It is early evening in the trauma bay and an extraordinarily
polite young man has just arrived with a posterior thoracoabdominal stab wound
just to the left of his T10 vertebrae. He is completely stable and comfortable,
but his positive “cell-phone sign” does not tell the whole story. CT imaging of
his abdomen clearly demonstrates a grade III laceration through the superior
pole of his left kidney. What is less clear is the question of an associated
pancreas injury.
Pancreatic trauma is a rare phenomenon historically
occurring in less than 5% of abdominal trauma.1 The absolute number
of traumatic pancreatic injuries may be small, however this injury has received
attention in the literature due to the associated morbidity and mortality. Injury
to the pancreas has been quoted as carrying a mortality rate as high as 46%,
although this is confounded by the mortality burden from the associated injuries
to adjacent structures.1 The American Association for the Surgery of
Trauma (AAST) defines any injury from any mechanism that involves the
pancreatic duct as Grade III or above.2 In one center’s experience mortality
associated with injury grade III or above effectively doubled the mortality
from 22% to 42% and doubled overall morbidity from 37.8% to 75%.3
Information about main pancreatic ductal integrity is premium, but not just for
prognosis. The Eastern Association for the Surgery of Trauma’s (EAST) guidelines
recommend simple closed suction drainage alone for Grade I or II injuries, and
resection and drainage for all injuries grade III or above.4
The stability of our patient allowed the luxury of
pre-operative imaging. MRCP has been shown to be an effective way to evaluate
the main pancreatic duct making it an intriguing imaging option.5 ERCP
has a reported sensitivity of only 75% and carries with it the risk of
exacerbating a disruption or causing pancreatitis, while CT imaging is only
around 50% sensitive for ductal injury.6,7 In our patient’s MRCP a
pancreas injury was clearly suggested, but no ductal injury was imaged.
Observation alone was briefly entertained by the group
before he developed peritonitis and was taken to the operating room. A recent survey
of a national database for pancreaticoduodenal injury revealed that from
1998-2009 53.4% of pancreas injuries were managed non-operatively.1
Upon exploration our patient was found to have a grade II through and through
laceration to the superior portion of the body of the pancreas without ductal
injury. He was successfully treated with a closed-suction drain and made a good
recovery.
References
1. Ragulin-Coyne E, Witkowski ER, Chau Z, Wemple D, Ng SC,
Santry HP, Shah SA, Tseng JF. National trends in pancreaticoduodenal trauma:
interventions and outcomes. HPB (Oxford). 2014 Mar;16(3):275-81
2. The American Association for the Surgery of Trauma.
Injury Scoring Scale: A Resource for Trauma Care Professionals. 2014. http://www.aast.org/library/traumatools/injuryscoringscales.aspx#pancreas
Accessed: December 13, 2014.
3. Antonacci, et al. Prognosis and treatment of
pancreaticoduodenal traumatic injuries: which factors are predictors of
outcome? J Hepatobiliary Pancreat Sci (2011) 18:195–201
4. The Eastern Association for the Surgery of Trauma.
Pancreatic Trauma, Diagnosis and Management of. 2009. http://www.east.org/resources/treatment-guidelines/pancreatic-trauma-diagnosis-and-management-of
Accessed: December 13th, 2014.
5. Rekhi S, Anderson SW, Rhea JT, Soto JA. Imaging of blunt
pancreatic trauma. Emerg Radiol (2010) 17:13–19.
6. Gillams AR, Kurzawinski T, Lees WR. Diagnosis of Duct
Disruption and Assessment of Pancreatic Leak with Dynamic Secretin-Stimulated
MR Cholangiopancreatography. AJR 2006; 186:499–506.
7. Phelan et. al. An Evaluation of Multidetector Computed
Tomography in Detecting Pancreatic Injury: Results of a Multicenter AAST Study.
J Trauma. 2009;66:641–647.
from Dr. Joshua Nash
No comments:
Post a Comment