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MANAGEMENT OF PENETRATING PANCREATIC
HEAD TRAUMA WITH DRAINAGE: CASE
REPORT
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Background
The definitive management of severe injuries
involving the head of the pancreas is still
controversial. The objective of this study
is to present one patient with ductal
disruption (grade IV pancreatic injury)
successfully treated by drainage at the time
of surgery.
Case report
A 25-year-old man was admitted
at the emergency room with two abdominal
gunshot injuries. The patient was with RTS
of 7.1. An exploratory laparotomy was
performed. A grade II injury of the liver
(segment III), a through-and-through lesion
of the stomach (grade II), a gonadal vein
injury and a pancreatic injury (grade IV)
were found perioperatively. A transection of
the pancreatic head, overlying the junction
of the splenic and superior mesenteric veins
was visualized, with minimal evidence of
desvitalization. The assessment of the
ductal status intraoperatively was
considered and not indicated. The lesion was
treated by external drainage with closed
suction drains. The patient developed a
fistula with output of 300-400 ml per day. A
CT scan performed on the 3rd postoperative
day showed transection of pancreatic head,
edema and peripancreatic fluid, with drain
in place. A second CT, eleven days after the
surgery, showed regression of pancreatic
edema and fluid collection. ERCP was done on
the 16th postoperative day, and showed
complete disruption of the major duct in the
head with extravasation of the contrast
media. Total parenteral nutrition was the
initial method of feeding and octreotide was
used since the 6th day after surgery. The
drain output rapidly decreased and oral
feeding was initiated twenty days after
surgery. The patient had pneumonia. The last
drain was removed on the thirty
postoperative day. The patient was
discharged forty five days postinjury and
remained asyntomatic at 1-year, with an
unrestricted diet.
Conclusions
In this case, the lesion was
treated by external drainage considering
that wipple procedure or distal
pancreatectomy have high morbitdity. The
patient had post-traumatic fistula with long
hospital stay, successfully managed
expectantly.
