organs and combined injuries at the BPI. Affected organ n % Spleen 36 16,3 Liver 31 14,0 Large intestine 32 14,5 Stomach 38 17,2 Kidney 23 10,4 Small intestine 25 11,3 Duodenum 10 4,5 Adrenal glands 4 1,8 Gall bladder 4 1,8 Diaphragm 6 2,7 Urinary bladder 2 0,9 Main vessels 10 4,5 Total 221 100,0 Injury location n % Abdomen 16 17,8 Chest + abdomen 15 16,7 Chest + abdomen + limbs 17 18,9 Abdomen + limbs 8 8,9 Head + chest + abdomen 14 15,6 Abdomen + pelvis + limbs 5 5,6 Head + chest + abdomen + limbs 5 5,6 Head + abdomen + limbs 2 2,2 Head + neck + chest + abdomen + pelvis + limbs 3 3,3 Head + neck + chest + abdomen + limbs 2 2,2 Chest + abdomen + pelvis 3 3,3 Total 90 100 Table 5. Postoperative complications in BPIs patients Abbreviations AIS: Abbreviated Injury Scale AST: advanced surgical team AAST: American Association for the Surgery of Trauma BPIS: battlefield pancreatic injury DCS: damage control surgery ERCP: endoscopic retrograde cholangiopancreatography EPF: external pancreatic fistula FAST: focused assessment with sonography in trauma ISS: Injury Severity Score ICU: intensive care unit ICG-FA: indocyanine green fluorescent angiography MPD: main pancreatic duct MMCCNRAFU: Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine MSCT: multispiral computed tomography OEF: Operation enduring freedom OIF: Operation Iraqi Freedom OIS: Organ Injury Scale PPC: pancreatic pseudocyst PTAP: post-traumatic acute pancreatitis SIRS: systemic inflammatory response syndrome WSES: World Society of Emergency Surgery Declarations Ethics approval and consent to participate Research was performed in compliance with the Helsinki Declaration and was approved by the ethics committee of Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, and the informed consent forms were obtained from all patients. All individual paticipants signed an informed consent form authorising the use of clinical data in scientific activities. These informed consent forms are an integral part of each inpatient's medical record. Clinical trial number Not applicable. Consent for publication Not applicable. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to data collected on Ukrainian Armed Forces personnel and during combat operations in Ukraine is currently restricted by law, but are available from the corresponding author on reasonable request. The publication of this scientific material does not violate Ukrainian legislation in force during this special period. Following the relevant decision and permission after the end of the war in Ukraine, the data will be publicly available. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors' contributions SAS conceived and designed the study. SAS, EMK, IPK, VVM and VVN developed the overall research methodology. Figures and tables were prepared by VVN, OVS, OVY and OHP. SAS and VVN drafted the manuscript. EMH, IPK, VVM and OHP contributed to revisions of the manuscript. SAS, OVS and OVY contributed to the acquisition and analysis of data. All authors read and approved the final manuscript for publication. Acknowledgements Not applicable. Authors' information EMK– Hero of Ukraine, Ph.D, M.D., Colonel of Medical Service, Head of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, 5 Kultury St., Kharkiv, 61000, Ukraine; Associate Professor of the Department of Surgery №4 of the Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; tel:+380676923120; E-mail: [email protected] ; ORCID: 0000-0003-1258-1319. IPK – M.D., Professor, Major General of Medical Service, Corresponding Member of the National Academy of Medical Sciences of Ukraine, Head of Kyiv City Clinical Hospital No. 8, 8 Yuriy Kondratyuk Street, Kyiv, 04201, Ukraine; tel:+380503580279; E-mail: [email protected] ; ORCID: 0000-0002-8199-5083 VVM – M.D., Professor, Head of the Department of Surgery №4 of the Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; surgeon at the Surgical Department of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, 5 Kultury St., Kharkiv, 61000, Ukraine; tel: +380679518382; E-mail: [email protected] ; ORCID: 0000-0002-4224-0294; VVN ­­– M.D., Professor, Colonel of Medical Service, Head of the Emergency Care Clinic (and Reception and Evacuation) of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, 5 Kultury St., Kharkiv, 61000, Ukraine; Professor of the Department of Surgery №4 of the Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; tel: +380504523273; E-mail: [email protected] ; ORCID: 0000-0003-4540-5207. SAS ­­­– Ph.D, M.D., Colonel of Medical Service, Deputy Unit Commander - Leading Surgeon of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, 5 Kultury St., Kharkiv, 61000, Assistant of the Department of Surgery №4 of Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; tel: +380501958371; E-mail: [email protected] ; ORCID: 0000-0002-1689-2213. OVY – M.D., Colonel of Medical Service, Chief Radiologist of the Armed Forces of Ukraine, Head of the Clinic of Computer and Radiological Diagnostics of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, 5 Kultury St., Kharkiv, 61000, Ukraine; tel: +380679026224; E-mail: [email protected] ; ORCID: 0009-0008-9474-7477. OVS ­– Ph.D, M.D., Head of the Endoscopy Department of the Kharkiv City Clinical Multiprofile Hospital No. 25, 122 Oleksandrivskiy avenue, Kharkiv, 61115, Ukraine; Associate Professor of Department of Surgery №1 of the Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; tel: +380506211833; E-mail: [email protected] ; ORCID: 0000-0001-7709-2407/ OHP – Ph.D, M.D., Associate Professor, Associate Professor of Department of Surgery №4 of the Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; tel: +380506321104; E-mail: [email protected] ; ORCID: 0000-0001-9411-994X. References Lurin I, Khoroshun E, Negoduiko V, Makarov V, Shypilov S, Boroday V, et al. Retrieval of ferromagnetic fragments from the lung using video-assisted thoracoscopic surgery and magnetic tool: a case report of combat patient injured in the war in Ukraine. Int J Emerg Med. 2023;16(1):51., Kazmirchuk A, Yarmoliuk Y, Lurin I, Gybalo R, Burianov O, Derkach S, et al. Ukraine’s experience with management of combat casualties using NATO’S four-tier “changing as needed” healthcare system. World J Surg. 2022. https://doi.org/10.1007/s00268-022-06718-3., Gumeniuk K, Lurin IA, Tsema I, Malynovska L, Gorobeiko M, Dinets A. Gunshot injury to the colon by expanding bullets in combat patients wounded in hybrid period of the Russian-Ukrainian war during 2014–2020. BMC Surg. 2023;23(1):23. Tsymbaliuk V, Lurin I, Gumeniuk K, Herasymenko O, Furkalo S, Oklei D, et al. Modeling of wound ballistics in biological tissues simulators. Med Perspekt. 2023;28(1):37–48. Golovko S, Gybalo R, Lurin I, Taraban I, Kobirnichenko A, Ganiuk V, et al. Penetrating gunshot wounds to the penis: a case report of combat patient injured in the war in Ukraine. Int J Emerg Med. 2023;16(1):5. Dave S, Toy FK, London S. Pancreatic Trauma. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459365/. Volodymyr M Kopchak, Yuriy O Khilko, Liudmyla O Pererva, Artem O Danyliuk, Iurii Snopok, Pancreatic Battlefield Injuries During Ukraine War, Military Medicine, 2025;, usaf084, https://doi.org/10.1093/milmed/usaf084, Vertrees A, Elster E, Jindal R, Ricordi C, Shriver C. Surgical management of modern combat-related pancreatic injuries: traditional management and unique strategies. Mil Med. 2014;179:315–9., G E Chinnery, J E J Krige, U K Kotze, P Navsaria, A Nicol, Surgical management and outcome of civilian gunshot injuries to the pancreas, British Journal of Surgery, Volume 99, Issue Supplement_1, January 2012, Pages 140–148, https://doi.org/10.1002/bjs.7761, Degiannis E, Levy RD, Velmahos GC, Potokar T, Florizoone MG, Saadia R. Gunshot injuries of the head of the pancreas: conservative approach. World J Surg 1996; 20: 68–71.; Degiannis E, Levy RD, Potokar T, Lennox H, Rowse A, Saadia R. Distal pancreatectomy for gunshot injuries of the distal pancreas. Br J Surg 1995; 82: 1240–1242.; Madiba TE, Mokoena TR. Favourable prognosis after surgical drainage of gunshot, stab or blunt trauma of the pancreas. Br J Surg 1995; 82: 1236–1239. J.E.J. Krige, U.K. Kotze, A.J. Nicol, P.H. Navsaria. Isolated pancreatic injuries: an analysis of 49 consecutive patients treated at a level 1 trauma centre. J Visc Surg, 152 (2015), pp. 349-355 http://dx.doi.org/10.1016/j.jviscsurg.2015.09.010, M. Heuer, B. Hussmann, R. Lefering, G. Taeger, G.M. Kaiser, A. Paul, et al. Pancreatic injury in 284 patients with severe abdominal trauma: outcome, course, and treatment algorithm. Arch Surg, 396 (2011), pp. 1067-1076., Petrone P, Moral Álvarez S, González Pérez M, Ceballos Esparragón J, Marini CP. Traumatismos de páncreas: manejo y revisión de la literatura. Cir Esp. 2017;95:123–130., K. Søreide. Pancreas injury: the good, the bad and the ugly. Injury, 46 (2015), pp. 827-829 http://dx.doi.org/10.1016/j.injury.2015.03.034, A.A. Memon, H. Zafar, R. Raza, G. Murtaza. Traumatic pancreatic injury – an elusive diagnosis: experience from a developing country urban trauma referral centre. J Pak Med Assoc, 63 (2013), pp. 440-444, Chui JN, Kotecha K, Gall TM, Mittal A, Samra JS. Surgical management of high-grade pancreatic injuries: Insights from a high-volume pancreaticobiliary specialty unit. World J Gastrointest Surg. 2023 May 27;15(5):834-846. doi: 10.4240/wjgs.v15.i5.834. PMID: 37342855; PMCID: PMC10277947. Michael Clemens, MD, Thomas Mitchell, MD, Timothy Vreeland, MD, Christopher White, Lorne Blackbourne. Combat associated Pancreatic injuries: 2002-2011 https://www.sages.org/meetings/annual-meeting/abstracts-archive/combat-associated-pancreatic-injuries-2002-2011/ Borden Institute Walter Reed Army Medical Center: Emergency War Surgery, pp 17.10–17.11. Maryland, Borden Institute, 2004. Availableat http://www.cs.amedd.army.mil/borden; accessed September 27, 2013. Lee PH, Lee SK, Kim GU, et al. Outcomes of hemodynamically stable patients with pancreatic injury after blunt abdominal trauma. Pancreatology 2012;12(6):487–492. Aprahamian C, Thompson BM, Towne JB, Darin JC. The effect of a paramedic system on mortality of major open intra-abdominal vascular trauma. J Trauma 1983;23:687-90. Coccolini, F., Kobayashi, L., Kluger, Y. et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 14, 56 (2019). https://doi.org/10.1186/s13017-019-0278-6), Eastern Association for the Surgery of Trauma (EAST) (https://www.east.org/search?q=pancreatic), Western Trauma Association Algorithms (https://westerntrauma.org//docs/ Management%20of%20 Pancreatic %20Injuries.png Wang GF, Li YS, Li JS. Damage control surgery for severe pancreatic trauma. Hepatobiliary Pancreat Dis Int 2007; 6: 569–571. Brenner M, Bochicchio G, Bochicchio K, Ilahi O, Rodriguez E, Henry S et al. Long-term impact of damage control laparotomy: a prospective study. Arch Surg 2011; 146: 395–399. ; Stawicki SP, Schwab CW. Pancreatic trauma: demographics, diagnosis, and management. Am Surg 2008; 74: 1133–1145. J.C. Vasquez, R. Coimbra, D.B. Hoyt, D. Fortlage. Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center. Injury, 32 (2001), pp. 753-759; J.E. Krige, E. Jonas, S.R. Thomson, U.K. Kotze, M. Setshedi, P.H. Navsaria, et al. Resection of complex pancreatic injuries: benchmarking postoperative complications using the accordion classification World J. Gastrointest. Surg., 9 (2017), pp. 82-91, N. Mansfield, K. Inaba, R. Berg, E. Beale, E. Benjamin, L. Lam, et al. Early pancreatic dysfunction after resection in trauma: an 18-year report from a level i trauma center J. Trauma Acute Care Surg., 82 (2017), pp. 528-533 Laura L. Meijer, Yrjö Vaalavuo, Sara Regnér, Ville Sallinen, Aurora Lemma, Urban Arnelo, Roberto Valente, Sofia Westermark, David An, John A.G. Moir, Ellen A. Irwin, Esther A. Biesel, Ulrich T. Hopt, Stefan Fichtner-Feigl, Uwe A. Wittel, Maximilian Weniger, Henning Karle, Frank W. Bloemers, Robert Sutton, Richard M. Charnley, Dietrich A. Ruess, Peter Szatmary, Clinical characteristics and long-term outcomes following pancreatic injury – An international multicenter cohort study, Heliyon, Volume 9, Issue 6, 2023, e17436, ISSN 2405-8440, https://doi.org/10.1016/j.heliyon.2023.e17436. Linsenmaier U, Wirth S, Reiser M, Körner M. Diagnosis and classification of pancreatic and duodenal injuries in emergency radiology. Radiographics. 2008;28:1591–602. Mahajan A, Kadavigere R, Sripathi S, Rodrigues GS, Rao VR, Koteshwar P. Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review. Injury. 2014;45:1384–93. Phelan HA, Velmahos GC, Jurkovich GJ, Friese RS, Minei JP, Menaker JA, Philp A, Evans HL, Gunn ML, Eastman AL, et al. An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study. J Trauma. 2009;66(3):641–646; discussion 6–7. Velmahos GC, Tabbara M, Gross R, Willette P, Hirsch E, Burke P, Emhoff T, Gupta R, Winchell RJ, Patterson LA, et al. Blunt pancreatoduodenal injury: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Arch Surg. 2009;144(5):413–419; discussion 9–20. Teh SH, Sheppard BC, Mullins RJ, Schreiber MA, Mayberry JC. Diagnosis and management of blunt pancreatic ductal injury in the era of high-resolution computed axial tomography. Am J Surg. 2007;193(5):641–643; discussion 3. Elbanna KY, Mohammed MF, Huang S-C, Mak D, Dawe JP, Joos E, et al. Delayed manifestations of abdominal trauma: follow-up abdominopelvic CT in posttraumatic patients. Abdom Radiol. 2018;43:1642–55. Rekhi S, Anderson SW, Rhea JT, Soto JA. Imaging of blunt pancreatic trauma. Emerg Radiol. 2010;17:13–9. Stewart BT, Sandstrom CK, O’Keefe G, Balmadrid B, Johnson GE. Multidisciplinary diagnosis and management of pancreatic trauma. Dig Dis Interv. 2018;02:179–92 Choi AY, Bodanapally UK, Shapiro B, Patlas MN, Katz DS. Recent advances in abdominal trauma computed tomography. Semin Roentgenol. 2018;53:178–86. Bhasin DK, Rana SS, Rawal P. Endoscopic retrograde pancreatography in pancreatic trauma: need to break the mental barrier. J Gastroenterol Hepatol. 2009;24(5):720–728.; Kim HS, Lee DK, Kim IW, Baik SK, Kwon SO, Park JW, Cho NC, Rhoe BS. The role of endoscopic retrograde pancreatography in the treatment of traumatic pancreatic duct injury. Gastrointest Endosc. 2001;54(1):49–55. Chen G, Yang H. Management of duodenal trauma. Chinese J Traumatol. 2011;14:61–4. Hofmann LJ, Learn PA, Cannon JW. Intraoperative ultrasound to assess for pancreatic duct injuries. J Trauma Acute Care Surg. 2015;78:888–91. Patel MQ, Osterkamp JT, Buitendag JJ, Forgan TR, Steyn E. Indocyanine green fluorescence angiography in the management of intestinal injuries following penetrating abdominal trauma: a case-control study comparing postoperative outcomes. Int J Surg. 2024 Dec 1;110(12):7624-7629. doi: 10.1097/JS9.0000000000002096. PMID: 39434689; PMCID: PMC11634155. F. Rodríguez, A. García, C. Ordoñez, C. Vernaza, J.P. Herrera, J.C. Puyana. Trauma pancreático penetrante severo-revisión retrospectiva de una serie de casos manejados con una estrategia simplificada en un centro de trauma nivel 1 Panamerican J Trauma Crit Care Emerg Surg, 4 (2015), pp. 147-154) Potoka DA, Gaines BA, Leppäniemi A, Peitzman AB. Management of blunt pancreatic trauma: what's new? Eur J Trauma Emerg Surg. 2015;41:239–250. Lopez PP, Benjamin R, Cockburn M, Amortegui JD, Schulman CI, Soffer D, et al. Recent trends in the management of combined pancreatoduodenal injuries. Am Surg. 2005;71:847–852. Brotman S, Cisternino S, Myers RA, Cowley RA. A test to help diagnosis of rupture in the injured duodenum. Injury. 1981;12:464–5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7462542","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":533191245,"identity":"edddbde0-95e9-4f01-b926-8f64f23e7f92","order_by":0,"name":"Eduard Mykolaiovych Khoroshun","email":"","orcid":"","institution":"Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine","correspondingAuthor":false,"prefix":"","firstName":"Eduard","middleName":"Mykolaiovych","lastName":"Khoroshun","suffix":""},{"id":533191246,"identity":"e1d18c53-11db-4a31-a7fc-51e41e70fadd","order_by":1,"name":"Ihor Petrovych Khomenko","email":"","orcid":"","institution":"City Clinical Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ihor","middleName":"Petrovych","lastName":"Khomenko","suffix":""},{"id":533191247,"identity":"66efb3f5-b03b-47e8-8b39-17cec911aa36","order_by":2,"name":"Vitalii Volodymyrovych Makarov","email":"","orcid":"","institution":"Kharkiv National Medical University","correspondingAuthor":false,"prefix":"","firstName":"Vitalii","middleName":"Volodymyrovych","lastName":"Makarov","suffix":""},{"id":533191248,"identity":"4aa6af77-7e2b-4aa3-a3fb-df68c8b632b4","order_by":3,"name":"Volodymyr Volodymyrovych Negoduyko","email":"","orcid":"","institution":"Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine","correspondingAuthor":false,"prefix":"","firstName":"Volodymyr","middleName":"Volodymyrovych","lastName":"Negoduyko","suffix":""},{"id":533191252,"identity":"3ba186f1-84b6-42e7-882d-40a3600e3283","order_by":4,"name":"Serhii Anatoliiovych Shipilov","email":"","orcid":"","institution":"Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine","correspondingAuthor":false,"prefix":"","firstName":"Serhii","middleName":"Anatoliiovych","lastName":"Shipilov","suffix":""},{"id":533191254,"identity":"4bc626c1-533d-4a26-a159-445a0fcd69da","order_by":5,"name":"Oleksandr Volodymyrovych Yasinskyi","email":"","orcid":"","institution":"Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine","correspondingAuthor":false,"prefix":"","firstName":"Oleksandr","middleName":"Volodymyrovych","lastName":"Yasinskyi","suffix":""},{"id":533191255,"identity":"b41e5067-0e79-40ba-8050-65b8e18c3cf8","order_by":6,"name":"Oleg Valentinovich Shadrin","email":"","orcid":"","institution":"Kharkiv City Clinical Multiprofile Hospital","correspondingAuthor":false,"prefix":"","firstName":"Oleg","middleName":"Valentinovich","lastName":"Shadrin","suffix":""},{"id":533191256,"identity":"a4efc796-7573-41de-b7e3-ae4d24daebfb","order_by":7,"name":"Oleksii Hennadiyovych Petiunin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYDACCRjJzMD4sAEiZkCElgSwFmZDUrSAmWySRGnhl25ge/Dxh0XidnbeY5Uzd2xLbGBv3ibB2GaHU4vknAPshjMSJBJ3NvOl3dx45nZiA8+xMqCWZJxaDG4ksEnzALVsOMxjdvNhG1CLRI4ZUAszfi1/oFoKwVrk34C01OPXwgDVwrgRbAsPSMth3H6Zkdhu2JMmYQzUYiw5s+22cRtPWrFFwrnjOLXwSyQfe/DDpk52w/kzhh97227L9rMf3njjQ1k1Ti0MDIxtqHw2EJGARwNMzSgYBaNgFIwC3AAATmNR27hv9LcAAAAASUVORK5CYII=","orcid":"","institution":"Kharkiv National Medical University","correspondingAuthor":true,"prefix":"","firstName":"Oleksii","middleName":"Hennadiyovych","lastName":"Petiunin","suffix":""}],"badges":[],"createdAt":"2025-08-26 11:38:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7462542/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7462542/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":94447911,"identity":"e8060191-a5a7-411a-92ec-4d5fab450bd6","added_by":"auto","created_at":"2025-10-27 14:36:15","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1308152,"visible":true,"origin":"","legend":"","description":"","filename":"BattlefieldpancreaticinjuriesduringthewarinUkraine1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/df2f5ffb4c98e2ce210e1788.docx"},{"id":94447947,"identity":"34f5fe92-0b66-4049-8740-f3bab767b63d","added_by":"auto","created_at":"2025-10-27 14:36:17","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9940,"visible":true,"origin":"","legend":"","description":"","filename":"99a642cb90da44e89a0cba4a588d8aea.json","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/9583c4768fc15b55d1789236.json"},{"id":94448248,"identity":"6b670906-8b86-4fe7-a1b6-b3c84cbe8aa1","added_by":"auto","created_at":"2025-10-27 14:36:36","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":147148,"visible":true,"origin":"","legend":"","description":"","filename":"99a642cb90da44e89a0cba4a588d8aea1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/b940fd0ad03537d93edb6046.xml"},{"id":94447788,"identity":"65e67c77-9ebd-4316-b2ad-bd224db18fa5","added_by":"auto","created_at":"2025-10-27 14:36:08","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":368432,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/f652b33fc616c0aeece0846b.jpeg"},{"id":94448352,"identity":"8e3b2405-2a1c-41bd-82aa-96d23e683e45","added_by":"auto","created_at":"2025-10-27 14:36:46","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":211405,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/214d3957e3771a9ce6723577.jpeg"},{"id":94447312,"identity":"26cfc226-2ae0-402f-894d-cc2db51e78a2","added_by":"auto","created_at":"2025-10-27 14:35:39","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":62819,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/1b44bb8d677cd7d817d48c17.jpeg"},{"id":94448241,"identity":"f01155a2-a80c-4b9b-b29c-5fd8d0707ee4","added_by":"auto","created_at":"2025-10-27 14:36:35","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":312008,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/7b0bd73bf3d8f151d10ccdd0.jpeg"},{"id":94448249,"identity":"92884151-7074-495f-b95f-aceac76c39db","added_by":"auto","created_at":"2025-10-27 14:36:36","extension":"jpeg","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":291794,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/a8cd0760cc0b2e784df2116d.jpeg"},{"id":94447901,"identity":"59874b54-2c65-4bb2-9ab0-b935e89acce8","added_by":"auto","created_at":"2025-10-27 14:36:14","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":221074,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/4b0bcca6b4cbae0a5d23779e.png"},{"id":94448344,"identity":"609fdd53-a284-4c5e-9f78-f31100ba53f8","added_by":"auto","created_at":"2025-10-27 