Indian Association of Surgical Gastroenterology, XXII National Conference of Indian Association of Surgical Gastroenterology

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Traumatic pancreatic transection: Do we always have to resect? An Experience.
manish kumar khare, Gaurav Kohli, Tarun Naik, Manish Dewangan

Last modified: 2012-08-20

Abstract


Introduction and Background:

 In this era of high speed vehicular accidents, the incidence of pancreatic trauma has risen. It commonly presents as pancreatic duodenal complex injuries and isolated pancreatic trauma is less common. Reported incidence has been estimated to be 1% to 2% in patients with blunt or penetrating trauma and can be as high as 3% to 12% in patients with other intra-abdominal injuries.  Management, as has been described in standard text are simple drainage to more radical procedures like distal pancreatectomy with or without splenectomy and pancreaticoduodenectomy in cases of compound injuries of head/ampullary avulsion.

Resection of whole or part of pancreas will lead to considerable exocrine and endocrine deficiency and in some cases, will render the patient pancreatic cripple

We wish to share our recent experience with three cases where we were able to salvage the whole of pancreas without any morbidity or mortality

We think that in certain subset of traumatic pancreatic transection, (without any parenchymal mutilation), and early pick up where pancreatitis has not set in, hence, the following mentioned technique may be adapted.

Aim:

This is not a designed study; we wish to share our experience with management of traumatic pancreatic transection with good results

Patients and Method:  

An 18 year old male patient presented to us on 26th October 2010 with a history of being run over by a tractor. Patient’s general condition was poor with unstable haemodynamic. After basic investigations he was taken up for emergency exploratory laparotomy. On opening up the abdomen the duodenum was found to be transected at the junction of D1 & D2. The pancreas was also found to be transected at the head region in the line of SMV. A primary repair of the duodenum was done over a controlled duodenal fistula with a T- Tube, one limb of which was placed beyond the pylorus into the stomach. The head of the pancreas was closed and a roux loop of the jejunum was anastomosed with the pancreatic duct over a 16G IV cannula (end to side). This was a duct to mucosa anastomosis. Duct to mucosa anastomosis was done using 5-0 PDS and 4 preplaced sutures used in the Posterior, anterior, superior and inferior placement. A feeding jejunostomy was done. This patient was operated within 6 hours of presentation.

                                   

Another 32 year old male patient presented to us on 8th November 2010 with a history of trauma to the abdomen by a bullock cart wooden log in upper abdomen when he was riding a bike at high speed. Patient had an abrasion over the epigastric region with tenderness over same region and mild guarding and rigidity. Patient’s hemodynamic status was stable at the time of presentation and was not deteriorating further hence patient was investigated further with a high suspicion for pancreatic injury. On CT scan of the abdomen the pancreas was found to be transected at the level of head/ body of pancreas. Patient was taken up for emergent surgery and an end to end primary ductal anastomosis was done over a 18 G Epidural catheter which was used to stent .to bridge the long rent between the two fractures fragments of pancreas .the ductal anastomosis was done using 5-0 PDS.The parenchyma was repaired over the anastomosis in the similar fashion using 3-0 prolene. Feeding jejunostomy was done. This patient was operated within 24 hours of presentation.

Next Case, a 22 year male patient presented to us on 12th November 2010 with a history of trauma to the abdomen by bike handle. He had no surface abrasions or lacerations, but had tenderness in the epigastric region. This patient was also hemodynamically stable at the time of presentation and maintained the hemodynamic status and hence patient was investigated further. The CT scan abdomen was suggestive of pancreatic transection at the midbody region. Patient was taken up for surgery and the pancreatic duct was stented with a 16 G epidural catheter over which it the duct was anastomosed in an end to end fashion. The pancreatic parenchyma was repaired over the ductal repair using 3-0 prolene. Feeding Jejunostomy was done. This patient was also operated within 24 hours of presentation

A 4th case , 45 year old male patient presented on 2nd April 2012 with a history of severe abdominal pain after an alleged history of sustaining a blunt trauma to abdomen after collision with high velocity vehical. Patient was hemodynamically stable , an oval erythematous impression was present over his epigastrium indicative of injury. There was generalized tenderness with guarding and rigidity. On clinical examination , patient was shifted to the O.R and laparotomy done. Pancreas was found to be transected overlying Sep. Mesentric Vein. With D-J junction disruption.  An epidural catherter of 10 F was passed into the undilated pancreatic duct and end to end primary repair done with 4-0 PDS. Pancreatoraphy was done with prolene 4-0 and primary repair of DJ was done. Feeding Jejunostomy was done even in this case.

Results:  

The 1st patient had bile leak from the drain site once oral sips were started controlled on the 3rd post-operative day which reduced in quantity and stopped on its own on the 6th post-operative day. Feeding was started by the feeding jejunostomy on the 3rd post-operative day and graduated to oral feeds by 6th post-operative day. This patient then had an uneventful post-op course and was discharged on 14th post-operative day with blocked controlled fistula. This fistula T tube was removed on the 28th day after contrast study. The follow-up of 15 months  did not reveal any endocrine/exocrine deficiency.

