Case series: Management and outcomes of five cases of blunt and open pancreatic trauma

Introduction

Pancreatic trauma is far less common than trauma to other solid organs such as the liver or spleen.^1,2 Despite their rarity, pancreatic injuries can be potentially serious, with mortality rates ranging from 5 to 30% and morbidity rates reaching 50%.¹ The management of pancreatic injuries remains controversial. Therapeutic options are numerous, and the indications are often challenging owing to anatomical complexity, the extent of the lesions, and their intimate contact with neighboring organs.

This work has been reported in line with the PROCESS criteria.¹

Methods

Our study aimed to describe the clinical and biological characteristics of pancreatic trauma and identify diagnostic and therapeutic modalities. This retrospective study was conducted from 2010 to 2021 in the General Surgery Department of Mahmoud El Matri Hospital, Ariana, TUNISIA. Five patients with blunt pancreatic and open trauma were included in the study. Analysis of these five observations yielded the following results (Table 1):

Results

Case 1

A 16-year-old boy, who was a victim of a physical assault (involving multiple punches and kicks to the abdomen), was admitted for blunt abdominal trauma. Upon examination, the patient was conscious and showed stable vital signs. Tenderness was evident in the upper abdominal region. Abdominal computed tomography (CT) revealed a transverse fracture at the junction of the pancreatic body and tail with moderate hemoperitoneum (Figure 1). The injury was classified as grade II according to the Lucas classification.³

Figure 1. Portal phase abdominal CT scan showing the fracture line in the body-tail junction of the pancreas (Yellow arrow).

Based on the patient’s stable hemodynamics and relatively favorable physical examination findings, a non-operative treatment approach was considered. The clinical course was uneventful, and the patient was discharged on the 4th day. A follow-up abdominal CT scan conducted 14 days after the incident revealed a pancreatic fracture accompanied by two interconnected collections, one located caudally and the other occupying the lesser sac, of 9.7 × 7 × 9.3 cm (Figure 2). The patient is asymptomatic.

Figure 2. CT scan showing the two pancreatic interconnected collections (white asterisk: pancreatic pseudo-cyst, yellow arrow: pancreatic tail collection).

On the 27th day following the accident, the patient presented with epigastric pain and postprandial vomiting. A subsequent CT scan demonstrated a pancreatic fracture, with communication to a 24 mm collection in the tail (Figure 3). This collection was also found to be interconnected with a bulky pseudocyst of the pancreas, which measured 100 × 70 × 90 mm, resulting in a mass effect on the stomach and provoking anterior displacement (Figure 3).

Figure 3. CT scan showing the pancreatic pseudocyst (white asterisk) with mass effect on the stomach (yellow arrow).

Magnetic Resonance Cholangiopancreatography (MRCP) was performed to confirm the communicative nature of the pancreatic pseudocyst (Figure 4).

Figure 4. MRCP showing the communicative nature of the pseudocyst (Yellow arrow: Wirsung duct).

Esophagogastroduodenoscopy revealed no gastric varices, and the patient underwent endoscopic cystogastric drainage with double-ended pigtail placement. The clinical outcomes were favorable. Four years after the accident, the patient reported no complaints, and exhibited no signs of diabetes.

Case 4

A 33-year-old patient was admitted to the emergency ward following a physical assault, resulting in blunt abdominal trauma. Physical examination revealed a conscious patient with low blood pressure and tachycardia, indicating a severe hemodynamic condition. Abdominal examination revealed tenderness of the epigastric region. Abdominal ultrasound revealed abundant intra-abdominal fluid, suggestive of abundant hemoperitoneum.

The patient underwent urgent laparotomy. Intraoperative exploration revealed abundant hemoperitoneum secondary to pancreatic isthmus injury. The duodenum is unaffected. No other injuries were noted. Peritoneal lavage was performed and a large drain was positioned in close proximity to the pancreas. The postoperative course was uneventful and the surgical drain was removed after 18 days.

A follow-up CT scan before discharge (Figure 5) revealed a transverse fracture at the isthmus-body junction of the pancreas. Injury was categorized as grade II according to the Lucas classification.³

Figure 5. Axial view from a follow-up abdominal CT scan showing a complete proximal section of the pancreas (yellow arrow).