14:36:46","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":227502,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/66615230bea89eeb47d25596.png"},{"id":94448262,"identity":"9219302d-4574-49d1-a3cf-125a6bf4fde9","added_by":"auto","created_at":"2025-10-27 14:36:38","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":53071,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/189ee9138590244d31942160.png"},{"id":94448092,"identity":"9b611a38-0505-4d38-bc02-dd7a567e8a90","added_by":"auto","created_at":"2025-10-27 14:36:25","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":350903,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/89a67b61137d2a040574c1a0.png"},{"id":94448335,"identity":"8e521444-cd6a-4101-ad8c-a6cc55d18a13","added_by":"auto","created_at":"2025-10-27 14:36:42","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":98925,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/7d75a1dcf1aebc979a6b2f9d.png"},{"id":94448263,"identity":"378a5939-d44b-4887-bc4f-49524a179ea6","added_by":"auto","created_at":"2025-10-27 14:36:38","extension":"xml","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":147572,"visible":true,"origin":"","legend":"","description":"","filename":"99a642cb90da44e89a0cba4a588d8aea1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/066bbd40bd785e896b921cff.xml"},{"id":94448255,"identity":"c0c4517b-2074-48d4-8a5f-0c043083ec7c","added_by":"auto","created_at":"2025-10-27 14:36:37","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":157195,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/16509166e27f64d9e31b0e9d.html"},{"id":94448393,"identity":"34e20cb3-8f10-44da-bef6-c803c839aa50","added_by":"auto","created_at":"2025-10-27 14:36:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":484140,"visible":true,"origin":"","legend":"\u003cp\u003eMSCT of patients with BPIS.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/98108db1210454ebd84a0cee.png"},{"id":94447717,"identity":"86d2740a-ce59-42c4-a928-01b0109d9e38","added_by":"auto","created_at":"2025-10-27 14:36:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":510123,"visible":true,"origin":"","legend":"\u003cp\u003eERCP and intraoperative ultrasonography of patients with BPIs\u003c/p\u003e\n\u003cp\u003ea. ERCP with contrast extravasation due to a perforating injury of the pancreatic body with damage to the MPD OIS III; b. Intraoperative photo of a perforating injury of the pancreatic body with damage to the MPD OIS III; c. Intraoperative ultrasonography of an injury to the pancreatic head with damage to the MPD OIS III.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/0f133cda5afa807252422c54.png"},{"id":94447769,"identity":"a17189db-cc5b-432c-a040-22768fda90fb","added_by":"auto","created_at":"2025-10-27 14:36:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":173924,"visible":true,"origin":"","legend":"\u003cp\u003eICG-FA of patients with BPIs\u003c/p\u003e\n\u003cp\u003ea, b. ICG-FA of the pancreas in penetrating abdominal trauma.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/9ad60826198215dda4d79998.png"},{"id":94447903,"identity":"b42011ad-b398-470e-8cdf-40fa34bf812d","added_by":"auto","created_at":"2025-10-27 14:36:15","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":948203,"visible":true,"origin":"","legend":"\u003cp\u003eTypes of BPIs\u003c/p\u003e\n\u003cp\u003ea. Intraoperative photo of a blind wound to the pancreatic body, OIS II; b. Intraoperative photo. Distal transection of the pancreas at the level of the pancreatic body, OIS III; c. Intraoperative photo of a perforating pancreatic wound with damage to the MPD, OIS II; d. Intraoperative photo. Explosive trauma with distal transection of the pancreas at the level of the pancreatic body, OIS III.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/d5d9cf50b84dbd2755ac8ecb.png"},{"id":94448396,"identity":"4cd400b6-447a-4497-918a-1982a82bb59f","added_by":"auto","created_at":"2025-10-27 14:36:50","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":248442,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart for the diagnosis and treatment of BPIs.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/057b604e6a561b64ecde3413.png"},{"id":104431468,"identity":"a52e44f1-834d-4d9c-8e23-b39a4d8994a7","added_by":"auto","created_at":"2026-03-11 15:42:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3778844,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7462542/v1/4d55206a-ca62-4669-ae97-5785fe73336d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Features of diagnosing battlefield pancreatic injuries during the war in Ukraine","fulltext":[{"header":"Background","content":"\u003cp\u003eThe large-scale armed aggression of the Russian Federation against Ukraine has resulted in serious injuries among military personnel and civilians [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The severity of combat injuries is associated with the enemy's use of high-tech new types of weapons and the specific characteristics of wound ballistics [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Exploded and gunshot wounds to the abdomen are among the most complex types of combat trauma in military surgery [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. According to our clinical observations, the number of gunshot wounds to the abdomen in the overall structure of combat injuries during the Russian‒Ukrainian war of 2022\u0026ndash;2024 was 7.6\u0026ndash;8.5%.\u003c/p\u003e\u003cp\u003ePancreatic injury is rare as it has been reported to occur as low as 0.2% to 1.1% of all trauma. Sixty-three percent are from penetrating gunshot and stab wounds while the remaining 37% are consequences of blunt abdominal trauma. The incidence of pancreatic injury in abdominal trauma is cited as low as 3% to 12% and 0.2% to 2% in all trauma [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA special group of patients with battlefield abdominal trauma consists of military personnel and civilians with battlefield pancreatic injuries (BPIs). Analysing the experience of treating gunshot wounds in the pancreas, it is not known exactly which therapeutic and diagnostic algorithm for the treatment of this type of injury leads to the most favourable results. According to a series of published articles on BPIs, most focus on blunt trauma and stab wounds during peacetime. A small number of articles have specifically valuated the results of treatment for gunshot wounds to the pancreas [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. On the bases of the experience of combat operations OIF (Operation Iraqi Freedom) and OEF (Operation Enduring Freedom), there is a general analysis of the characteristics of BPIS treatment wartime without a clear treatment and diagnostic algorithm [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Current recommendations for BPIs in emergency war surgery are limited and focus on the treatment of long-term complications [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe most important determinant of the outcome of treatment for pancreatic trauma is the time from injury to final diagnosis. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The diagnostic algorithm in accordance with the level of care for BPIs has not been described in the available literature.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe aim\u003c/b\u003e of this study is to demonstrate the experience of diagnosing BPIs during Russia's large-scale invasion of Ukraine (2022\u0026ndash;2024) under the conditions of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, Kharkiv (MMCCNRAFU).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis article presents a retrospective analysis of the use of various methods for diagnosing battlefield abdominal trauma in patients with abdominal injuries at the MMCCNRAFU from 2022\u0026ndash;2024. The inclusion criteria were military personnel and civilians who had suffered combat abdominal trauma, which was confirmed intraoperatively or via special imaging methods. Battlefield abdominal trauma during combat operations with a treatment duration at the MMCCNRAFU of more than 5 days until discharge or evacuation to the next level of medical care (Regional Medical Centre). The exclusion criteria were patients with BPIs with a treatment period of up to 5 days, and incomplete data in the accompanying documentation or medical records of the hospitalized patient, which made it impossible to analyse the data under study. Data on the diagnosis and treatment of patients with BPIs, including surgical, resuscitation, radiological, endoscopic, and multidisciplinary clinic reports, were collected retrospectively from inpatient medical records.\u003c/p\u003e\u003cp\u003eThese included demographic indicators (age, sex), distribution by mechanism and damaging factors of injury, severity of general status according to the Abbreviated Injury Scale (AIS), overall severity of injury according to the Injury Severity Score (ISS), number and location of combined intra- or extraperitoneal injuries, injuries to the pancreas (amylase peak, location of injury, World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) severity assessment), diagnostic methods (general clinical blood tests, biochemical blood analysis with determination of serum alpha-amylase, ultrasonography of the abdominal organs according to the Focused Assessment with Sonography in Trauma (FAST) protocol, X-ray of the chest, abdomen and pelvis, endoscopic retrograde cholangiopancreatography (ERCP), indocyanine green fluorescent angiography (ICG-FA), intraoperative revision of the pancreato-duodenal complex), treatment (conservative, endoscopy, surgical intervention) and treatment outcomes (mortality, duration of hospital stay).\u003c/p\u003e\u003cp\u003eThe diagnosis of BPI was performed via multispiral computed tomography (MSCT) of the abdominal cavity or intraoperatively (in the case of initial surgery in the intensive care unit). The decision to perform primary laparotomy depended on the hemodynamic status at the time of admission and/or the presence of concomitant injuries requiring surgical examination. Intraoperative examination of the pancreas was performed only in stable patients. Damage to the main pancreatic duct was diagnosed on a routine basis. In cases of severe physiological disorders (hemodynamic instability, hypothermia, acidosis), a limited laparotomy was performed via the \u0026lsquo;damage control surgery\u0026rsquo; (DCS) approach.