The 2nd patient had an uneventful post-op course and enteral feeding started by FJ on the 3rd post-operative day and graduated to oral on 6th day. He was discharged on the 9th post-operative day. MRCP done 6 weeks after the surgery revealed stent in situ. He underwent upper GI endoscopy after 12 weeks, which did not reveal any stent in situ (emerging from ampulla).(? Migration).

The 3rd patient also had an uneventful post-op course with enteral feeding initiated on 3rd post-op day and switched to oral by 5th day. He was discharged on the 10th post-op day. The follow up MRI done after  8 weeks showed parenchyma and ductal continuity with no demonstrable stricture.it was represented by linear signal intensity in post-op MRI.

In 4th case, F/J was strted on 2nd day . the drain in lesser sac started to drain approximately 1200ml/day bile. This was controlled by gradual slow removal of the drain, leading to spontaneous stopping of bile drain on 10th day.MRCP done after 6 weeks shows healed pancreas and no stricture at repair area.

First 3 patients have a follow-up of 18months, and last has a F/u of 3 months with no exo/endo deficiency.

The follow up MRI and MRCP was done of the 3 cases of primary repair, which showed a continuity in the pancreatic duct, with no stricture formation and near normal pancreatic tissue. There is no pseudo-pancreatic cyst, collection or pancreatic necrosis.

Disscussion:

 Interestingly all the injuries were grade 5 injuries and were diagnosed early which led to the successful management of the injuries. We tried to salvage the pancreatic parenchyma which was not crushed and was a clean cut transection. One case was reconstructed as after central pancreatectomy and in two cases primary ductal repair over a stent followed by parenchymal repair was done. We wish to discuss the variables involved in the uneventful postoperative period and early recovery. One common factor was that these patients were taken up for surgery within 24 hour of injury. Early intervention in stable patient could make a vital difference. All patients belonged to young age group with no other comorbidities. Follow up is of 18 months. They were investigated for exocrine and endocrine deficiency and none were found. A 18 month follow up shows no parenchymal abnormality, or PD stricture.

Conclusion:

Primary repair of pancreatic transection with end to end ductal anastomosis over a stent and parenchymal repair is possible. One can opt for pancreatico-gastrostomy . Other option is reconstruction as after central pancreatectomy. With patience, undilated duct could be cannulated. We used no. 16G and 18G epidural catheter to bridge the rent because of its length. 

Why we did it :

1. Early Intervention, Young Patients, No other organ injury (in two cases)

2. Clean transection of parenchyma without any crushing with good vascularity(parenchymal preservation)

3. Undilated duct could be identified and cannulated bridging the long gap using epidural catheter.

4. Organ/Parenchymal Preservation is the norm of the day.

References:

1.                  Pseudopancreatitis in Trauma Patients. Olga R. Brook1, Doron Fischer1, Daniela Militianu1, Ayelet Eran1, Ludmila Guralnik1, Shlomi Israelit2 and Ahuva Engel1

http://www.ajronline.org/content/193/3/W193.abstract

2.                  Computed tomography of pancreatic trauma. R B Jeffrey, Jr, M P Federle and R A Crass

http://radiology.rsna.org/content/147/2/491.short

3.                   Pancreaticoduodenal injuries: re-evaluating current management approaches. S Afr J Surg. 2010 Feb;48(1):10-4. Chinnery GE, Madiba TE.

4.                  Safety of repair for severe duodenal injuries. World J Surg. 2008 Jan;32(1):7-12. Velmahos GC, Constantinou C, Kasotakis G.

5.                  Pancreatic and duodenal injuries: keep it simple. ANZ J Surg. 2005 Jul;75(7):581-6. Rickard MJ, Brohi K, Bautz PC.

6.                  Primary repair of blunt pancreatic transection. Injury.2004 Jan;35(1):29-34. Review. Aucar JA, Losanoff JE.

7.                  Successful primary repair of complete pancreatic disruption caused by
blunt abdominal trauma: a report of two cases. Surgery. 1998 Jun;123(6):702-5.
Hashimoto T, Otobe Y, Matsuo Y, Nakamura T, Suzuki T, Shimizu Y, Hayashi S,
Manabe T.

8.                  Challenges in the management of pancreatic and duodenal injuries. J Natl Med Assoc. 1993 Oct;85(10):767-72. Moncure M, Goins WA.

9.                  A case of primary repair of pancreatic transection.Injury. 1987 Sep;18(5):354-5. Raymond SP, Dane TE.

Pancreatic injuries. Diagnosis, treatment.AORN J. 1991 Apr;53(4):917-8, 920-1, 924-

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