Complete disruption of the main pancreatic duct: a case successfully managed by percutaneous drainage

Percutaneous drainage treatment of traumatic pancreatic rupture with pancreatic transection

Management of traumatic pancreatic pseudocyst associated with pancreatic duct laceration is controversial. Surgical therapy has been clasically considered the treatment of choice for those pseudocysts. However, several authors have published good results with percutaneous drainage. Percutaneous drainage can be performed easily, with minimal complication and may facilitate the resolution of a pseudocyst. We present a case of a 16-year-old boy who sustained blunt abdominal trauma in a vehicle accident. A large pancreatic pseudocyst developed, with complete disruption of the main pancreatic duct. Percutaneous drainage under ultrasound guidance was performed and was associated with the administration of octreotide (to inhibit exocrine pancreatic secretion). The drainage flow decreased gradually until ceasing, and the pseudocyst disappeared.

[Blunt injuries of the pancreas in children]

STUDY AIM

Conservative management is mainly proposed for pancreatic trauma without ductal injuries. The aim of this retrospective study was to assess our experience with traumatic pancreatic injuries and to compare patients with medical or surgical treatment.

PATIENTS AND METHOD

From January 1989 to December 1998, 21 children, 13 boys and 8 girls with a mean age of 8 years (range: 1 to 17 years) were treated for pancreatic injuries. Main mechanisms of injuries were bicycle's falls (n = 7), passengers in motor vehicle collision (n = 6), and other road collisions (n = 5). Diagnosis of pancreatic trauma in 17 patients was made through ultrasonography and/or CT scan. In 4 patients, the diagnosis was made intraoperatively. Associated injuries were splenic (n = 6), hepatic (n = 5) and duodenal (n = 5). Thirteen patients had only medical treatment and 8 patients required laparotomy. The two groups were comparable according to the rate of high grade pancreatic lesions.

RESULTS

Two complications, a pancreatic fistula and a pseudocyst, occurred in the operative group and improved spontaneously. One death due to a head trauma, one acute pancreatitis and seven pancreatic pseudocysts (six required percutaneous drainage), occurred after medical treatment. The mean hospital stay, shorter after medical treatment, was not significantly different between the two groups (26 days vs 32 days). During the follow-up, no late complications have been observed.

CONCLUSION

Traumatic pancreatic injuries are rarely lethal but are often associated with other intra-abdominal injuries. Conservative treatment is advocated for grade 1 to 4 isolated pancreatic injuries. This conservative approach may be associated with the development of post-traumatic pancreatic pseudocysts which are easily cured by percutaneous drainage.

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.

Nonoperative management of pancreatic injuries in children

PURPOSE

The safety and efficacy of nonoperative management of pancreatic contusions and transections was examined by reviewing the case histories of 35 consecutive children with pancreatic injuries treated over the past 10 years.

METHODS/RESULTS

Surgical exploration was performed for the management of associated injuries only. The diagnosis of pancreatic trauma was suspected in children with abdominal pain, tenderness, elevated serum amylase levels and findings consistent with pancreatic injury on abdominal ultrasound scan or computerized tomography (CT) examination. After children were diagnosed with pancreatic injury, enteral feedings were withheld and total parenteral nutrition administered until abdominal pain resolved and serum amylase levels and radiographic findings improved. Twenty-three children received diagnosis within 24 hours of injury, and in 12, the diagnosis was delayed 2 to 14 days. Hyperamylasemia was found in 27 of 35 children. Twenty-eight children sustaining pancreatic injuries were treated nonoperatively. Abdominal imaging in these children demonstrated pancreatic contusion in 14, transection in 11, and pseudocyst in three. Enteral feeding resumed an average of 15 days after injury. The average hospital stay was 21 days. Pseudocysts formed in 10 children (2 of 14 with contusion; 5 of 11 with transection; three children presented late, and the type of pancreatic injury could not be determined), whose average hospital stay was 25 days. All pseudocysts were successfully managed nonoperatively, although percutaneous aspiration or drainage was required in six children. Children underwent follow-up for an average of 10 months after injury (range, 1 to 144 months). Abdominal pain and radiological abnormalities resolved in all children before discharge from the clinic.

CONCLUSIONS

Nonoperative management of pancreatic contusion and transection diagnosed radiologically is effective and safe. Pseudocysts may form after pancreatic injury, and if large or symptomatic, can be managed successfully by percutaneous drainage.

Management of traumatic pancreatic pseudocysts in children

Eight children with pancreatic injuries after blunt abdominal trauma are presented. One patient with pancreatitis without complications was treated successfully with medication; seven (87.5%) developed pseudocysts, which resolved spontaneously with conservative treatment in four cases (57.1%). Non-resolving pseudocysts in 3 patients finally required surgical intervention. Pseudocysts that resolve spontaneously and those that require surgical intervention can be distinguished. The two groups showed different time sequences in both serum amylase values and pseudocyst size. Analyses of these clinical data revealed three factors with significant predictive value. On the basis of these findings, a new management strategy for traumatic pancreatic pseudocysts in children is proposed. The cyst is likely to resolve spontaneously in cases showing any two or more of the following factors: (1) cyst presentation after day 6; (2) maximum serum amylase below 1,600 IU/l; and (3) serum amylase below 600 IU/l on day 20. However, early surgical intervention is required in the presence of two or more of the following: (1) cyst presentation before day 4; (2) maximum serum amylase above 1,900 IU/l; or (3) serum amylase above 1,200 IU/l on day 20.