\u003c/p\u003e\u003cp\u003eContrast-enhanced MSCT was routinely performed for all patients who were stable at the time of admission to the MMCCNRAFU. When deciding on selective nonoperative management (SNOM), patients with pancreatic trauma are cured according to the acute pancreatitis protocol. The severity of pancreatic injury was assessed via the AAST Organ Injury Scale (OIS). Complications, both general and organ-specific, which directly related to pancreatic injury were analysed separately. The organ-specific complications observed were bleeding, posttraumatic acute pancreatitis (PTAP), peritonitis, external pancreatic fistula (EPF), and pancreatic pseudocyst (PPC). Complications were considered serious when they required surgical or interventional treatment or intensive care, corresponding to Dindo-Clavien grade III or higher. PTAP was defined as a plasma amylase level above three times the normal value for three or more consecutive days in combination with characteristic clinical symptoms. Peritonitis was defined as a generalized complication associated with systemic inflammatory response syndrome (SIRS).\u003c/p\u003e\u003cp\u003ePostoperative EPF was defined as drainage fluid with amylase levels at least three times greater than normal. The surgical technique included a complete examination of the pancreas and assessment of the integrity of the main pancreatic duct (MPD), especially if there were signs of pancreatic trauma, including fluid accumulation in the omental bursa, the presence of bile in the retroperitoneal space, steatonecrotic spots on the peritoneum, and hematoma located in the pancreas area. Length of hospital stay and length of stay in the intensive care unit (ICU) were expressed in calendar days.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong all patients with penetrating combat abdominal trauma, BPIS was diagnosed in 117 (8.7%) patients. Ninety patients were included for further analysis. Due to incomplete data and short treatment durations, 27 patients were excluded. All patients were male. The average age of the patients was 39.1\u0026plusmn;3.4 years. The average time from injury to evacuation to the appropriate level of medical care (R2-4) was 11.6 hours (range 2-48). The diagnostic algorithm corresponded to the patient\u0026apos;s haemodynamic status and the material, technical and personnel capabilities of individual levels of medical care (R2-4). According to the international AIS scale, 80 (88.9%) victims were hospitalized in severe and profound conditions. The overall severity of injuries was determined via the ISS scale, with an average ISS of 28.8 (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. Severity of injuries according to the ISS.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eSeverity according to the ISS scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e9 \u0026ndash; 15 \u0026nbsp;Moderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e4,4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e16 \u0026ndash; 24 Severe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e38,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026gt;/=25 \u0026nbsp;Profound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e56,7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe associated injuries to the abdominal organs and structures of the combined injuries are presented in\u0026nbsp;Table 2.\u003c/p\u003e\n\u003cp\u003eThe distributions by location of pancreatic injury and severity according to the AAST-OIS are presented in Table 3.\u003c/p\u003e\n\u003cp\u003eTable 3. Location of pancreatic injury and severity according to the AAST-OIS\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eLocation of pancreatic injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eHead\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e18,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eHead and tail\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eBody\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e14,4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eBody and tail\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e7,8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eTail\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e55,6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eIsthmus and Body\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e1,1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eGrade by AAST-OIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eGrade I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e28,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eGrade II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e38,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eGrade III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e23,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eGrade IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e5,6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e100,0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFAST of the abdominal cavity in BPIs was determined to be positive in 79 (87.7%) victims.\u003c/p\u003e\n\u003cp\u003eOn the basis of the results of preoperative ultrasound examination of the abdominal organs, BPIS was diagnosed in 57 (63.3%) patients.\u003c/p\u003e\n\u003cp\u003eAccording to the results of X-ray examination of the abdominal organs, 57 (63.3%) patients had foreign bodies detected in the projection of the pancreas.\u003c/p\u003e\n\u003cp\u003eElevated serum amylase levels in patients with BPIs were detected in 46 (51.5%) patients with an average value of 183 U/L.\u003c/p\u003e\n\u003cp\u003eMSCT was performed in all 90 (100%) patients with BPIS. Direct signs of BPIS were the presence of foreign bodies (fragments, bullets, and other wounding projectiles) in the pancreatic parenchyma, which was detected in 57 (63.3%) patients (Fig.1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDirect signs of pancreatic damage also included rupture, focal enlargement, or hematoma of the pancreas coinciding with the trajectory of the wound channel (Fig. 1a, b, c).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the case of pancreatic rupture, complete or partial loss of pancreatic structure can be identified (Fig. 1d, e, f).\u003c/p\u003e\n\u003cp\u003eIndirect MSCT signs of pancreatic damage included nonspecific peripancreatic fluid (Fig. 1f) in the right pararenal space or in the omental bursa cavity, peripancreatic fat consolidation, and thickening of the left anterior renal fascia.\u003c/p\u003e\n\u003cp\u003eTo assess the condition of the MPD at BPI 43 (47.7%), patients underwent ERCP (Fig. 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring laparotomy to diagnose parenchymal damage or the condition of the MPD in cases of small wounds of the pancreas located in the projection of the MPD, intraoperative ultrasonography of the pancreas was performed in 26 (28.8%) patients (Fig. 2c).\u003c/p\u003e\n\u003cp\u003eTo determine the viability of the parenchyma of the pancreas, visualize fluorescent structures in real time with the determination of optimal tissue perfusion for penetrating abdominal wounds with BPI and develop a surgical strategy, ICG-FA was used in 8 (8.8%) patients (Fig. 3).\u003c/p\u003e\n\u003cp\u003eAccording to the SNOM acute pancreatitis treatment protocol, 1 (1.2%) patient with explosive trauma with liver contusion and OIS I and severe skeletal trauma was cured. The patient was transferred on the third day in a moderate condition to the next stage of medical care. For 89 (98.8%) patients with penetrating abdominal trauma, intraoperative revision of the pancreato-duodenal complex was performed. The number of undiagnosed cases of BPIS after preoperative examination was 25 (27.7%) (Fig. 4).\u003c/p\u003e\n\u003cp\u003eA total of 89 (98.8%) patients underwent 248 surgical interventions for concomitant pancreatic injuries, which amounted to 2.8 operations per case, and 179 surgeries for the treatment of pancreatic injuries (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4. Surgery performed for patients with BPIs\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eType of surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eDCS I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eDCS III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eTamponade/drainage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e146\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eSuturing of the pancreas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eRemoval of pancreatic fragments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eDistal resection with splenectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eDistal resection with spleen preservation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eCentral resection of the pancreas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003ePancreatoduodenal resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003ePancreatectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e179\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTwenty (22.4%) patients had no general postoperative complications and had an average hospital stay of 7 days before discharge or transfer to the next stage of evacuation (Table 5). The remaining 70 (77.6%) patients had a total of 138 general complications, with a median of 2.6 complications per patient in this subgroup (range 1\u0026ndash;7) (Table 5).\u003c/p\u003e\n\u003cp\u003eOn the basis of the available study results, we propose a diagnostic algorithm for BPIs in accordance with the level of medical care (Fig. 5).\u003c/p\u003e\n\u003cp\u003eRole 2-3: In the case of a hemodynamically unstable patient with penetrating abdominal injury, an emergency laparotomy with revision of the omental bursa is performed to diagnose BPIS and other associated injuries.\u003c/p\u003e\n\u003cp\u003eSuch surgery is completed with a hemostatic manoeuver, tamponade of the damaged area of the pancreas and the formation of a closed laparostomy. The sensitivity of intraoperative revision of the abdominal organs for the diagnosis of BPIS during emergency laparotomy in hemodynamically unstable patients with penetrating abdominal wounds was 14 (60.8%). In hemodynamically stable patients, preoperative examination is available in the form of clinical and laboratory tests with determination of serum alpha-amylase, abdominal FAST, X-ray of the abdominal organs and diagnostic laparotomy as indicated. The sensitivity of the abbreviated diagnostic algorithm for diagnosing BPIs during emergency laparotomy in hemodynamically stable patients with penetrating abdominal wounds was 44 (77.2%).\u003c/p\u003e\n\u003cp\u003eRole 4: In the case of a hemodynamically unstable patient with penetrating abdominal injury, an emergency laparotomy with revision of the omental bursa is performed to diagnose BPIS and other associated injuries.\u003c/p\u003e\n\u003cp\u003eAll hemodynamically stable patients and all stabilized patients after preliminary treatment by the advanced surgical team (AST) underwent a complete clinical and instrumental examination.