Complete Pancreatic Transection Research Articles

Indocyanine green fluorescence-guided laparoscopic central pancreatectomy for complete pancreatic transection trauma: a rare case and literature review

BackgroundPancreatic trauma is a rare solid organ injury. Conservative treatment is often indicated in patients with no pancreatic duct injury, while patients with high-grade pancreatic damage most often require surgical intervention. Laparoscopic central pancreatectomy (LCP) is a parenchyma-sparing approach and can prevent endocrine and exocrine insufficiency after pancreatic resection. Indocyanine green (ICG) fluoroscopy can help the surgeon assess the blood supply of the target organ.Case presentationThe case we describe here is a 33-year-old male patient who was transferred to our hospital due to blunt abdominal trauma caused by a car accident. The patient was hemodynamically stable on admission and was diagnosed with isolated pancreatic trauma by a multidisciplinary team that included radiologists, emergency physicians, and pancreatic surgeons. The patient then underwent emergency laparoscopic central pancreatectomy, during which we used ICG fluoroscopy to assess the blood perfusion of the damaged pancreas to determine the extent of resection. The patient developed a biochemical fistula (grade A pancreatic fistula) after surgery, and no other intervention was performed except for continuous drainage. The patient was discharged on postoperative day 13. At the 3-month follow-up, the patient did not present any clinical manifestations of pancreatic endocrine and exocrine insufficiency.ConclusionTo the best of our knowledge, there have been no reports of ICG-guided emergency LCP for blunt abdominal trauma. In selected patients, emergency LCP is feasible and should be supported by a multidisciplinary team and performed by an experienced pancreatic surgeon with advanced laparoscopic skills.

Case report of an isolated pancreatic transection from low impact blunt abdominal trauma necessitating resective surgery

Introduction and importanceIsolated pancreatic injury from blunt force trauma is an extremely rare entity accounting for less than 1 % of trauma presentations. This case highlights the diagnostic difficulties of identifying a ductal injury and presents a rare instance of an isolated pancreatic transection from a relatively low-impact blunt abdominal trauma.Case presentationA 30 year old lady presented to the emergency department 24 h following a low impact abdominal trauma. CT scan showed a complete pancreatic transection with significant peripancreatic free fluid. MRCP showed the main pancreatic duct to be in alignment on either side of the transection plane, however given the significant surrounding free fluid she was taken to the operating theatre for exploration and resective surgery. Intraoperative findings were that of a complete pancreatic transection involving the main pancreatic duct.DiscussionCurrent management guidelines focus on the correct evaluation of main pancreatic duct integrity. Timely intervention is essential for improving mortality and morbidity outcomes. Reported sensitivity and specificity for imaging modalities vary between studies, likely reflecting inherent challenges in accurately identifying pancreatic duct injuries. Multi-modal assessment is recommended to reach a timely diagnosis and hence, institute the appropriate therapy.ConclusionLow-energy trauma can result in isolated injuries of the pancreas. Multi-modal imaging should be encouraged for evaluation of main pancreatic duct integrity. This will facilitate timely decision making regarding the need for definitive surgery.

Complete pancreatic transection secondary to severe acute pancreatitis

Complete pancreatic transection secondary to severe acute pancreatitis

Complete pancreatic transection associated with splenic injury resulting from blunt trauma

ABSTRACT Injury to the pancreas after blunt abdominal trauma is less frequent than that of other solid organs. The clinical presentation can be subtle resulting in delayed treatment with high morbidity and mortality. A seventeen years male presented with pain jaw and abdomen following fall from tree. He was haemodynamically stable with signs of mandible injury. Investigations revealed splenic contusion with moderate haemoperitoneum. Laparotomy revealed complete transection of distal third of body of pancreas. Pancreatic resection with splenectomy was performed. The case is being reported because of the unusual location of complete pancreatic transection resulting from a blunt trauma. A high degree of clinical suspicion with due consideration to the mechanism of injury is key to good outcome in these patients. Major ductal injury is the critical issue in the management and a number of therapeutic choices are available specific to the location of insult. Copyright © 2014, Indian Journal of Medical Specialities. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.

