Successful nonoperative management by endoscopic and percutaneous drainage for penetrating pancreatic duct injury: a case report

Abstract Background 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. 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 presentation A 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. Conclusions Although 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.

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Novel Promising Technique for Traumatic Pancreatic Injury Management.

10.21203/rs.3.rs-35661/v1 ◽

2020 ◽

Author(s):

Mohammed Hamada Takrouney ◽

Vipul Prakash Bothara ◽

Bhushan Jahhav ◽

Mohamed Abdelkader Osman ◽

Ibrahim Ali Ibrahim ◽

...

Keyword(s):

Pancreatic Duct ◽

Median Time ◽

Main Pancreatic Duct ◽

Primary Repair ◽

Pancreatic Injury ◽

Pancreatic Trauma ◽

Average Hospital ◽

Pancreatic Injuries ◽

The Status ◽

Average Operative Time

Abstract Introduction: Pancreatic injuries in children are relatively uncommon. The precise location of the injury, the status of the main pancreatic duct, and the time between diagnosis and intervention are a potentially useful guide for management decisions. We report a successful endoscopic simple primary repair with the pancreatic preservation even with transected main pancreatic duct without duct stenting.Patients and Methods: Between May 2017and December 2019, 3 patients with pancreatic trauma and duct transection underwent endoscopic (laparoscopic and robotic) repair. Demographics, Operative data, Postoperative complications, and clinical outcomes were documented and analyzed.Results: Three patients with pancreatic fractures, 2 patients with grade IV, and one patient grade III injury. The median age was 11 years, the median time of hospital admission after the trauma was 72 hours. The median time of surgical intervention was 24 hours. Average operative time was160 minute and the average hospital stay was 9 days with no recorded postoperative or follow up complications till now.Conclusion: Primary simple pancreatic repair is a promising and plausible technique for the management of pancreatic trauma, especially with duct transaction it maybe instead of all other modalities of pancreatic trauma treatment. We implore all pediatric surgery centers to espouse this technique.

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Efficacy of damage control surgery and staged endoscopic pancreatic ductal double stenting therapy for severe pancreatic head injury: a case report

Journal of Medical Case Reports ◽

10.1186/s13256-021-02995-z ◽

2021 ◽

Vol 15 (1) ◽

Author(s):

Futoshi Nagashima ◽

Satoshi Inoue ◽

Daisaku Matsui ◽

Yuki Bansyoutani ◽

Rina Tokuda ◽

...

Keyword(s):

Head Injury ◽

Pancreatic Duct ◽

Damage Control ◽

Pancreatic Head ◽

Damage Control Surgery ◽

Pancreatic Injury ◽

Drainage Tube ◽

High Grade ◽

Endoscopic Nasopancreatic Drainage ◽

Nasopancreatic Drainage

Abstract Background A high-grade pancreatic injury is a life-threatening injury that is associated with high mortality and morbidity. It is currently unclear which treatment strategy results in good clinical outcomes. Case presentation A 23-year-old Japanese woman sustained severe injury in a motor vehicle accident. Abdominal computed tomography revealed severe pancreatic head injury with extravasation of contrast media. Since it was not possible to insert an endoscopic pancreatic stenting tube into the main pancreatic duct, damage control surgery was performed. On day 3, we could insert the endoscopic pancreatic stenting tube from the ampulla of Vater and an endoscopic nasopancreatic drainage tube in the distal pancreatic duct from the accessory ampulla before the second operation. Drainage tubes were placed around the pancreatic head in the second operation. The endoscopic nasopancreatic drainage tube tube was converted to endoscopic pancreatic stenting tube on day 9. On day 51, the patient was discharged on foot from our hospital without serious complications. Conclusion Early and effective hemostasis, staged pancreatic duct drainage with stenting, and surgical external drainage around the pancreas in combination with an endoscopic procedure and damage control surgery were considered appropriate therapeutic strategy for high-grade pancreatic injury.