\u003c/p\u003e\n\u003cp\u003eThe priority is a clinical and laboratory examination and MSCT of the abdominal cavity and pelvis. If the injury was sustained within 12\u0026ndash;24 hours prior to hospitalization, MSCT with intravenous contrast was performed. On the basis of the results of the examination, ERCP is indicated if damage to the MPD is suspected.\u003c/p\u003e\n\u003cp\u003eThe most diagnostically valuable is a detailed (complete) intraoperative examination of the pancreato-duodenal complex in hemodynamically stable or stabilized patients during phase 3 of DCS. During emergency laparotomy with visual signs of acute pancreatitis, intraoperative ultrasonography and ICG-FA can be used for additional intraoperative examination of the pancreas. The sensitivity of the extended diagnostic algorithm for the diagnosis of severe acute pancreatitis was 89.98.8%.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eA special group of wounded patients during combat operations are those with penetrating abdominal wounds with BPIs. The diagnosis and treatment of patients with BPIs remains one of the most difficult and resource-intensive problems of medical care in combat conditions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The current guidelines for diagnosing abdominal trauma are based on the examination of patients in medical institutions of various levels at the peacetime [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. There is insufficient information on the analysis of BPIs in the available literature.\u003c/p\u003e\u003cp\u003eIn this study, which was conducted at the MMCCNRAFU during Russia's large-scale invasion of Ukraine from 2022\u0026ndash;2024, we confirmed that BPI was diagnosed in 8.7% of combat abdominal injuries. This differs sharply from a series of studies reporting that pancreatic injury occurs in 0.21\u0026ndash;5.37% of patients with penetrating abdominal trauma [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis may be due to the specific characteristics of wound ballistics, when the wound element crosses the abdominal cavity and/or retroperitoneal space, causing damage to the pancreas.\u003c/p\u003e\u003cp\u003ePatients with BPIs constitute a relatively homogeneous group of predominantly young adult males (the average age of patients was 39.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4 years), with minor or no concomitant pathology. Patients with BPIs are hospitalized at the MMCCNRAFU from the AST area of responsibility and directly from the battlefield or the site of injury by medical transport accompanied by a resuscitation team. Patients were delivered to the AST or the MMCCNRAFU with an average time from injury of 11.6 hours (range 2\u0026ndash;48), which is associated with the operational and tactical situation on the front line and the complexity of evacuating the wounded.\u003c/p\u003e\u003cp\u003eThe severity of patients with abdominal trauma is associated with a high incidence of combined severe injuries to the abdominal organs and major visceral vessels in penetrating abdominal trauma [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Multivisceral injury of the abdominal organs in pancreatic injury is the rule rather than the exception [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis is due to the overall impact of the shock wave on the body and the damaging effect of primary and secondary wounding elements during an explosion, with the potential for not only multiple abdominal injuries, but also the development of blast trauma and combined injuries to other locations (head, chest, pelvis, limbs, etc.) Krige et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] reported isolated lesions in only 11% of cases. In a study by Petrone P. et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], 9110 intra-abdominal lesions were diagnosed in 4559 patients with blast injuries (1.9 per patient). The most common combined intra-abdominal injuries included liver (20.9%), stomach (17.2%), and vascular (14.3%) injuries. Among combined injuries, 8.5% were duodenal damage, with a tendency to increase to 12%-21% in cases of penetrating trauma.\u003c/p\u003e\u003cp\u003eAmong extra-abdominal injuries, chest injuries predominated (44.5%), followed by musculoskeletal injuries (26.2%) and head injuries (17.5%) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, isolated BPIS was diagnosed in only 1 (1.1%) of 90 patients. All other patients had combined injuries. Combined intra-abdominal injuries were found in 89 (98.8%) patients. The most common intra-abdominal injuries were stomach injuries (38 (17.2%)); spleen injuries (36 (16.3%)); colon injuries (32 (14.5%)); liver injuries (31 (14.0%)); small intestine injuries (25 (11.3%)); and duodenum injuries (10 (4.5%)). Among the 90 victims with BPIs, 14 (15.5%) had damage to one other abdominal organ, 29 (32.2%) had damage to two organs, 30 (33.3%) had damage to three organs, 23 (25.5%) had damage to four organs, 12 (13.3%) had damage to five organs, 6 (6.6%) had damage to six organs, and 7 (7.7%) had damage to seven organs. Combined injuries to major vessels were diagnosed in 10 (11.1%) patients, including damage to the inferior vena cava in 3 (3.6%) patients, the renal artery and renal vein in 2 (2.4%) patients, the superior mesenteric artery and vein in 5 (6.0%) patients, the aorta in 1 (1.2%) patient, the portal vein in 1 (1.2%) patient, the splenic vein in 2 (2.2%) patients, the left gastric artery in 1 (1.2%) patient, the femoral artery and vein in 2 (2.4%) patients. A total of 74 (82.2%) of the wounded had extra-abdominal combat injuries and required a multidisciplinary approach. According to the analysis, 23 (25.5%) patients had 1 extra-abdominal injury, 41 (45.5%) of patients had 2, 5 (5.5%) patients had 3, 2 (2.2%) had 4, and 3 (3.3%) had 5 combined injuries to organs in other anatomical areas.\u003c/p\u003e\u003cp\u003eMost commonly (17 (18.9%)), the injured had a combination of chest, abdominal, and limb injuries. Isolated abdominal injuries were diagnosed in only 16 (17.8%) patients. A total of 90 patients had 336 combined injuries at various locations (3.7 injuries per patient), including 221 combined abdominal injuries (2.5 injuries per patient).\u003c/p\u003e\u003cp\u003ePancreatic injuries during combat operations have specific distribution patterns depending on the mechanism of injury. Gunshot wounds to the abdominal cavity predominated \u0026mdash; 77 (85.5%), of which 73 (81.1%) were shrapnel wounds and 4 (4.4%) were bullet wounds.\u003c/p\u003e\u003cp\u003eInjuries resulting from explosive trauma were diagnosed in 11 (12.2%) patients. Non firearm injuries were recorded in only 2.2% of the cases. This differs sharply from data recorded in the United States or South Africa [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], where the ratio of blunt to penetrating injuries is the opposite. In a review by Petrone P. et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], among 1,236 patients, closed trauma accounted for 59.8%, and penetrating trauma accounted for 40.2%. Among patients with penetrating trauma, only 59% were injured by firearms.\u003c/p\u003e\u003cp\u003eAccording to the results of the present study, mild BPI according to OIS I-II was diagnosed in 61 (67.8%) patients, and severe BPI with obstruction of MPD according to OIS III-V was diagnosed in 29 (32.2%) patients. Damage to the tail of the pancreas was more common (50 patients; 55.6%), and multiple injuries were detected in 10 (11.1%) patients. The distribution differs from the data reported by Laura L. et al. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], where pancreatic trauma was accompanied by damage to the MPD in 30.6% of cases. The high proportion of MPD damage among BPIs is associated with the characteristics of gunshot wounds with direct projectile impact, wounding, side impact and counterimpact. The formation of a wound channel with foci of contusion, destruction and deposition, and a zone of secondary molecular concussion with hypoxia and ischemia of the abdominal wall tissue contributes to damage to the MPD.\u003c/p\u003e\u003cp\u003eElevated amylase levels after abdominal trauma were previously considered indicators of pancreatic damage. However, upon hospitalization, normal blood amylase levels are found in 40% of patients with pancreatic trauma, and elevated levels are not specific to this type of trauma. Serum amylase may also be elevated in head, liver, and intestinal injuries, in alcohol abuse, and after pancreatic hypoperfusion [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. An increase in amylase levels more than 3 times after trauma may indicate pancreatic damage, so a series of follow-up tests is recommended. According to the results of our study, the reference values for α-amylase at hospitalization were detected in 32 (35.6%) patients with BPI.\u003c/p\u003e\u003cp\u003eLaboratory diagnosis with serum amylase measurement is neither sensitive nor specific for definitive screening or diagnosis of pancreatic injury, especially within the first 3\u0026ndash;6 hours after trauma. FAST of the abdomen is a quick and effective method for diagnosing free fluid and damage to parenchymal organs. However, it is nonspecific and therefore not useful for assessing BPIs. Ultrasonography is not recommended for the routine diagnosis of duodenopancreatic trauma according to WSES-AAST guidelines [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. According to our data, in 33 (36.7%) patients, it is impossible to visualize the pancreas clearly on the basis of ultrasonography results because of gas accumulation in the transverse colon in cases of penetrating abdominal injury.\u003c/p\u003e\u003cp\u003eThe two most important determinants of the outcome of pancreatic trauma treatment are the time from injury to final diagnosis and the condition of the MPD [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. MSCT is the diagnostic method of choice in patients with hemodynamically stable abdominal trauma for the diagnosis of pancreatic injury. The sensitivity for detecting pancreatic injury varies widely, ranging from 47% to 79% [\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe detection of MPD damage via MSCT is sensitive, ranging from 52% to 54% with a specificity ranging from 90% to 95%. