Conservative management of complete traumatic pancreatic body transection; A case report

An analysis of 77 cases of pancreatic injuries at a level one trauma center: Outcomes of conservative and surgical treatments

Backgrounds/Aims

Traumatic pancreatic injury (TPI) is rare as an isolated injury. There is a trend to perform conservative treatment even in patients with complete duct dissection and successful treatment. This study reviewed our 20 years of experience in the management of TPI and assessed patient outcomes according to age group and treatment strategy.

Methods

A retrospective analysis of patients diagnosed and treated with TPI at a level-I trauma center from 2000-2019. Patients were divided into two groups: adults and pediatrics. Conservative treatment cases were subjected to subgroup analysis. Level of evidence: IV.

Results

Of a total of 77 patients, the mean age was 24.89 ± 15.88 years. Fifty-six (72.7%) patients had blunt trauma with motor vehicle accident. Blunt trauma was the predominant mechanism in 42 (54.5%) patients. Overall, 38 (49.4%) cases had grade I or II injury, 24 (31.2%) had grade III injury, and 15 (19.5%) had grade IV injury. A total of 30 cases had non-operative management (NOM). Successful NOM was observed in 16 (20.8%) cases, including eight (32.0%) pediatric cases and eight (15.4%) adult cases. Higher American association for the surgery of trauma (AAST) grade of injury was associated with NOM failure (16.7% for grade I/II, 100% for grade III, and 66.7% for grade IV injury; p = 0.001). An independent factor for NOM failure was female sex (69.2% in females vs. 29.4% in males; p = 0.03).

Conclusions

High AAST grade TPI is associated with a high rate of NOM failure in both pediatric and adults.

Domestic violence and assault leading to isolated grade III pancreatic injury managed conservatively; A rare case report

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The haemodynamically stable grade III pancreatic injury may be managed conservatively.

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Assault with punching leading to isolated grade III pancreatic injury in an adult is extremely rare to occur.

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The decision of operation is mainly based on the clinical conditions of patients.

Introduction

Isolated complete pancreatic transection following blunt trauma abdomen is associated with very high mortality. Conservative management in such a scenario is a rare experience. Majority of the patients with American Association for Surgery of Trauma (AAST) grade III or IV pancreatic injury are treated with surgical options and have poor outcomes. As per the available literature we are reporting a rare case of isolated AAST grade III pancreatic injury managed conservatively in adult.

Case presentation

A 37-year-old female presented with complaints of severe epigastric pain with the alleged history of domestic violence. CECT of the patient suggested isolated pancreatic injury with complete transection of pancreas. Considering the clinical and hemodynamic status of the patient a trial of conservative management was started. Serial assessment of biochemical and clinical parameters depicted improvement in the clinical status of the patient. She was doing well at 6 months of follow up.

Discussion

Operative procedures in patients with high grade pancreatic injury are associated with high risk of mortality and morbidity. Emergency surgeries can be avoided in patient with stable clinical and haemodynamic status. In selected cases decision on the basis of radiology may lead to unnecessary surgeries, whereas conservative approach may have better outcomes.

Conclusion

Tailored approach in cases of high-grade pancreatic injury will augment the decision taking between operative and non-operative management. Clinical and haemodynamic status should play a pivotal role and radiology should be used as an adjunct for deciding the management.