Complete pancreatic transection associated with splenic injury resulting from blunt trauma

ABSTRACT Injury to the pancreas after blunt abdominal trauma is less frequent than that of other solid organs. The clinical presentation can be subtle resulting in delayed treatment with high morbidity and mortality. A seventeen years male presented with pain jaw and abdomen following fall from tree. He was haemodynamically stable with signs of mandible injury. Investigations revealed splenic contusion with moderate haemoperitoneum. Laparotomy revealed complete transection of distal third of body of pancreas. Pancreatic resection with splenectomy was performed. The case is being reported because of the unusual location of complete pancreatic transection resulting from a blunt trauma. A high degree of clinical suspicion with due consideration to the mechanism of injury is key to good outcome in these patients. Major ductal injury is the critical issue in the management and a number of therapeutic choices are available specific to the location of insult. Copyright © 2014, Indian Journal of Medical Specialities. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.

Isolated pediatric pancreatic transection secondary to ocean-related trauma.

Isolated pancreatic transection is a rare but well-recognized complication following blunt trauma of the abdomen. Diagnosis at presentation may be difficult and delayed due to subtle initial symptoms and evolving nature of the injury.We describe an isolated complete pancreatic transection in a 14-year-old female secondary to a previously unreported and highly unusual mechanism (being tossed by a wave). Diagnosis was obtained by computed tomography scan 24 hours following initial trauma. She was managed operatively with an open distal pancreatectomy with splenic preservation and no subsequent complications.The force sustained from the blunt abdominal trauma of being tossed by a wave can be significant. The management of pancreatic injuries in children, particularly in the context of ductal transection, is controversial. Timely recognition and management is critical to optimal outcomes. Early operative intervention may help to avoid complications such as abscess or pseudocyst formation.

Isolated Pancreatic Transection in a Case of Blunt Abdominal Trauma

A 20-year-old male patient presented with complaint of epigastric pain and vomiting, 1day after an episode of bike handle injury. Ultrasound showed only mild free fluid in the abdomen. The patient gradually developed tachycardia, hypotension and guarding in the abdomen. CT scan revealed complete pancreatic transection between the neck and the body with segmental separation about an inch. Serum lipase was raised. Exploratory laparotomy revealed acute pseudocyst formation and necrotic slough on the transected ends. Distal pancreatectomy without splenectomy was performed. The patient recovered uneventfully.

Operative Intervention for Complete Pancreatic Transection in Children Sustaining Blunt Abdominal Trauma: Revisiting an Organ Salvage Technique

Complete pancreatic transection (CPT) in children is managed commonly with distal pancreatectomy (DP). Alternatively, Roux-en-Y distal pancreaticojejunostomy (RYPJ) may be performed to preserve pancreatic tissue. The purpose of this study was to review our experience using either procedure in the management of children sustaining CPT after blunt abdominal trauma. We retrospectively reviewed the records of all children admitted to our institution during the last 15 years who were confirmed at operation to have CPT after blunt mechanisms. Summary statistics of demographic data were performed to describe children receiving either RYPJ or DP. CPT occurred in 28 children: 15 had DP, 10 had RYPJ, and three had cystogastrostomy. RYPJ children, compared with DP, were younger (7.5 vs. 12.3 years, P = 0.039) and sustained more grade IV pancreatic injuries (70% vs. 14%, P = 0.01). DP patients were 5.63 times more likely to tolerate full enteral feeds (P = 0.009). Nevertheless, when controlling for age, injury severity score, and pancreatic injury grade, procedure type did not statistically affect total and postoperative lengths of stay and postoperative complications. In the operative management algorithm of children sustaining CPT, DP may afford an earlier return to full enteral feeds. RYPJ seems otherwise equivalent to DP and preserves significant pancreatic glandular tissue and the spleen.

