Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2002  |  Volume : 8  |  Issue : 3  |  Page : 96-98
Conservative management of traumatic pancreatic fistula


Department of Surgery and Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia

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Date of Submission17-Apr-2001
Date of Acceptance06-Jul-2002
 

How to cite this article:
Al Sebayel MI, Khalaf HA, Al Mofleh IA, Shibli SY, Abu Ella KA. Conservative management of traumatic pancreatic fistula. Saudi J Gastroenterol 2002;8:96-8

How to cite this URL:
Al Sebayel MI, Khalaf HA, Al Mofleh IA, Shibli SY, Abu Ella KA. Conservative management of traumatic pancreatic fistula. Saudi J Gastroenterol [serial online] 2002 [cited 2019 Aug 19];8:96-8. Available from: http://www.saudijgastro.com/text.asp?2002/8/3/96/33399


Both blunt and penetrating pancreatic traumas have been associated with fistula formation. The injury is usually detected at laparotomy; with fistulae occurs either as a complication of pancreatic resection or as a result of an undetected pancreatic ductal disruption, with pancreatic secretions noted from the drains postoperatively. The operative versus non­operative management of major pancreatic ductal injuries remains controversial. In recent year, non­operative means including bowel rest, total parenteral nutrition, pancreatic secretion inhibitors and endoscopic management, have gained increasing acceptance and was successful in 40-90% of patients [1],[2],[3] . Failure of conservative treatment has traditionally been dealt with using surgery; however, significant morbidity and mortality are associated with operative treatment [4],[5] This case reports non­operative approach, which was successfully adopted in a patient who would have otherwise considered as candidates for surgery.


   Case Report Top


A 20-year-old male patient was referred to King Khalid University Hospital, Riyadh, Saudi Arabia with history of blunt abdominal trauma while playing football five weeks prior to his referral. He was admitted in a local hospital with signs of peritonitis and hence his abdomen was explored at the same night of admission. About 1000ml of blood was evacuated. There was a transverse laceration across the body of the pancreas. The pancreatic duct could not be visualized in the lacerated area. No other injury was detected.

The pancreatic laceration was repaired with silk suture and a wide bore drain was inserted in the lesser sac up to the 27th day postoperative day. The drain continued to drain pancreatic secretions. Upon receiving the patient, his drain was bringing an average of 200m1 of pure pancreatic juice daily. The patient was then investigated further. Abdominal ultrasonography showed dilatation of the pancreatic duct (4mm) from the neck region to the tail. There was a vertical lucency over the neck of the pancreas, which was attributed to the acoustic shadow of the suture line. The rest of the abdomen was normal. CT scan showed a pancreatic fracture at the neck region with moderate dilatation of pancreatic duct distal to the fracture. There was minimal peri­pancreatic reaction and the drainage catheter was seen with its tip lying at the gastrohepatic ligament just superior to the pancreas [Figure - 1]. Endoscopic retrograde cholangiole-pancreatography (ERCP) showed disruption of the main pancreatic duct with a leak at the region of the neck and failure to visualize the rest of the pancreatic duct [Figure - 2]. Endoscopic papillotomy of pancreatic orifice done which was uneventful. The patient was kept NPO and was managed with total parenteral nutrition (TPN). Octreotide was started at a dose of 50 mcg S/C 6 hourly. For two weeks, the drainage reduced in amount to an average of 15 cc/24h. Enteral feeding was started on the 22nd days after admission through a naso-jejunal tube with a rate of 83cc per hour of (vital) till midnight and to be resumed again at 6 a.m. for one week. Patient tolerated it well with complete cessation of the pancreatic drainage. The patient was then started on normal diet without any adverse effect. A repeated CT scan showed no significant interval change. The drainage tube was removed and the patient was discharged in a good condition. He was well with no significant problem on subsequent follow up (more than one year).


