Abstract
BackgroundPancreatic trauma is a rare condition with a wide presentation, ranging from hematoma or laceration without main pancreatic duct involvement, to massive destruction of the pancreatic head. The optimal diagnosis of pancreatic trauma and its management approaches are still under debate. The East Association of Surgery for Trauma (EAST) guidelines recommend operative management for high-grade pancreatic trauma; however, several reports have reported successful outcomes with nonoperative management (NOM) for grade III/IV pancreatic injuries. Herein, we report a case of grade IV pancreatic injury that was nonoperatively managed through endoscopic and percutaneous drainage.Case presentationA 47-year-old Japanese man was stabbed in the back with a knife; upon blood examination, both serum amylase and lipase levels were within normal limits. Contrast-enhanced computed tomography (CT) showed extravasation of the contrast medium around the pancreatic head and a hematoma behind the pancreas. Abdominal arterial angiography revealed a pseudo aneurysm in the inferior pancreatoduodenal artery, as well as extravasation of the contrast medium in that artery; coil embolization was thus performed. On day 12, CT revealed a wedge-shaped, low-density area in the pancreatic head, as well as consecutive pseudocysts behind the pancreas; thereafter, percutaneous drainage was performed via the stab wound. On day 22, contrast radiography through the percutaneous drain revealed the proximal and distal parts of the main pancreatic duct. The injury was thus diagnosed as a grade IV pancreatic injury based on the American Association for the Surgery of Trauma guidelines. On day 26, an endoscopic nasopancreatic drainage tube was inserted across the disruption; on day 38, contrast-enhanced CT showed a marked reduction in the fluid collection. Finally, on day 61, the patient was discharged.ConclusionsAlthough the EAST guidelines recommend operative treatment for high-grade pancreatic trauma, NOM with appropriate drainage by endoscopic and/or percutaneous approaches may be a promising treatment for grade III or IV trauma.
Highlights
BackgroundPancreatic trauma is a rare condition for which the optimal diagnosis and management are still under debate
Pancreatic trauma is a rare condition with a wide presentation, ranging from hematoma or laceration without main pancreatic duct involvement, to massive destruction of the pancreatic head
Conclusions: the East Association of Surgery for Trauma (EAST) guidelines recommend operative treatment for high-grade pancreatic trauma, nonoperative management (NOM) with appropriate drainage by endoscopic and/or percutaneous approaches may be a promising treatment for grade III or IV trauma
Summary
Pancreatic trauma is a rare condition for which the optimal diagnosis and management are still under debate. We report a case of grade IV pancreatic injury that was nonoperatively managed through endoscopic and percutaneous drainage. Contrastenhanced computed tomography (CECT) showed extravasation of the contrast medium around the pancreatic head, as well as hematomas behind the pancreas and in the left psoas muscle (Fig. 1); no other visceral or major vascular injuries were presented. On day 1, the serum amylase level was elevated (1366 U/L); duct injury was not confirmed via CT. On day 12, CT revealed a wedge-shaped, low-density area in the pancreatic head, and consecutive pseudocysts behind the pancreas and in the left psoas muscle (Fig. 3). On day 22, contrast radiography through the percutaneous drain revealed the proximal and distal parts of the main pancreatic duct (Fig. 4); the patient was diagnosed with AAST grade IV pancreatic injury. The ERPD tube was removed 10 months later, and stenosis has not been confirmed on magnetic resonance cholangiopancreatography after 1.5 years
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