Another CT scan, conducted two months after the accident, revealed a 17 mm pseudocyst. The decision was made to respect the pseudocyst.

After 12 months of follow-up, the pseudocyst remained asymptomatic and did not increase in size, as evidenced by subsequent pancreatic MRI (Figure 6).

Figure 6. Axial view of a biliary MRI showing a stable pancreatic pseudocyst (yellow arrow).

A CT scan performed 2 years after the initial trauma showed complete disappearance of the pseudocyst.

Case 5

A 30-year-old man was admitted to our hospital following a road traffic accident. He was the driver of a car involved in a head-on collision with the steering wheel impacting his abdomen, resulting in blunt abdominal trauma. Physical examination revealed tenderness in the epigastric region. His hemodynamic parameters were within the normal ranges. His hemoglobin level were 14.1 g/dL, and his lipase level was recorded as 528 U/L, respectively.

An abdominal CT scan (Figure 7) revealed a laceration in segment III of the liver and a transverse fracture of the body of the pancreas, accompanied by a disconnection syndrome, and peri-pancreatic and pouch Douglas effusions. No other visceral injury was observed. Injury was categorized as grade I according to the Lucas classification.³

Figure 7. Abdominal CT scan showing the transverse fracture of the pancreas (yellow arrow).

Non-operative treatment was initiated, and a follow-up CT scan at 72 hours showed regression of the hepatic laceration and stability of the pancreatic lesion.

After clinical and biological improvements, the patient was discharged 14 days after hospitalization.

An abdominal CT scan after 3 weeks revealed 20 mm fluid collection in the lesser sac, suggesting a pancreatic pseudocyst.

Eleven months post-accident, the pseudocyst had disappeared on the CT scan, with complete restitution of the pancreas, and the patient remained completely asymptomatic.

Discussion

Pancreatic trauma is much rarer than trauma involving other solid organs, such as the liver or spleen.^1,2 In the United Kingdom Trauma and Research Network (TARN), among 356,000 trauma patients, PD injuries accounted for 0.32%.⁴ Although liver, spleen, and kidney injuries are more common, pancreatic injuries occur in less than 10% of all abdominal traumas.¹

In an acute setting, the diagnosis of a pancreatic injury should adhere to the general principles applicable to all trauma patients. Trauma patients with hemorrhagic shock should be promptly taken to the operating room for vigorous resuscitation and exploratory laparotomy, with foregoing radiological exploration to prevent treatment delays.

It is essential to recognize that the initial clinical indicators of pancreatic injury are nonspecific and laboratory assessments often lack specificity. Elevations in lipase and amylase levels are generally modest and nonspecific during the first 6 h following an accident,⁵ and they do not necessarily correlate with more severe pancreatic injuries.⁶

An abdominal CT scan with a pancreatic protocol exhibits a sensitivity of approximately 80% and reduced sensitivity for injuries to the Wirsung duct.⁷ CT scans may reveal peri-pancreatic effusion, pancreatic laceration, contusion with varying degrees of parenchymal engagement, or even pancreatic fractures with or without contrast extravasation. CT scans also evaluate canal involvement and duodenal injury, establishing the foundation for the Lucas classification.³

Pancreatic MRI or Wirsung-MRI, along with endoscopic retrograde cholangiopancreatography (ERCP), exhibits a sensitivity of nearly 100%.⁷ MRI has the advantage of being non-invasive and can be conducted on trauma patients in stable condition to assess pancreatic or canal injuries.^8,9

The presence of an intra-parenchymal hematoma could compress the Wirsung duct, resulting in a loss of the duct signal at this level. This signal loss should be distinguished from an actual discontinuity or ductal section. Endoscopic retrograde cholangiopancreatography (ERCP) was performed both diagnostically and therapeutically. Despite being an invasive procedure, it is the gold standard for Wirsung exploration. It allows differentiation between compression and (complete or incomplete) ductal sectioning while also initiating the management of these lesions by placing a stent within the Wirsung duct.¹⁰

Given the infrequency of pancreatic traumas, management recommendations and strategies rely on consensus guidelines with limited levels of evidence.^10–15 The severity of pancreatic trauma can range from mild symptoms resembling pancreatitis to severe damage involving the pancreatic parenchyma, occasionally leading to complete gland section. Therapeutic options include nonoperative conservative management, surgical treatment, and endoscopic interventions. Decisions hinge on the patient’s hemodynamic stability, imaging quality, type and severity of the pancreatic lesion, canal involvement, associated injuries, and available technical capabilities.

