Combination therapy with early nasopancreatic drainage and minimum surgery for blunt high‐grade pancreatic trauma

Abstract

Case

A 22‐year‐old man suffered blunt, high‐grade, pancreatic trauma; however, duct‐related complications were avoided by combining early nasopancreatic drainage with minimal surgery. Endoscopic retrograde pancreatography confirmed rupture of the main pancreatic duct and massive retroperitoneal extravasation. A nasopancreatic catheter was placed across the rupture site, laparotomy was carried out, and a grade IV pancreatic head laceration was sutured. Because the nasopancreatic catheter shifted out intraoperatively, another was inserted and left in place for 12 days.

Outcome

The patient recovered well without any duct‐related complications such as pseudocyst or external pancreatic fistula.

Conclusion

A combination of early therapeutic endoscopic retrograde pancreatography and surgical repair may be useful for treating high‐grade pancreatic trauma when pancreatic resection is unnecessary.

Introduction

Endoscopic retrograde pancreatography (ERP)—a useful diagnostic tool for pancreatic trauma—can also be used therapeutically (e.g., for endoscopic nasopancreatic drainage (ENPD) or transpapillary stenting) in patients with delayed duct‐related complications, such as pseudocyst or external pancreatic fistula.1 However, its role in acute pancreatic trauma has not been established. Here, we present a case of main pancreatic duct (MPD) injury due to blunt trauma managed by a combination of early nasopancreatic drainage and surgical repair, without subsequent duct‐related complications.

Case

A 22‐year‐old male driver presented to our unit 2 h after being injured in a car accident. He soon developed severe epigastric pain and vomiting, and pancreatic/duodenal injury was suspected; his vital signs were stable. Computed tomography (CT) revealed a low‐density discontinuity in the pancreatic head, retroperitoneal fluid accumulation around the duodenal C‐loop, and minor liver injury (Fig. 1). After CT, the patient became highly agitated by severe pain, and was sedated and intubated for further examination. Duodenoscopy showed a normal duodenal lumen and papilla. Endoscopic retrograde pancreatography confirmed partial disruption of the MPD in the pancreatic head, with vast extravasation of contrast medium and filling of the duct distal to the rupture site (Fig. 2). A guidewire was easily passed across the break to the distal duct, and a smooth ENPD catheter was advanced across the rupture, over the guidewire. The patient remained stable during ERP, and a laparotomy was scheduled.

Figure 1.

Initial computed tomography of a 22‐year‐old man who suffered blunt, high‐grade, pancreatic trauma revealed grade IV pancreatic injury, retroperitoneal fluid accumulation, and minor liver injury.

Figure 2.

Preoperative endoscopic retrograde pancreatography in a 22‐year‐old man who suffered blunt, high‐grade, pancreatic trauma showed extravasation of contrast medium with filling of the duct distal to the site of rupture.

During laparotomy, the Kocher maneuver was carried out to rinse out accumulated pancreatic juice from the periduodenal retroperitoneum. Then, the lesser sac was opened to investigate the extent of pancreatic damage, and a partial thickness laceration of the pancreatic head was found near the trunk of Henle. The pancreatic injury was grade IV, according to the Organ Injury Scale of the American Association for the Surgery of Trauma.2 We expected to locate the MPD break easily, as the ENPD catheter had been inserted preoperatively; however, the catheter was not found in the laceration as it had slipped out during the Kocher maneuver. The ruptured MPD was not easily identified until leaking pancreatic juice was detected. The MPD rupture was semicircular, and the posterior wall of the duct remained intact. The pancreatic parenchyma showed little damage, apart from the laceration, indicating the possibility of a simple restoration. The ruptured MPD was repaired with a single suture, and the laceration was closed with multiple sutures; the suture line was covered with an omental patch. A peritoneal drain was placed in both the lesser sac and Morison's pouch. A feeding jejunostomy was also fashioned. Surgical placement of pancreatic drainage through the jejunum was not carried out because it was considered too invasive and technically complex.

