Kanno Hiroki, Hirakawa Yusuke, Yasunaga Masafumi, Midorikawa Ryuta, Taniwaki Shinichi, Uchino Yoshihiro, Sasaki Shin, Kojima Satoki, Nomura Yoriko, Nakayama Goichi, Goto Yuichi, Sato Toshihiro, Kawahara Ryuichi, Sakai Hisamune, Ishikawa Hiroto, Hisaka Toru, Okuda Koji
Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan.
J Med Case Rep. 2021 Feb 3;15(1):33. doi: 10.1186/s13256-020-02647-8.
Pancreatic trauma is a rare condition with a wide presentation, ranging from hematoma or laceration without main pancreatic duct involvement, to massive destruction of the pancreatic head. The optimal diagnosis of pancreatic trauma and its management approaches are still under debate. The East Association of Surgery for Trauma (EAST) guidelines recommend operative management for high-grade pancreatic trauma; however, several reports have reported successful outcomes with nonoperative management (NOM) for grade III/IV pancreatic injuries. Herein, we report a case of grade IV pancreatic injury that was nonoperatively managed through endoscopic and percutaneous drainage.
A 47-year-old Japanese man was stabbed in the back with a knife; upon blood examination, both serum amylase and lipase levels were within normal limits. Contrast-enhanced computed tomography (CT) showed extravasation of the contrast medium around the pancreatic head and a hematoma behind the pancreas. Abdominal arterial angiography revealed a pseudo aneurysm in the inferior pancreatoduodenal artery, as well as extravasation of the contrast medium in that artery; coil embolization was thus performed. On day 12, CT revealed a wedge-shaped, low-density area in the pancreatic head, as well as consecutive pseudocysts behind the pancreas; thereafter, percutaneous drainage was performed via the stab wound. On day 22, contrast radiography through the percutaneous drain revealed the proximal and distal parts of the main pancreatic duct. The injury was thus diagnosed as a grade IV pancreatic injury based on the American Association for the Surgery of Trauma guidelines. On day 26, an endoscopic nasopancreatic drainage tube was inserted across the disruption; on day 38, contrast-enhanced CT showed a marked reduction in the fluid collection. Finally, on day 61, the patient was discharged.
Although the EAST guidelines recommend operative treatment for high-grade pancreatic trauma, NOM with appropriate drainage by endoscopic and/or percutaneous approaches may be a promising treatment for grade III or IV trauma.
胰腺创伤是一种罕见疾病，临床表现多样，从无主胰管受累的血肿或撕裂伤，到胰头的广泛破坏。胰腺创伤的最佳诊断及其治疗方法仍存在争议。东部创伤外科学会（EAST）指南推荐对高级别胰腺创伤进行手术治疗；然而，有几份报告称，对Ⅲ/Ⅳ级胰腺损伤采用非手术治疗（NOM）也取得了成功的结果。在此，我们报告一例通过内镜和经皮引流进行非手术治疗的Ⅳ级胰腺损伤病例。
一名47岁的日本男性背部被刀刺伤；血液检查显示血清淀粉酶和脂肪酶水平均在正常范围内。增强计算机断层扫描（CT）显示胰头周围造影剂外渗，胰腺后方有血肿。腹部动脉血管造影显示胰十二指肠下动脉有假性动脉瘤，且该动脉有造影剂外渗；因此进行了弹簧圈栓塞术。在第12天，CT显示胰头有一个楔形低密度区，胰腺后方有连续的假性囊肿；此后，通过刺伤伤口进行了经皮引流。在第22天，经皮引流管造影显示了主胰管的近端和远端。根据美国创伤外科学会指南，该损伤被诊断为Ⅳ级胰腺损伤。在第26天，通过破裂处插入了一根内镜鼻胰引流管；在第38天，增强CT显示积液明显减少。最后，在第61天，患者出院。
尽管EAST指南推荐对高级别胰腺创伤进行手术治疗，但通过内镜和/或经皮途径进行适当引流 的NOM可能是Ⅲ级或Ⅳ级创伤的一种有前景的治疗方法。