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Pancreas-preserving double pancreaticogastrostomy after traumatic injury to the head of the pancreas: a case report

Journal of International Medical Research ◽

10.1177/0300060520962967 ◽

2020 ◽

Vol 48 (10) ◽

pp. 030006052096296

Author(s):

Yuichi Aoki ◽

Hideki Sasanuma ◽

Yuki Kimura ◽

Akira Saito ◽

Kazue Morishima ◽

...

Keyword(s):

Gastrointestinal Bleeding ◽

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Traumatic Injury ◽

Pancreatic Head ◽

Pancreatic Injury ◽

Roux Limb ◽

Pancreas Head ◽

Pancreatic Fluid ◽

Head Of The Pancreas

Traumatic injury to the main pancreatic duct requires surgical treatment, but optimal management strategies have not been established. In patients with isolated pancreatic injury, the pancreatic parenchyma must be preserved to maintain long-term quality of life. We herein report a case of traumatic pancreatic injury with main pancreatic duct injury in the head of the pancreas. Two years later, the patient underwent a side-to-side anastomosis between the distal pancreatic duct and the jejunum. Eleven years later, he presented with abdominal pain and severe gastrointestinal bleeding from the Roux limb. Emergency surgery was performed with resection of the Roux limb along with central pancreatectomy. We attempted to preserve both portions of the remaining pancreas, including the injured pancreas head. We considered the pancreatic fluid outflow tract from the distal pancreatic head and performed primary reconstruction with a double pancreaticogastrostomy to avoid recurrent gastrointestinal bleeding. The double pancreaticogastrostomy allowed preservation of the injured pancreatic head considering the distal pancreatic fluid outflow from the pancreatic head and required no anastomoses to the small intestine.

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Successful combination strategy of preoperative placement of an endoscopic nasopancreatic drainage catheter and pancreas preservation surgery for pancreatic injury with major pancreatic duct disruption: a case report

Surgical Case Reports ◽

10.1186/s40792-019-0743-1 ◽

2019 ◽

Vol 5 (1) ◽

Author(s):

Kenji Kandori ◽

Wataru Ishii ◽

Ryoji Iizuka

Keyword(s):

Pancreatic Duct ◽

Pancreatic Resection ◽

Pancreatic Injury ◽

Combination Strategy ◽

Pancreatic Body ◽

First Case ◽

Endoscopic Nasopancreatic Drainage ◽

Pancreas Preservation ◽

Nasopancreatic Drainage ◽

Grade Iii

Abstract Background The guidelines recommend pancreatic resection for grade III and IV pancreatic injuries. On the other hand, organ preservation is an important issue. Herein, we present the first case of pancreatic injury with major pancreatic duct (MPD) disruption that was treated with the combination of preoperative placement of endoscopic nasopancreatic drainage (ENPD) catheter and pancreas preservation surgery after endoscopic pancreatic stenting (EPS) failure. Case presentation A 70-year-old female diagnosed with pancreatic injury was admitted to our hospital. She was hemodynamically stable. ERP revealed MPD disruption, and EPS failed. An ENPD catheter was placed preoperatively at the site of injury. During laparotomy, we identified a partial-thickness laceration in the pancreatic body. At the site of injury, the tip of the ENPD catheter was found; therefore, the patient was diagnosed with grade III pancreatic body injury with MPD disruption. The extent of crush was not severe, and we had no difficulty in identifying the distal MPD segment. We inserted the ENPD catheter into the distal MPD segment. The ruptured MPD and the laceration was sutured, then pancreatic resection was prevented. She was discharged on POD 56. Conclusion The treatment strategy incorporated ERP, placement of an ENPD catheter preoperatively, and a simple surgery in a hemodynamically stable patient with pancreatic injury allows the pancreas and spleen to be preserved.