   Discussion Top


Blunt pancreatic injuries (BPI) are rare and often not suspected, leading to a prolonged interval between injury and diagnosis. Main pancreatic duct (MPD) injury is the principle cause of fistula formation and any delay in recognizing MPD injury leads to increased mortality and morbidity. [6] Therefore, timely diagnosis is the most difficult aspect of BPI. Although serial serum amylase levels and CT scan may help in diagnosing parenchymal injuries, they are of limited value in diagnosing MPD injury. [3],[6],[7],[8] Endoscopic retrograde pancreatography (ERP) should be done whenever MPD injury is suspected. ERP provides not only a conclusive diagnosis, but also an effective and safe non-operative treatment tool [3],[9] Even when the diagnosis of post-traumatic pancreatic fistula is established, opinions differ regarding the optimal form of management. Most agree that pancreatic fistulas should be managed primarily by conservative means, and that operative management should be reserved to failures of conservative treatment, MPD injury, peritonitis, and associated duodenal injury [6],[10],[11],[12] The introduction of endoscopic techniques in managing patients with traumatic pancreatic fistulas has gained increasing acceptance over the past decade, this approach has been extended to patients with MPD injury previously considered as candidates for surgery aiming to avoid the significant morbidity and mortality associated with operative treatment [3]

.In our patient the pancreatic injury was not associated with severe tissue damage; however the main duct was completely disrupted. Since he was referred to us with an external drainage tube, and because of his stable condition, we felt that a more conservative approach was warranted despite the condition of the main pancreatic duct. We therefore recommend, selectively, a more conservative approach in the management of pancreatic duct injury in the form of TPN followed by enteral feeding and octreotide therapy. Patients selected for this approach should be stable with no evidence of abdominal sepsis and with minimal soft tissue injury.

 
   References Top

1.Lansden FT, Adams DB, Anderson MC. Treatment of external pancreatic fistulas with somatostatin. Am Surg. 1989; 55: 695-8.  Back to cited text no. 1    
2.Vitale G, MacLeod S. Pancreatic Trauma in Scottish Children. J R Coll Surg Edinb 2002; 47: 520.  Back to cited text no. 2  [PUBMED]  
3.Goffette PP, Laterre PF. Traumatic injuries: imaging and intervention in post-traumatic complications (delayed intervention). Eur Radiol 2002; 12: 994­-1021.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Ridgeway MG, Stabile BE. Surgical management and treatment of pancreatic fistulas. Surg Clin North Am 1996;76:1159-73.  Back to cited text no. 4  [PUBMED]  
5.Farrell RJ, Krige JE, Bomman PC, Knottenbelt JD, Terblanche J. Operative strategies in pancreatic trauma. Br J Surg 1996; 83: 934-7.  Back to cited text no. 5    
6.Bradley EL 3rd, Young PR Jr, Chang MC, Allen JE, Baker CC, Meredith W, Reed L, Thomason M. Diagnosis and initial management of blunt pancreatic trauma: guidelines from a multiinstitutional review. Ann Surg 1998; 227:861-9.  Back to cited text no. 6    
7.Olsen WR. The serum amylase in blunt abdominal trauma. J Trauma 1973: 13: 200-4.  Back to cited text no. 7    
8.Wright MJ, Stanski C. Blunt pancreatic trauma: a difficult injury. South Med J 2000; 93: 383-5.  Back to cited text no. 8  [PUBMED]  
9.Costamagna G, Mutignani M. Ingrosso M. Vamvakousis V, Alevras P, Manta R, Perri V. Endoscopic treatment of postsurgical external pancreatic fistulas. Endoscopy 2001: 33: 317-22.  Back to cited text no. 9    
10.Loungnarath R, Blanchard H, Saint-Vil D. Blunt injuries of the pancreas in children. Ann Chir 2001; 126: 992-5.  Back to cited text no. 10  [PUBMED]  
11.Haller JA Jr. Papa P, Drugas G. Colombani P. Nonoperative management of solid organ injuries in children. Is it safe? Ann Surg 1994; 219: 625-31.  Back to cited text no. 11    
12.Farrell RJ, Krige JE, Bornman PC, Knottenbelt JD, Terblanche J. Operative strategies in pancreatic trauma. Br J Surg 1996; 83: 934-7.  Back to cited text no. 12  [PUBMED]  

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Correspondence Address:
Mohammed Ibrahim Al Sebayel
P 0 Box 952, Riyadh 11352
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19861800

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