Conservative treatment is recommended for patients with equivalent of “traumatic pancreatitis” with limited pancreatic involvement without canal or duodenal injuries. It is also appropriate for Lucas type I pancreatic trauma (pancreatic contusion or laceration with limited parenchymal involvement, without canal or duodenal injury).

Management in a surgical intensive care unit includes pain control with analgesics, gastrointestinal rest until symptoms regress, and digestive intolerance if present. Proton pump inhibitors were administered to prevent stress ulcers, and the volume status was restored. The administration of somatostatin or its synthetic analogs was also carried out to inhibit pancreatic exocrine secretion and reduce postoperative morbidity in patients with pancreatic trauma,^13,14 although some authors and the consensus of the Eastern Association for the Surgery of Trauma in 2017 questioned the beneficial effects of somatostatin.^12–16

After blunt pancreatic trauma, when canal involvement is confirmed, endoscopic treatment may be considered for hemodynamically stable patients without other associated injuries. Endoprosthesis placement can play a central role in the management and healing of canal injuries.¹⁷ In a systematic review, Björnsson et al. suggested that early ERCP and canal stenting can lead to symptom resolution and canal healing in 30–100% of cases.¹⁸ The success rate of endoscopic treatment for duct lesions is 98%, both in the acute phase and in cases of complications such as pseudocysts or pancreatic fistulas.¹⁷ Encouraging results have been reported in published series, but cases of secondary canal stenosis have also been reported.^19–21

For patients with limited canal rupture, simple superficial debridement of the pancreatic abrasion with pancreatic drainage in the lesser sac is recommended. Medium-depth parenchymal injuries without canal involvement can be sutured with epiploplasty, which may reduce the duration of drainage.^22,23 However, the nature (aspiration vs. passive) and duration of drainage remain controversial. Pancreatic resection may be necessary in cases of a duct rupture.

Left pancreatectomy is recommended for distal pancreatic lesions, especially corporocaudal lesions. For cephalic pancreatic lesions, cephalic duodenopancreatectomy, a major and morbid procedure, is still a viable option, aiming to prevent peritoneal contamination by digestive fluid leaking through a duodenal perforation. Some authors support delaying immediate restoration of digestive continuity when the patient’s hemodynamic status is unstable, following the concept of “shortened laparotomy”.²⁴ In our study, pancreatic resection was avoided even in cases of duct rupture (cases 2 and 5).

Cephalic duodenopancreatectomy (DPC) should remain an exceptional indication for dilation of the head of the pancreas and duodenum, with severe vascular injuries.

Conclusion

Pancreatic trauma presents a complex clinical challenge, requiring a comprehensive approach that takes into account various factors, such as the severity of the injury, anatomical location, and patient condition. Diagnostic modalities, including advanced imaging techniques such as CT, Wirsung-MRI, and ERCP, play a pivotal role in accurate assessment. Although conservative management remains a viable option for select cases, endoscopic interventions have emerged as effective tools for treating canal injuries, offering a high success rate and contributing to optimal patient outcomes. Surgical interventions, such as duodenopancreatectomy, should be reserved for specific and severe cases, ensuring a balanced treatment approach. Continued research and collaboration are essential to further refine our understanding of pancreatic trauma management and to enhance patient care in these challenging scenarios, with the aim of proposing guidelines to facilitate decision-making for management.

Ethical approval

Ethical approval: Patient approval was provided. This study was exempt from ethical approval by our institution (Medical University of Tunis).

Consent for publish

Written informed consent for the publication of this case and the associated images was obtained from the patient.

Author contributions

Anis BELHADJ: Supervision, Validation Visualization

Med Dheker TOUATI: Writing – Original Draft Preparation

Mohamed Raouf Ben Othmane: Conceptualization, Data curation

Fahd KHEFACHA: Conceptualization, Writing – Original Draft Preparation

Ahmed Bouzid: Formal Analysis

Ahmed SAIDANI: Supervision, Validation Visualization

Faouzi CHEBBI: Supervision, Writing – Review & Editing