https://orcid.org/0009-0006-8496-0587
Abstract
Blunt pancreatic trauma is rare and often associated with delayed diagnosis and significant morbidity, particularly in the presence of ductal injury. We report an 18-year-old female presenting 10 days after minor blunt abdominal trauma with worsening epigastric pain and vomiting. Imaging revealed a Grade IV pancreatic injury with transection at the neck and main duct disruption. She successfully underwent distal pancreatectomy and splenectomy, with an uncomplicated postoperative course and no evidence of endocrine or exocrine insufficiency on follow-up. This case highlights the challenges of delayed presentation in isolated pancreatic trauma and supports operative management for high-grade injuries with ductal involvement.
Introduction
Pancreatic trauma is rare, accounting for between 0.2% and 2% of all trauma patients [1–3]. The retroperitoneal placement often protects the pancreas from blunt injury, but blunt injuries account for ~20%–30% of all pancreatic trauma cases [3, 4]. They carry a mortality of up to 35%, but a large portion of deaths are attributed to concomitant extra-pancreatic injuries [3, 5]. Delayed management is associated with increased morbidity and mortality [5]. Surgical management options for severe injuries are limited and carry significant morbidity and mortality. Here we present a rare case of isolated blunt pancreatic trauma with a delayed presentation and the attendant surgical management.
Case report
An 18-year-old woman was referred to a trauma centre after presenting with complaints of abdominal pain and vomiting for 10 days after sustaining a single kick to the upper abdomen. She experienced sudden onset epigastric and supraumbilical pain, which progressively worsened. The pain was associated with multiple episodes of bilious vomiting and upper abdominal distention but normal bowel habits.
On examination, she was anicteric, acyanotic, and afebrile with normal vital signs except for a mild tachycardia of 106 bpm. Tenderness with associated guarding and rebound was elicited in the epigastrium and left hypochondrium. Fullness was noted in the epigastrium, but no discrete mass. Bowel sounds were normal. Rectal examination was unremarkable.
Her laboratory investigations were normal. Computed tomography (CT) of the abdomen and pelvis demonstrated a linear lucent defect running across the anterior and posterior margins of the neck of the pancreas, consistent with a laceration with disruption of the main pancreatic duct (Fig. 1). Moderate volume peri-pancreatic and pelvic free fluid was noted with moderate fat stranding in the peri-pancreatic tissues.
CT abdomen/ pelvis, axial view – Grade IV (AAST) pancreatic injury.
A diagnosis of a Grade IV American Association for the Surgery of Trauma (AAST) pancreatic injury secondary to blunt abdominal trauma was made, and the patient was prepared for surgery.
A reversed modified Makuuchi incision was used to enter the abdomen (Fig. 2).
Modified reverse Makuuchi incision.
Significant inflammatory changes were noted to the viscera and omentum in the upper abdomen (Fig. 3). The gastrocolic ligament was divided, and the stomach was reflected cephalad to access the lesser sac.
Intra-operative picture demonstrating severe peri-pancreatic inflammation.
After careful dissection and mobilization, a distal pancreaticosplenectomy was performed (Figs 4 and 5).
Intra-operative picture demonstrating pancreatic laceration.
Operative specimen – distal pancreaticosplenectomy.
A 6–0 prolene was used to ligate the main pancreatic duct, and the parenchyma was controlled with horizontal mattress sutures. A closed active drain was placed in the lesser sac before standard mass closure.
Her postoperative course was uneventful. On Day 2, she was commenced on and tolerated diet. The drain amylase done on Day 3 post-op was 91, and the drain was discontinued. She was discharged on postoperative Day 4 and received her usual post-splenectomy vaccination organisms 2 weeks later. Her reviews in the surgical outpatient department have been unremarkable, with no evidence of exocrine or endocrine insufficiency.