Experience with totally laparoscopic distal pancreatectomy with splenic preservation for pediatric trauma—2 techniques

PurposeBlunt pancreatic traumatic injury in children, although rare, can be managed with a variety of methods from nonoperative, early operative, or delayed operative strategies. In the appropriate setting, early operative intervention has been associated with shorter hospitalization and decreased morbidity for these patients. Case reports describe laparoscopic distal pancreatectomy for isolated pancreatic laceration in children. This article presents the experience and results of the first series of totally laparoscopic, spleen-preserving distal pancreatectomies for trauma in children. MethodsThree children aged 8 to 13 years underwent laparoscopic distal pancreatectomy with splenic preservation for traumatic pancreatic transection within 72 hours of initial injury. Computed tomography imaging in all patients demonstrated complete pancreatic transection. The details of 2 operative techniques used for totally laparoscopic distal pancreatectomy are described. The data for associated injuries, amylase/lipase levels, operative management, postoperative course, length of stay, complications, and follow-up were collected for all patients. ResultsAll 3 children aged 8, 10, and 13 years underwent laparoscopic distal pancreatectomy without splenectomy within 72 hours of injury (23, 48, and 72 hours). The mechanism of injury was from a bicycle handle, knee to abdomen, and dirt bike handle, respectively. The length of hospital stay was 6, 15, and 7 days with follow-up of 12, 35, and 34 months. The 2 older children underwent pancreatic transection with an endostapler, and the 8-year-old had the pancreatic remnant oversewn by hand. Use of postoperative total parenteral nutrition continued for 0, 13, and 7 days. Complications included an abdominal wall hematoma and prolonged ileus with mild pancreatitis. There were no pancreatic fistulae or insufficiency. All patients are doing well and are asymptomatic from prior injury and laparoscopic distal pancreatectomy. ConclusionsIn the appropriate pediatric patient with traumatic pancreatic transection, a laparoscopic distal pancreatectomy with splenic preservation can be performed safely, with low morbidity and good outcomes. Further studies with larger series of patients with these injuries would be useful.

Pancreaticojejunostomy in proximal pancreatic transection: A viable option.

Complete pancreatic transection following blunt abdominal trauma is not a common injury. Distal pancreatectomy with or without splenectomy is routinely performed if the transection is to the left of the superior mesenteric vessels. We performed pancreaticojejunostomy on a six-year-old female patient who presented with complete transection at the pancreatic neck following blunt abdominal trauma. The aim was to preserve the pancreatic parenchyma and the spleen and assess the feasibility of the procedure. The patient has been followed for more than one year and is doing well. We conclude that the procedure should be considered in proximal pancreatic transection, particularly in the pediatric age group.

Complete Pancreatic Transection in a Child Treated by Drainage and Sphincterotomy

Complete Pancreatic Transection in a Child Treated by Drainage and Sphincterotomy

Long-term outcome after nonoperative management of complete traumatic pancreatic transection in children

Purpose: The treatment of complete pancreatic transection (CPT) from blunt trauma remains controversial. To determine the natural history and long-term outcome of nonoperative management of CPT, we analyzed all such patients over the last 10 years at a level I trauma center. Methods: Retrospective analysis between 1990 and 1999 was performed on 10 consecutive patients. Complete records were available for 9 patients. Data pertaining to their trauma admission, plus long-term radiologic and clinical outcome were analyzed. Results: There were 6 boys and 3 girls with a median age of 8 years (range, 4 to 16 years) and a median injury severity score (ISS) of 25. All patients displayed CPT on admission computed tomography (CT) scan. Four patients (44%) had associated intraabdominal injuries, but only 2 were significant. All patients were treated nonoperatively. Four patients (44%) had pseudocysts, and 3 required percutaneous drainage. Other complications included a single drainage of subphrenic collection, 1 inadvertent removal of drainage catheter, and 2 cases of line sepsis. The duration of percutaneous drainage was 14 to 60 days. The median length of hospitalization was 24 days (range, 6 to 52 days). After median follow up of 47 months, no patients showed exocrine or endocrine insufficiency. One patient had abdominal pain not related to the pancreatic injury. Follow-up abdominal CT scans in 8 of 9 patients showed complete atrophy of the body and tail in 6 patients and 2 completely normal glands. Conclusions: Pancreatic transection is rare and commonly is found in isolation of other major abdominal injuries. No patients required surgery for their pancreatic transection. Pseudocysts can be managed effectively with percutaneous drainage. After a median follow-up of 47 months, no patients had endocrine or exocrine dysfunction. Anatomically, the distal body and tail usually atrophies; however, occasionally, the gland can heal and appear to recanalize. To the authors' knowledge, this is the first report to show the effectiveness of nonoperative management after complete pancreatic transection. J Pediatr Surg 36:823-827. Copyright © 2001 by W.B. Saunders Company.