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] A disadvantage of this method is the need to determine the ideal moment, since immediately after injury, the pancreas may appear normal in 20% to 40% of cases, which is performed within the first 12 hours [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Pancreatic injuries become more pronounced 12 to 24 hours after injury [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Repeated MSCT with a specific pancreatic phase of the pancreas (35\u0026ndash;40 seconds after iodine injection) helps in the diagnosis of MPD damage [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In our study, MSCT provided the most reliable information about the extent of pancreatic damage. However, in 30\u0026ndash;33.3% of patients with BPIS without foreign bodies in the parenchyma, mild BPI OIS I-II may be misdiagnosed by MSCT of the abdomen due to the absence of significant morphological changes, which is performed within the first 12 hours after combat trauma.\u003c/p\u003e\u003cp\u003eIf it is impossible to determine the severity of the injury via MSCT results or if there is marginal damage to the parenchyma, ERCP is useful and more sensitive for assessing the condition of the MPD. However, its widespread use is limited, among other things, owing to the risk of developing PTAP, which reaches 3\u0026ndash;14%, and mortality of 0.2\u0026ndash;1%. [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The sensitivity and specificity of ERCP in our study were 81.4%.\u003c/p\u003e\u003cp\u003eFinally, the most invasive diagnostic option, which is mandatory in unstable patients, is surgery [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. During laparotomy, confirming the status of the MPD is important, as the lesion may be small and undetected. The use of intraoperative ultrasonography may help in the diagnosis of parenchymal or even ductal lesions. However, there is a lack of conclusive evidence on the value of the procedure, and the need for trained surgeons makes this technique unrecommended for routine investigations in trauma [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In our study, we used intraoperative ultrasonography of the pancreas in cases of small pancreatic wounds located in the projection of the MPD. In 15 (53.8%) patients, signs of MPD deformity were detected: narrowing of the lumen, and edema around the wound channel. ICG-FA is a promising method for real-time visualization of fluorescent structures and determination of optimal tissue perfusion for penetrating abdominal wounds with BPIs. Intraoperative ICG-FA can help surgeons diagnose lesions and modify the surgical plan, resulting in fewer postoperative complications [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In our study, 2 (2.2%) patients underwent increased resection of the pancreatic parenchyma due to irreversible changes in the blood supply of the organ. However, the small sample size makes it difficult to determine specific conclusions.\u003c/p\u003e\u003cp\u003eThe application of this technique requires further research. Ultimately, in patients with hemodynamic instability, diagnostic uncertainty or worsening clinical presentation, negative radiological and/or laboratory changes due to penetrating abdominal wounds and laparotomy without prior MSCT imaging should be performed. In these cases, pancreatic injuries are assessed intraoperatively. [\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePenetrating abdominal trauma requires a meticulous examination with revision of the retroperitoneal space to identify pancreatic injuries [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. After fluid resuscitation, the patient was prepared for repeat surgical intervention.\u003c/p\u003e\u003cp\u003eIn our study, initial resuscitation was performed according to ATLS quidelines. Surgical treatment of BPIS was performed according to a specific surgical strategy: emergency control of intra-abdominal bleeding, closure of visceral lesions to prevent abdominal cavity contamination and rapid volume replacement to correct acidosis, coagulopathy and hypothermia.\u003c/p\u003e\u003cp\u003eIn our study, 79 (87.8%) patients with injuries to the pancreas and associated organs complicated by significant blood loss, acidosis, coagulopathy and hypothermia were cured by DCS tactics and received an average of 11 (range 2\u0026ndash;35) units of blood. Tamponade of the pancreatic area for hemostatic purposes, such as DCS I was performed in 82 (91.1%) patients, and drainage of the omental bursa completed treatment in 64 (71.1%) patients. In the case of severe OIS IIІ damage to the pancreas, distal resection of the pancreas was performed in 14 (15,5%) patients.\u003c/p\u003e\u003cp\u003eCentral resection at the penetrating wound of the proximal part of the pancreatic body with MPD damage was performed in 1 (1,1%) patient. Five (5,5%) patients with severe combined trauma to the pancreas and duodenum OIS V underwent pancreaticoduodenal resection (PDR). Pancreatectomy was performed in 1 (1.1%) patient with severe postoperative portal vein hemorrhage after PDR. The most common organ-specific complication of BPI in 43 (47.7%) patients in our study was PTAP. Most pancreas-related complications occurred in patients with OIS grade III injuries.\u003c/p\u003e\u003cp\u003eThe average length of hospital stay was 10.4 (1\u0026ndash;56) days. Forty (44.5%) patients were discharged from the hospital with a definite outcome. Twenty five (27.8%) patients died, while 50 (55.5%) stable patients were transferred to the next stage of medical evacuation. All 25 patients who died were cured with DCS with a median ISS of 28.8 (range 16\u0026ndash;50). Six (6.6%) patients died in the first 3 days after severe injury from irreversible hemorrhagic shock. Twenty-four (26.6%) patients died after multiple reoperative interventions from progressive multiple organ failure with a background of severe distributive shock, 1 (1.1%) \u0026ndash; died from ischemic necrosis of the small intestine with a background of thrombosis of the superior mesenteric vein. Fifty-four (60.0%) patients who survived in the DCS group underwent 2 to 7 relaparotomies.\u003c/p\u003e\u003cp\u003eIn our study, 7 (28%) patients who died had combined injury to the major vessels, with superior mesenteric vein and inferior vena cava injuries being the most commonly diagnosed. Patients who died had an average of 3 (range 1\u0026ndash;6) complications, and 7 (28%) had four or more complications. Fifteen (60.0%) of the 25 patients who died were in shock at the time of admission. Among the 21 (23.3%) patients with proximal pancreatic injury, 6 (28.6%) died.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eBPI during combat operations occurs mainly as a result of explosive devices with significant accompanying anatomical damage.\u003c/p\u003e\u003cp\u003eThe complexity of diagnosing BPI is associated with its rarity, the anatomical and topographical features of the organ, the absence of pathognomonic signs and the polysymptomatic clinical presentation in cases of combined and multiple injuries, manifestations of traumatic and hypovolemic shock, and the development of peritonitis.\u003c/p\u003e\u003cp\u003eThe leading diagnostic methods for BPIs are MSCT of the abdominal cavity and pelvis within 12\u0026ndash;24 hours with intravenous contrast and detailed (complete) intraoperative revision of the pancreato-duodenal complex, which increases the diagnostic accuracy of BPIs to 98.8%.\u003c/p\u003e\u003cp\u003eFurther research is needed on the characteristics of the diagnosis and treatment of acute pancreatitis in combat conditions.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociated injuries to the abdominal organs and combined injuries at the BPI.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAffected organ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpleen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14,0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLarge intestine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14,5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStomach\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17,2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKidney\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10,4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmall intestine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuodenum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4,5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdrenal glands\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1,8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGall bladder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1,8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiaphragm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2,7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrinary bladder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0,9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMain vessels\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4,5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e221\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100,0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInjury location\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbdomen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17,8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest\u0026thinsp;+\u0026thinsp;abdomen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16,7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest\u0026thinsp;+\u0026thinsp;abdomen\u0026thinsp;+\u0026thinsp;limbs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18,9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbdomen\u0026thinsp;+\u0026thinsp;limbs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8,9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHead\u0026thinsp;+\u0026thinsp;chest\u0026thinsp;+\u0026thinsp;abdomen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15,6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbdomen\u0026thinsp;+\u0026thinsp;pelvis\u0026thinsp;+\u0026thinsp;limbs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5,6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHead\u0026thinsp;+\u0026thinsp;chest\u0026thinsp;+\u0026thinsp;abdomen\u0026thinsp;+\u0026thinsp;limbs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5,6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHead\u0026thinsp;+\u0026thinsp;abdomen\u0026thinsp;+\u0026thinsp;limbs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2,2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHead\u0026thinsp;+\u0026thinsp;neck\u0026thinsp;+\u0026thinsp;chest\u0026thinsp;+\u0026thinsp;abdomen\u0026thinsp;+\u0026thinsp;pelvis\u0026thinsp;+\u0026thinsp;limbs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHead\u0026thinsp;+\u0026thinsp;neck\u0026thinsp;+\u0026thinsp;chest\u0026thinsp;+\u0026thinsp;abdomen\u0026thinsp;+\u0026thinsp;limbs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2,2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest\u0026thinsp;+\u0026thinsp;abdomen\u0026thinsp;+\u0026thinsp;pelvis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;5. Postoperative