Postoperatively, the patient was sedated. On day 2, ERP was carried out again to reinsert the ENPD catheter. The distal MPD filled without major leakage, and another ENPD catheter with fixing flaps was easily inserted using a guidewire. The patient remained sedated to secure the ENPD catheter, and enteral feeding was initiated. Endoscopic nasopancreatic drainage was continued for 12 days, with approximately 1,000 mL pancreatic juice being drained daily. In contrast, little fluid was collected from the peritoneal drains, that is, minimal pancreatic ascites occurred. Before the ENPD catheter was removed, pancreatography revealed slight dilatation and irregularity of the MPD, without extravasation. The patient was extubated after ENPD was completed. Oral feeding was started and continued uneventfully; peritoneal drains were then removed.

The patient was discharged 41 days after the accident, without any MPD‐related complications. At the 3‐month follow‐up, the MPD appeared normal on magnetic resonance cholangiopancreatography, apart from slight dilatation (Fig. 3). At the 1‐year follow‐up, the patient was asymptomatic with no abnormal findings on CT.

Figure 3.

At the 3‐month follow‐up of a 22‐year‐old man who suffered blunt, high‐grade, pancreatic trauma, the main pancreatic duct appeared normal on magnetic resonance cholangiopancreatography, apart from slight dilatation.

Discussion

High‐grade (grade III–V) pancreatic trauma is typically treated surgically to prevent pancreatic ascites and fistulas.2 However, MPD disruption does not always require pancreatic resection if the parenchymal damage can be repaired. In this situation, ERP is useful for definitively diagnosing MPD disruption and also for supportive therapy.3 Theoretically, if the ERP contrast medium fills the duct, distal to the site of rupture, catheterization and bridging across the rupture can reduce the pressure on the distal duct and stop the leakage, thereby promoting healing. However, therapeutic ERP has conventionally been limited for managing delayed complications, including pseudocysts and fistulas, which result from incomplete healing of a ruptured duct, and for treating proximal duct injury in pediatric patients, allowing for the formation and drainage of a pseudocyst.4

Thus, experience in the use of early therapeutic ERP to avoid duct‐related complications in patients with high‐grade pancreatic trauma is limited. Early therapeutic ERP and conservative management are likely to result in successful treatment of relatively mild injuries with limited leakage of pancreatic fluid,5, 6 whereas the combination of early therapeutic ERP and surgery may be a better choice for patients with massive leakage in whom pancreatic resection is judged to be unnecessary.7, 8 In the present case, laparotomy was the sole option for draining the retroperitoneal fluid; however, the surgical procedure was minimally invasive, comprising the Kocher maneuver, irrigation, drainage, and suturing of the pancreatic laceration.

We consider ENPD to be more reliable than transpapillary stenting as a supportive surgery following pancreatic trauma because the physician can easily check the properties and amount of fluid draining through the catheter, flush the lumen when required, and carry out contrast studies as needed. These advantages compensate for the patient's discomfort during its short‐term use. Some authors have reported MPD stricture(s) after transpapillary stenting9 that are related to relatively long stenting durations. In our patient, an MPD stricture was not noted 3 months after discharge.

In the present case, because of the patient's stable general condition, preoperative ENPD catheterization could be safely and efficiently carried out with diagnostic ERP. The preoperatively inserted catheter was expected to aid in identifying and repairing the MPD rupture; however, the catheter shifted out of position during the Kocher maneuver. Therefore, we think that the initial use of an ENPD catheter with fixing flaps would have been preferable and that pancreatic exploration should have been performed before the Kocher maneuver. Regardless, intraoperative, but not preoperative, ENPD catheterization is desirable, if possible. Furthermore, postoperative ENPD is not recommended because of the risk of catheter breakage through a repaired duct, although this procedure was successful in the present case. The efficacy of surgical placement of pancreatic drainage is equal to that of ENPD; however, the procedure is more invasive and complicated, and does not fulfill the “minimal surgical intervention” recommended for pancreatic trauma.

This case demonstrated that duct‐related complications can be avoided after high‐grade pancreatic trauma by combining early ENPD with minimal surgery. This strategy is theoretically superior to aggressive surgery when the anatomical damage to the pancreas is slight, apart from MPD disruption. The present report is expected to encourage other surgeons to adopt a similar approach in the management of such injuries.

Conflict of Interest

None.