Discussion
Blunt pancreatic injury is rare, being reported in <2% of all cases of blunt trauma and up to 40% of pancreas-specific trauma [3]. Pancreatic injury typically results from a sudden localized application of force to the upper abdomen, with the energy being transmitted through the anterior abdominal wall to the viscera and ultimately to the pancreas, where a compressive force is exerted on the pancreatic parenchyma, mainly the neck, onto the vertebral column, particularly at the L1 vertebral level [1–3, 6]. While high-energy mechanisms typically result in immediate presentation, minor blunt trauma can present in a delayed fashion and run a more insidious clinical course, as was seen in our patient. The delayed presentation of 10 days observed in this case suggests an evolving injury or sequestration of an injury. The initial minor blunt force compressing the pancreas against the vertebra may cause a localized contusion or partial ductal disruption. The pancreas, being enveloped within the retroperitoneum and further contained anteriorly by the lesser sac, does not immediately result in generalized peritonitis [3]. This anatomic containment effectively but temporarily masks the severity of the injury while progressive autodigestion of the pancreatic parenchyma occurs, eventually culminating in complete transection and severe symptomatic presentation days later [7]. Concomitant multi-visceral injury is seen in over 90% of cases, making the isolated injury seen in our presented patient even more distinctive [3].
The main determinants of management include the patient's clinical status, the degree and location of the injury, and the presence of/degree of duct disruption. Non-operative management has been recommended for Grades I–II injury. This includes bowel rest with nasogastric decompression, serial abdominal evaluation and monitoring of serum amylase levels. Nutritional support, such as total parenteral nutrition, may be necessary. Peri-pancreatic drain placement may be considered when collections are present [2, 3]. For higher-grade injuries, non-operative management may include endoscopic retrograde cholangiopancreatography (ERCP) with stent placement, but may result in increased morbidity, including acute pancreatitis, pseudocyst formation, sepsis, fistula formation, abscess formation, and death. Duct stenosis post-ERCP is also a recognized sequelae after stent removal, warranting re-intervention [3, 8].
The Eastern Association for Surgery for Trauma conditionally recommends operative intervention for image-confirmed Grade III / IV pancreatic injury, mirroring the recommendation from Soreide et al. and Potoka et al. in their statements on pancreatic trauma [2, 3, 8, 9]. These findings mirrored those of other series where both morbidity and mortality rates were reduced for injuries with ductal disruption treated with surgery compared to drainage only [2]. In patients who undergo an operation in the acute period for non-pancreatic-related injuries and are discovered to have a low-grade pancreatic injury, no pancreas-specific intervention is indicated [2, 8, 10]. Our patient, who was found to have a Grade IV injury on CT, met the criteria for operative intervention. Little evidence directly examines delayed presentation; however, some studies suggest increased morbidity and hospital stay [2].
A reversed modified Makuuchi incision provided optimal access to the supracolic and lesser sac compartments. Improved ergonomics, with better access to deeper structures, make this incision ideal for complex hepatobiliary trauma, where visualization and control are critical compared to a standard midline incision [11]. A resection-based approach is recommended for high-grade pancreatic injuries [2, 3, 8, 10]. Closure of the divided parenchyma may be achieved with sutures or staples, with no significant difference in outcome [12]. Splenic preservation is preferred if patient stability and technical feasibility allow [8, 10]. The hostile milieu created by the degree of local inflammation and the need for swift definitive control in this case made the distal pancreatectomy with en bloc splenectomy a safer and more pragmatic choice. There is limited evidence regarding the reimplantation of distal pancreatic tissue via a pancreaticojejunostomy. Given the relatively low morbidity and mortality of the resection approach, we, the authors, discourage re-implantation, as no clear evidence exists of long-term benefit, and the potential morbidity associated with pancreaticoenteric anastomoses, including fistula formation [2]. We additionally posit that the reimplanted distal remnants may undergo atrophy and thus not contribute significantly to exocrine or endocrine function. Drain placement and removal following pancreatectomy remains divisive, but intraoperative placement and early removal in the absence of a demonstrated post-operative fistula remains a safe and effective strategy [6].
In conclusion, isolated blunt pancreatic neck transection can present deceptively late after minor trauma due to the containing effect of the lesser sac and gradual enzymatic autodigestion. A high index of suspicion, optimized surgical exposure via a modified Makuuchi incision, and adherence to established trauma and International Study Group for Pancreatic Surgery guidelines for resection and postoperative management are critical for achieving excellent clinical outcomes.
Conflicts of interest
None declared.
Funding
None declared.