complications in BPIs patients\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIS: Abbreviated Injury Scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAST: advanced surgical team\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAAST: American Association for the Surgery of Trauma\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBPIS: battlefield pancreatic injury\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDCS: damage control surgery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eERCP: endoscopic retrograde cholangiopancreatography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEPF: external pancreatic fistula\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFAST: focused assessment with sonography in trauma\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eISS: Injury Severity Score\u003c/p\u003e\n\u003cp\u003eICU: intensive care unit\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eICG-FA: indocyanine green fluorescent angiography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMPD:\u0026nbsp;main pancreatic duct\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMMCCNRAFU: Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine\u003c/p\u003e\n\u003cp\u003eMSCT: multispiral computed tomography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOEF: Operation enduring freedom\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOIF: Operation Iraqi Freedom\u003c/p\u003e\n\u003cp\u003eOIS: Organ Injury Scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePPC: pancreatic pseudocyst\u003c/p\u003e\n\u003cp\u003ePTAP: post-traumatic acute pancreatitis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSIRS: systemic inflammatory response syndrome\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWSES: World Society of Emergency Surgery\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch was performed in compliance with the Helsinki Declaration and was approved by the ethics committee of Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, and the informed consent forms were obtained from all patients. All individual paticipants signed an informed consent form authorising the use of clinical data in scientific activities. These informed consent forms are an integral part of each inpatient's medical record.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to data collected on Ukrainian Armed Forces personnel and during combat operations in Ukraine is currently restricted by law, but are available from the corresponding author on reasonable request. The publication of this scientific material does not violate Ukrainian legislation in force during this special period. Following the relevant decision and permission after the end of the war in Ukraine, the data will be publicly available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSAS conceived and designed the study. SAS, EMK, IPK, VVM and VVN developed the overall research methodology. Figures and tables were prepared by VVN, OVS, OVY and OHP. SAS and VVN drafted the manuscript. EMH, IPK, VVM and OHP contributed to revisions of the manuscript. SAS, OVS and OVY contributed to the acquisition and analysis of data. All authors read and approved the final manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEMK– Hero of Ukraine, Ph.D, M.D., Colonel of Medical Service, Head of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, 5 Kultury St., Kharkiv, 61000, Ukraine; Associate Professor of the Department of Surgery №4 of the Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; tel:+380676923120; E-mail: [email protected];\u003c/p\u003e\n\u003cp\u003eORCID: 0000-0003-1258-1319.\u003c/p\u003e\n\u003cp\u003eIPK – M.D., Professor, Major General of Medical Service, Corresponding Member of the National Academy of Medical Sciences of Ukraine, Head of Kyiv City Clinical Hospital No. 8, 8 Yuriy Kondratyuk Street, Kyiv, 04201, Ukraine; tel:+380503580279; E-mail: [email protected]; ORCID: 0000-0002-8199-5083\u003c/p\u003e\n\u003cp\u003eVVM – M.D., Professor, Head of the Department of Surgery №4 of the Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; surgeon at the Surgical Department of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, 5 Kultury St., Kharkiv, 61000, Ukraine; tel: +380679518382; E-mail: [email protected]; ORCID: 0000-0002-4224-0294;\u003c/p\u003e\n\u003cp\u003eVVN ­­– M.D., Professor, Colonel of Medical Service, Head of the Emergency Care Clinic (and Reception and Evacuation) of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, 5 Kultury St., Kharkiv, 61000, Ukraine; Professor of the Department of Surgery №4 of the Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; tel: +380504523273; E-mail: [email protected]; ORCID: 0000-0003-4540-5207.\u003c/p\u003e\n\u003cp\u003eSAS ­­­– Ph.D, M.D., Colonel of Medical Service, Deputy Unit Commander - Leading Surgeon of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, 5 Kultury St., Kharkiv, 61000, Assistant of the Department of Surgery №4 of Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; tel: +380501958371; E-mail: [email protected]; ORCID: 0000-0002-1689-2213.\u003c/p\u003e\n\u003cp\u003eOVY – M.D., Colonel of Medical Service, Chief Radiologist of the Armed Forces of Ukraine, Head of the Clinic of Computer and Radiological Diagnostics of the Military Medical Clinical Centre of the Northern Region of the Armed Forces of Ukraine, 5 Kultury St., Kharkiv, 61000, Ukraine; tel: +380679026224; E-mail: [email protected]; ORCID: 0009-0008-9474-7477.\u003c/p\u003e\n\u003cp\u003eOVS ­– Ph.D, M.D., Head of the Endoscopy Department of the Kharkiv City Clinical Multiprofile Hospital No. 25, 122 Oleksandrivskiy avenue, Kharkiv, 61115, Ukraine; Associate Professor of Department of Surgery №1 of the Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; tel: +380506211833; E-mail: [email protected]; ORCID: 0000-0001-7709-2407/\u003c/p\u003e\n\u003cp\u003eOHP – Ph.D, M.D., Associate Professor, Associate Professor of Department of Surgery №4 of the Kharkiv National Medical University, 4 Nauky avenue, Kharkiv, 61022, Ukraine; tel: +380506321104; E-mail: [email protected]; ORCID: 0000-0001-9411-994X.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLurin I, Khoroshun E, Negoduiko V, Makarov V, Shypilov S, Boroday V, et al. Retrieval of ferromagnetic fragments from the lung using video-assisted thoracoscopic surgery and magnetic tool: a case report of combat patient injured in the war in Ukraine. Int J Emerg Med. 2023;16(1):51., \u003c/li\u003e\n\u003cli\u003eKazmirchuk A, Yarmoliuk Y, Lurin I, Gybalo R, Burianov O, Derkach S, et al. Ukraine\u0026rsquo;s experience with management of combat casualties using NATO\u0026rsquo;S four-tier \u0026ldquo;changing as needed\u0026rdquo; healthcare system. World J Surg. 2022. https://doi.org/10.1007/s00268-022-06718-3., \u003c/li\u003e\n\u003cli\u003eGumeniuk K, Lurin IA, Tsema I, Malynovska L, Gorobeiko M, Dinets A. Gunshot injury to the colon by expanding bullets in combat patients wounded in hybrid period of the Russian-Ukrainian war during 2014\u0026ndash;2020. BMC Surg. 2023;23(1):23.\u003c/li\u003e\n\u003cli\u003eTsymbaliuk V, Lurin I, Gumeniuk K, Herasymenko O, Furkalo S, Oklei D, et al. Modeling of wound ballistics in biological tissues simulators. Med Perspekt. 2023;28(1):37\u0026ndash;48.\u003c/li\u003e\n\u003cli\u003eGolovko S, Gybalo R, Lurin I, Taraban I, Kobirnichenko A, Ganiuk V, et al. Penetrating gunshot wounds to the penis: a case report of combat patient injured in the war in Ukraine. Int J Emerg Med. 2023;16(1):5. \u003c/li\u003e\n\u003cli\u003eDave S, Toy FK, London S. Pancreatic Trauma. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459365/.\u003c/li\u003e\n\u003cli\u003eVolodymyr M Kopchak, Yuriy O Khilko, Liudmyla O Pererva, Artem O Danyliuk, Iurii Snopok, Pancreatic Battlefield Injuries During Ukraine War, Military Medicine, 2025;, usaf084, https://doi.org/10.1093/milmed/usaf084, \u003c/li\u003e\n\u003cli\u003eVertrees A, Elster E, Jindal R, Ricordi C, Shriver C. Surgical management of modern combat-related pancreatic injuries: traditional management and unique strategies. Mil Med. 2014;179:315\u0026ndash;9., \u003c/li\u003e\n\u003cli\u003eG E Chinnery, J E J Krige, U K Kotze, P Navsaria, A Nicol, Surgical management and outcome of civilian gunshot injuries to the pancreas, British Journal of Surgery, Volume 99, Issue Supplement_1, January 2012, Pages 140\u0026ndash;148, https://doi.org/10.1002/bjs.7761, \u003c/li\u003e\n\u003cli\u003eDegiannis E, Levy RD, Velmahos GC, Potokar T, Florizoone MG, Saadia R. Gunshot injuries of the head of the pancreas: conservative approach. World J Surg 1996; 20: 68\u0026ndash;71.; \u003c/li\u003e\n\u003cli\u003eDegiannis E, Levy RD, Potokar T, Lennox H, Rowse A, Saadia R. Distal pancreatectomy for gunshot injuries of the distal pancreas. Br J Surg 1995; 82: 1240\u0026ndash;1242.; \u003c/li\u003e\n\u003cli\u003eMadiba TE, Mokoena TR. Favourable prognosis after surgical drainage of gunshot, stab or blunt trauma of the pancreas. Br J Surg 1995; 82: 1236\u0026ndash;1239. \u003c/li\u003e\n\u003cli\u003eJ.E.J. Krige, U.K. Kotze, A.J. Nicol, P.H. Navsaria. Isolated pancreatic injuries: an analysis of 49 consecutive patients treated at a level 1 trauma centre. J Visc Surg, 152 (2015), pp. 349-355 http://dx.doi.org/10.1016/j.jviscsurg.2015.09.010, \u003c/li\u003e\n\u003cli\u003eM. Heuer, B. Hussmann, R. Lefering, G. Taeger, G.M. Kaiser, A. Paul, et al. Pancreatic injury in 284 patients with severe abdominal trauma: outcome, course, and treatment algorithm. Arch Surg, 396 (2011), pp. 1067-1076., \u003c/li\u003e\n\u003cli\u003ePetrone P, Moral \u0026Aacute;lvarez S, Gonz\u0026aacute;lez P\u0026eacute;rez M, Ceballos Esparrag\u0026oacute;n J, Marini CP. Traumatismos de p\u0026aacute;ncreas: manejo y revisi\u0026oacute;n de la literatura. Cir Esp. 2017;95:123\u0026ndash;130., \u003c/li\u003e\n\u003cli\u003eK. S\u0026oslash;reide. Pancreas injury: the good, the bad and the ugly. Injury, 46 (2015), pp. 827-829 http://dx.doi.org/10.1016/j.injury.2015.03.034, \u003c/li\u003e\n\u003cli\u003eA.A. Memon, H. Zafar, R. Raza, G. Murtaza. Traumatic pancreatic injury \u0026ndash; an elusive diagnosis: experience from a developing country urban trauma referral centre. J Pak Med Assoc, 63 (2013), pp. 440-444, \u003c/li\u003e\n\u003cli\u003eChui JN, Kotecha K, Gall TM, Mittal A, Samra JS. Surgical management of high-grade pancreatic injuries: Insights from a high-volume pancreaticobiliary specialty unit. World J Gastrointest Surg. 2023 May 27;15(5):834-846. doi: 10.4240/wjgs.v15.i5.834. PMID: 37342855; PMCID: PMC10277947.