PANCREATIC INJURY

Dr A Rajsekar

A 45 year old male patient was transferred from a peripheral hospital 5 days after admission following a road traffic accident. He was driving a car which had collided with a lorry. On admission he was haemodynamically stable. Abdominal examination revealed features of peritonitis. He also had left brachial plexus injury. Ultrasound of the abdomen revealed significant free fluid and the pancreatic tail could not be visualised properly. Laparotomy was performed and showed features of traumatic pancreatitis (Figure 1).

The stomach, greater omentum and transverse colon were inflamed and densely adherent to one another. After careful dissection, the lesser sac was entered. The head and body of the pancreas were felt to be normal. However the tail of the pancreas was surrounded by necrotic tissue and structures could not be identified (Figure 2).

Figure 2 Necrotic tissue around the tail of the pancreas

Necrosectomy was performed and two 34 F intercoastal drains were placed around the tail of the pancreas. The abdomen was closed primarily. The patient recovered without complications. The drain output remained over 100mls of serosanginous fluid even by the 14th post-operative day. The patient was discharged home with the pancreatic drain in-situ.

He was followed up in the out-patient clinic weekly and on the third visit patient was complaining of intermittent fever and left upper quadrant pain. The drain fluid was purulent. A CT scan showed a mutiloculated collection around the tail of the pancreas and the transverse mesocolon. The drain was lying anterior to the collection. Laparotomy showed extensive adhesions between omentum and transverse colon. After careful dissection the lesser sac entered. There was further necrotic tissue with pus around the area of the tail of the pancreas. Necrosectomy was again performed and more drains placed around the tail of pancreas. A feeding jejunostomy was fashioned.

Figure 3 Laparotomy showing the necrotic tissue around the tail of the pancreas

Figure 4 Necrosectomy specimen

Figure 5 Pancreatic bed drains and feeding jejunostomy

He made good progress in the immediate post-operative period but on the 5th post operative day he developed features of ARDS and required ventilatory support. On the 10th postoperative day feaculent discharge appeared in the drains. Laparotomy revealed no further necrosis and the leak was found to be from the jejunostomy which was taken down. He required ventilatory and inotropic support for few days and gradually recovered. He was discharged home with the drain placed in the perisplenic region.

Figure 6 Laparotomy for closure of jejunostomy leak shows no necrosis

Figure 7 Patient discharged home with a drain placed in the perisplenic region

The drain was shorted on weekly basis and was removed after a month.