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Improvement of the Diagnosis of Isoattenuating Pancreatic Carcinomas by Defining their Characteristics on Contrast Enhanced Computed Tomography and Endosonography with Fine-Needle Aspiration (EUS-FNA)

Diagnostics ◽

10.3390/diagnostics11050776 ◽

2021 ◽

Vol 11 (5) ◽

pp. 776

Author(s):

Robert Psar ◽

Ondrej Urban ◽

Marie Cerna ◽

Tomas Rohan ◽

Martin Hill

Keyword(s):

Computed Tomography ◽

Pancreatic Cancer ◽

Pancreatic Duct ◽

Fine Needle Aspiration ◽

Pancreatic Head ◽

Needle Aspiration ◽

Characteristic Analysis ◽

Fine Needle ◽

Contrast Enhanced ◽

Secondary Signs

(1) Background. The aim was to define typical features of isoattenuating pancreatic carcinomas on computed tomography (CT) and endosonography and determine the yield of fine-needle aspiration endosonography (EUS-FNA) in their diagnosis. (2) Methods. One hundred and seventy-three patients with pancreatic carcinomas underwent multiphase contrast-enhanced CT followed by EUS-FNA at the time of diagnosis. Secondary signs on CT, size and location on EUS, and the yield of EUS-FNA in isoattenuating and hypoattenuating pancreatic cancer, were evaluated. (3) Results. Isoattenuating pancreatic carcinomas occurred in 12.1% of patients. Secondary signs of isoattenuating pancreatic carcinomas on CT were present in 95.2% cases and included dilatation of the pancreatic duct and/or the common bile duct (85.7%), interruption of the pancreatic duct (76.2%), abnormal pancreatic contour (33.3%), and atrophy of the distal parenchyma (9.5%) Compared to hypoattenuating pancreatic carcinomas, isoattenuating carcinomas were more often localized in the pancreatic head (100% vs. 59.2%; p < 0.001). In ROC (receiver operating characteristic) analysis, the optimal cut-off value for the size of isoattenuating carcinomas on EUS was ≤ 25 mm (AUC = 0.898). The sensitivity of EUS-FNA in confirmation of isoattenuating and hypoattenuating pancreatic cancer were 90.5% and 92.8% (p = 0.886). (4) Conclusions. Isoattenuating pancreatic head carcinoma can be revealed by indirect signs on CT and confirmed with high sensitivity by EUS-FNA.

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Pancreatic trauma: proposal for management algorithm

International Surgery ◽

10.9738/intsurg-d-20-00015.1 ◽

2020 ◽

Author(s):

Daisuke Hashimoto ◽

Tomohisa Yamamoto ◽

So Yamaki ◽

Kazuhito Sakuramoto ◽

Rintaro Yui ◽

...

Keyword(s):

Interventional Radiology ◽

Mortality Rate ◽

Pancreatic Duct ◽

Conservative Management ◽

Main Pancreatic Duct ◽

Surgical Techniques ◽

Postoperative Mortality ◽

Pancreatic Trauma ◽

Endoscopic Nasopancreatic Drainage ◽

Nasopancreatic Drainage

IntroductionPancreatic trauma is potentially lethal despite recent improvements in surgical techniques and conservative management. However, no guidelines for the management of pancreatic trauma have been established. In this report, we propose an algorithm for the management of pancreatic trauma based on our experience of nine cases and a literature review.Case presentationThis study included nine patients with pancreatic trauma (five men and four women). The patients’ median age was 40 years (range, 17–75 years). The overall mortality rate was 22.2%, and the postoperative mortality rate was 16.7%. Superficial trauma was present in two patients. Deep trauma without injury to the main pancreatic duct was present in one patient, and this patient was treated successfully with endoscopic nasopancreatic drainage. Active bleeding was present in two patients and controlled by interventional radiology. Deep trauma with injury to the main pancreatic duct was present in six patients. Among them, one patient died after conservative treatment with endoscopic nasopancreatic drainage. The other five patients underwent surgery (pancreatic resection in four and necrosectomy in one).ConclusionThe herein-described algorithm recommends interventional radiology for active arterial bleeding, conservative management for trauma without ductal injury, and surgery for trauma with ductal injury. This algorithm may provide a basis for future establishment of guidelines.

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