A CASE OF TRAUMATIC PANCRETIC TRANSECTION IN WHICH THE PANCREATIC FUNCTION WAS SUCCESSFULLY PRESERVED BY PANCREATOGASTROSTOMY

We successfully treated a patient with traumatic pancreatic transection by pancreatogastrostomy aiming at the preservation of the pancreas. A 32-year-old woman was seen at the hospital by an ambulance car for a traffic accident. Fracture of the right medial malleolus of the tibia and traumatic left hemopneumothorax were noted. The patient was admitted to the hospital. On admission no abdominal abnormalities were found out and abdominal ultasonography also revealed no abnormality in the abdominal cavity. Epigastric pain occurred about 6 hours after the trauma and re-ultrasonography visualiged a small tumorous mass in the body of the pancreas. Injury of the pancreas was suspected. Ultrasonography was performed in different times thereafter and an enlargement of the tumor was shown. After emergency endoscopic retrograde cholan-giopancreatography (ERCP), an emergency operation was carried out with a diagnosis of complete pancreatic transection. The pancreas was completely transected at the body. Entertaining her age, we employed a pancreatogastostomy for the purpose of preserving the body and tail of the pancreas. The post-operative course was uneventful without any complications. The pancreatic function has been kept in a good condition. We often see reports of removing the tail-side pancreas for pancreatic transection in a review of the literature. In terms of preservation of the pancreas, pancreatogastrostomy appears to be recommended, because it permits less anastomoses and minimal complications.

Surgical management of acute pancreatic injuries in children

This study was undertaken to review traumatic injuries of the pancreas in children. Fifty-one children from 2 to 16 yr of age underwent 52 operations for pancreatic injuries over a 37-yr period at Jefferson Davis Hospital, Ben Taub General Hospital, and Methodist Hospital in Houston. Nineteen sustained penetrating injuries, and 32 received blunt trauma. Twenty-one of the children with blunt trauma and none of those with penetrating injuries had elevated serum amylase concentrations on admission. Forty-seven patients were operated on acutely, and 1 patient was operated on 10 days following injury. Four patients were operated on for complications of pancreatic injury following previous laparotomy. Immediately following injury 19 children were found to have through-and-through perforation or laceration, 21 were found to have pancreatic contusion, and 11 were found to have complete transection of the pancreas. Findings at operation for complications of pancreatic injury included three pseudocysts and one pancreatic fistula with complete transection of the pancreas. One hundred and fifty-one associated injuries, including 16 vascular injuries, were found; they ranged from 1 to 10 per patient. Seven operative procedures were employed. In 32 children external drainage only was performed; pancreatorrhaphy and external drainage were performed in 6 children; distal pancreatectomy was used in 7 children following complete pancreatic transection. Two patients, one with postoperative fistula formation with transection of the pancreas, required distal pancreatojejunostomy and oversewing of the proximal pancreatic stump. Two patients with severe duodenal injury and transection of the head of the pancreas underwent Whipple procedures. Two patients with pseudocysts had cystogastrostomies, and 1 patient had external drainage. Operative deaths occurred in 4 children and were the result of complications unrelated specifically to pancreatic injury. Fourteen patients developed complications of pancreatic injury: 11 pancreatic fistulas and 3 pseudocysts. Surgical indications, operative technique, and complications are presented in detail. The management of pancreatic injuries in children begins with diagnosis. All patients sustaining penetrating abdominal injuries should be explored, and those with blunt trauma should be evaluated on physical findings, with peritoneal lavage and determinations of serum amylase concentration serving as supportive evidence. The presence of a pancreatic injury always warrants external drainage, preferably with soft Penrose drains. Salvage of the distal gland following transection is preferred if the patient's condition permits, if the spleen is intact, and if the distal gland is not in need of debridgement. Pancreatic fistula is the most common complication of pancreatic trauma, but it rarely presents a management problem and usually is closed by the second postoperative week.