\u003c/li\u003e\n\u003cli\u003eMichael Clemens, MD, Thomas Mitchell, MD, Timothy Vreeland, MD, Christopher White, Lorne Blackbourne. Combat associated Pancreatic injuries: 2002-2011 https://www.sages.org/meetings/annual-meeting/abstracts-archive/combat-associated-pancreatic-injuries-2002-2011/\u003c/li\u003e\n\u003cli\u003eBorden Institute Walter Reed Army Medical Center: Emergency War Surgery, pp 17.10\u0026ndash;17.11. Maryland, Borden Institute, 2004. Availableat http://www.cs.amedd.army.mil/borden; accessed September 27, 2013.\u003c/li\u003e\n\u003cli\u003eLee PH, Lee SK, Kim GU, et al. Outcomes of hemodynamically stable patients with pancreatic injury after blunt abdominal trauma. Pancreatology 2012;12(6):487\u0026ndash;492.\u003c/li\u003e\n\u003cli\u003eAprahamian C, Thompson BM, Towne JB, Darin JC. The effect of a paramedic system on mortality of major open intra-abdominal vascular trauma. J Trauma 1983;23:687-90.\u003c/li\u003e\n\u003cli\u003eCoccolini, F., Kobayashi, L., Kluger, Y. et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 14, 56 (2019). https://doi.org/10.1186/s13017-019-0278-6), \u003c/li\u003e\n\u003cli\u003eEastern Association for the Surgery of Trauma (EAST) (https://www.east.org/search?q=pancreatic), \u003c/li\u003e\n\u003cli\u003eWestern Trauma Association Algorithms (https://westerntrauma.org//docs/ Management%20of%20 Pancreatic %20Injuries.png\u003c/li\u003e\n\u003cli\u003eWang GF, Li YS, Li JS. Damage control surgery for severe pancreatic trauma. Hepatobiliary Pancreat Dis Int 2007; 6: 569\u0026ndash;571. \u003c/li\u003e\n\u003cli\u003eBrenner M, Bochicchio G, Bochicchio K, Ilahi O, Rodriguez E, Henry S et al. Long-term impact of damage control laparotomy: a prospective study. Arch Surg 2011; 146: 395\u0026ndash;399. ; \u003c/li\u003e\n\u003cli\u003eStawicki SP, Schwab CW. Pancreatic trauma: demographics, diagnosis, and management. Am Surg 2008; 74: 1133\u0026ndash;1145.\u003c/li\u003e\n\u003cli\u003eJ.C. Vasquez, R. Coimbra, D.B. Hoyt, D. Fortlage. Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center. Injury, 32 (2001), pp. 753-759; \u003c/li\u003e\n\u003cli\u003eJ.E. Krige, E. Jonas, S.R. Thomson, U.K. Kotze, M. Setshedi, P.H. Navsaria, et al. Resection of complex pancreatic injuries: benchmarking postoperative complications using the accordion classification World J. Gastrointest. Surg., 9 (2017), pp. 82-91, \u003c/li\u003e\n\u003cli\u003eN. Mansfield, K. Inaba, R. Berg, E. Beale, E. Benjamin, L. Lam, et al. Early pancreatic dysfunction after resection in trauma: an 18-year report from a level i trauma center J. Trauma Acute Care Surg., 82 (2017), pp. 528-533\u003c/li\u003e\n\u003cli\u003eLaura L. Meijer, Yrj\u0026ouml; Vaalavuo, Sara Regn\u0026eacute;r, Ville Sallinen, Aurora Lemma, Urban Arnelo, Roberto Valente, Sofia Westermark, David An, John A.G. Moir, Ellen A. Irwin, Esther A. Biesel, Ulrich T. Hopt, Stefan Fichtner-Feigl, Uwe A. Wittel, Maximilian Weniger, Henning Karle, Frank W. Bloemers, Robert Sutton, Richard M. Charnley, Dietrich A. Ruess, Peter Szatmary, Clinical characteristics and long-term outcomes following pancreatic injury \u0026ndash; An international multicenter cohort study, Heliyon, Volume 9, Issue 6, 2023, e17436, ISSN 2405-8440, https://doi.org/10.1016/j.heliyon.2023.e17436. \u003c/li\u003e\n\u003cli\u003eLinsenmaier U, Wirth S, Reiser M, K\u0026ouml;rner M. Diagnosis and classification of pancreatic and duodenal injuries in emergency radiology. Radiographics. 2008;28:1591\u0026ndash;602.\u003c/li\u003e\n\u003cli\u003eMahajan A, Kadavigere R, Sripathi S, Rodrigues GS, Rao VR, Koteshwar P. Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review. Injury. 2014;45:1384\u0026ndash;93.\u003c/li\u003e\n\u003cli\u003ePhelan HA, Velmahos GC, Jurkovich GJ, Friese RS, Minei JP, Menaker JA, Philp A, Evans HL, Gunn ML, Eastman AL, et al. An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study. J Trauma. 2009;66(3):641\u0026ndash;646; discussion 6\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eVelmahos GC, Tabbara M, Gross R, Willette P, Hirsch E, Burke P, Emhoff T, Gupta R, Winchell RJ, Patterson LA, et al. Blunt pancreatoduodenal injury: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Arch Surg. 2009;144(5):413\u0026ndash;419; discussion 9\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eTeh SH, Sheppard BC, Mullins RJ, Schreiber MA, Mayberry JC. Diagnosis and management of blunt pancreatic ductal injury in the era of high-resolution computed axial tomography. Am J Surg. 2007;193(5):641\u0026ndash;643; discussion 3.\u003c/li\u003e\n\u003cli\u003eElbanna KY, Mohammed MF, Huang S-C, Mak D, Dawe JP, Joos E, et al. Delayed manifestations of abdominal trauma: follow-up abdominopelvic CT in posttraumatic patients. Abdom Radiol. 2018;43:1642\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eRekhi S, Anderson SW, Rhea JT, Soto JA. Imaging of blunt pancreatic trauma. Emerg Radiol. 2010;17:13\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eStewart BT, Sandstrom CK, O\u0026rsquo;Keefe G, Balmadrid B, Johnson GE. Multidisciplinary diagnosis and management of pancreatic trauma. Dig Dis Interv. 2018;02:179\u0026ndash;92\u003c/li\u003e\n\u003cli\u003eChoi AY, Bodanapally UK, Shapiro B, Patlas MN, Katz DS. Recent advances in abdominal trauma computed tomography. Semin Roentgenol. 2018;53:178\u0026ndash;86.\u003c/li\u003e\n\u003cli\u003eBhasin DK, Rana SS, Rawal P. Endoscopic retrograde pancreatography in pancreatic trauma: need to break the mental barrier. J Gastroenterol Hepatol. 2009;24(5):720\u0026ndash;728.; \u003c/li\u003e\n\u003cli\u003eKim HS, Lee DK, Kim IW, Baik SK, Kwon SO, Park JW, Cho NC, Rhoe BS. The role of endoscopic retrograde pancreatography in the treatment of traumatic pancreatic duct injury. Gastrointest Endosc. 2001;54(1):49\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eChen G, Yang H. Management of duodenal trauma. Chinese J Traumatol. 2011;14:61\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eHofmann LJ, Learn PA, Cannon JW. Intraoperative ultrasound to assess for pancreatic duct injuries. J Trauma Acute Care Surg. 2015;78:888\u0026ndash;91.\u003c/li\u003e\n\u003cli\u003ePatel MQ, Osterkamp JT, Buitendag JJ, Forgan TR, Steyn E. Indocyanine green fluorescence angiography in the management of intestinal injuries following penetrating abdominal trauma: a case-control study comparing postoperative outcomes. Int J Surg. 2024 Dec 1;110(12):7624-7629. doi: 10.1097/JS9.0000000000002096. PMID: 39434689; PMCID: PMC11634155.\u003c/li\u003e\n\u003cli\u003eF. Rodr\u0026iacute;guez, A. Garc\u0026iacute;a, C. Ordo\u0026ntilde;ez, C. Vernaza, J.P. Herrera, J.C. Puyana. Trauma pancre\u0026aacute;tico penetrante severo-revisi\u0026oacute;n retrospectiva de una serie de casos manejados con una estrategia simplificada en un centro de trauma nivel 1 Panamerican J Trauma Crit Care Emerg Surg, 4 (2015), pp. 147-154) \u003c/li\u003e\n\u003cli\u003ePotoka DA, Gaines BA, Lepp\u0026auml;niemi A, Peitzman AB. Management of blunt pancreatic trauma: what\u0026apos;s new? Eur J Trauma Emerg Surg. 2015;41:239\u0026ndash;250. \u003c/li\u003e\n\u003cli\u003eLopez PP, Benjamin R, Cockburn M, Amortegui JD, Schulman CI, Soffer D, et al. Recent trends in the management of combined pancreatoduodenal injuries. Am Surg. 2005;71:847\u0026ndash;852.\u003c/li\u003e\n\u003cli\u003eBrotman S, Cisternino S, Myers RA, Cowley RA. A test to help diagnosis of rupture in the injured duodenum. Injury. 1981;12:464\u0026ndash;5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Battlefield pancreatic injury, battlefield abdominal injury, advanced surgical team, damage control surgery, distal resection of the pancreas, pancreatoduodenal resection, focused assessment with sonography in trauma, multispiral computed tomography with contrast enhancement, intraoperative indocyanine green fluorescent angiography","lastPublishedDoi":"10.21203/rs.3.rs-7462542/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7462542/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe diagnosis of battlefield pancreatic injury (BPI) has specific features related to the stages of care and remains one of the most complex and resource-intensive problems in medical care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRetrospective analyses of 1345 medical records of military personnel and civilian patients with battlefield abdominal injuries were performed. Biochemical blood analysis with determination of serum alpha-amylase, focused assessment with sonography in trauma (FAST), abdominal X-ray, multispiral computed tomography (MSCT) of the abdominal and pelvic organs, endoscopic retrograde cholangiopancreatography, intraoperative ultrasonography, indocyanine green fluorescent angiography and intraoperative revision of the pancreato‒duodenal complex were used.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBPI was diagnosed in 117 (8.7%) patients. A total of 90 patients were included. Gunshot shrapnel pancreatic wounds were diagnosed in 81.1% of patients. Injury to the head of the pancreas was diagnosed in 18.9% of the patients, to the neck in 1.1%, to the body in 14.4%, and to the tail in 55.6%. Multiple injuries were detected in 10% of the patients. Intraoperative revision of the pancreato‒duodenal complex in hemodynamically unstable patients diagnosed with BPI in 78.2% of patients. BPI diagnosis in 85.7% of hemodynamically stable patients was based on preoperative serum alpha-amylase, FAST, and intraoperative X-ray. At the hospital stage of medical care, the sensitivity of the extended BPI diagnostic algorithm was 98.8%.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBPI diagnosis is difficult because of its rarity, anatomical and topographical features of the pancreas, polysymptomatic clinical presentation in combined and multiple injuries, manifestations of traumatic and hypovolemic shock, and peritonitis. The main examination methods for BPI are MSCT of the abdominal cavity and pelvis and detailed intraoperative revision of the pancreato‒duodenal complex.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrial registration\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNot applicable. This retrospective study did not require trial registration.\u003c/p\u003e","manuscriptTitle":"Features of diagnosing battlefield pancreatic injuries during the war in Ukraine","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-26 00:32:56","doi":"10.21203/rs.3.rs-7462542/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1b48867a-892b-4d8d-aee6-5b2fc11f24f1","owner":[],"postedDate":"October 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T15:41:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-26 00:32:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7462542","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7462542","identity":"rs-7462542","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}