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.