Blunt Pancreatic Injury in Major Trauma: Decision-Making between Nonoperative and Operative Treatment

Abstract

Blunt trauma injuries to the pancreas are rare but are associated with significant overall mortality and a high complication rate. Motor vehicle collisions are the leading cause of blunt pancreatic trauma, followed by falls, and sports injuries. We discuss the decision-making process used during the clinical courses of 3 patients with life-threatening blunt pancreatic injuries caused by traumatic falls. We also discuss the utility of the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS), which provides a system for grading pancreatic trauma. Retrospectively, the cases reviewed were classified as AAST-OIS grade II, III, and IV in each one patient. Although the nonoperative approach was initially preferred, surgery was required in each case due to pseudocyst formation, pancreatic necrosis, and posttraumatic pancreatitis. In each case, complete healing was achieved through exploratory laparotomy with extensive lavage and placement of abdominal drains for several weeks postoperatively. These cases show that nonoperative management of pancreatic ductal trauma results in poor outcomes when initial therapy is less than optimal.

Figure 1

(Patient 1, scan 1) 18 days after trauma. CT scan of the abdomen showing pancreatitis with large expanding pseudocysts with a maximum diameter of 8 cm in the pancreas head-corpus transition area. Pigtail drainage was placed with guidance from CT in the fluid accumulation/pseudocyst from the left flank side. The drainage system emptied brown-tinged serous fluid.

Figure 2

(Patient 1, scan 2) CT scan 25 days after trauma. After iatrogenic removal of drainage, a large retrogastric pseudocyst with a surrounding capsule was observed. Obviously, a narrow aisle was found where fluid accumulation continued to expand caudally below the transverse column. The pseudocyst was again punctured from the left lateral side with 9.5 French Lunderquist drainage, and contrast medium was injected into the pseudocyst cavity. There was a narrow connection path for retrogastric fluid accumulation. Thus, all the caves were drained adequately.

Figure 3

(Patient 1, scan 3) CT scan 4 months after trauma. Compared to the previous CT scan, no additional evidence of new pseudocyst or abscess formation was found. The drains that were previously placed in the bursa omentalis were removed.

Figure 4

(Patient 2, scan 1) CT scan 15 days after trauma and admission after hospital referral. CT scan after the introduction of drainage from the left lateral to the retroperitoneal. The pancreas appears to be altered beside the corpus and the tail. In particular, hypointense formation in the pancreatic body is shown in the ventral part of the pancreas due to the injury. It connects with the remaining drainage. Free fluid is shown in the perihepatic and perisplenic areas.

Figure 5

(Patient 2, scan 2) CT scan 22 days after trauma. Compared to the CT scan 7 days ago, there was an increase in septate fluid accumulation in the bursa omentalis and peripancreatically in the demarcation of the Gerota fascia. Drainage from the left side was still present. In the case of known pancreatic injury, the pancreas has a linear (sometimes up to 1 cm subtotal) interruption of the parenchyma, as in the case of subtotal rupture in the distal third of the pancreas corpus. The other parts of the pancreas were homogeneously contrasted. There was a significant increase in perihepatic ascites and no abscesses.

Figure 6

(Patient 3, scan 1) CT scan 19 days after trauma and 17 days after laparotomy due to pancreatitis. Drainage at the level of the upper abdomen placed along the left hepatic lobe of the pancreas head and body. There are discrete air pockets between the left hepatic lobe and the pancreatic head. The pancreas appears to be vigorous and slightly blurred. In the peripancreatic tissue, low-density increases are observed. No new liquid formations are observed.