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Complete disruption of the main pancreatic duct: A case successfully managed by percutaneous drainage
Complete Disruption of the Main Pancreatic A Case Successfully Managed by Percutaneous By Yasuharu
Ohno,
Hiroshi
Ohgami, Akira Nagasaki, Fukuoka, Japan
and Ryuichiro
Duct: Drainage Hirose
0 The authors report on a 7-year-old boy who sustained blunt abdominal trauma on a bicycle handlebar. A large traumatic pancreatic pseudocyst developed, for which percutaneous external drainage under ultrasound guidance was performed. Both the catheter fistulogram and endoscopic retrograde cholangiopancreatogram showed complete disruption of the main pancreatic duct. During continuous external drainage, the pseudocyst disappeared. The drainage flow decreased gradually and ceased. The patient is well, with normal endocrine and exocrine pancreatic functions, 2 years after discharge. Copyright o 1995 by W. B. Saunders Company INDEX WORDS: Pancreatic injury; major percutaneous external drainage, treatment.
ductal
disruption;
ERCUTANEOUS external drainage (PED) is one of the therapeutic procedures for traumatic pancreatic pseudocyst. la2PED may facilitate the resolution of a pseudyocyst and shorten the hospital stay. Even in an emergency patient with impending risk, PED can be performed easily, with minimal complication. In this report the authors describe a case of complete disruption of the main pancreatic duct successfully managed by PED.
P
CASE REPORT A 7-year-old boy was admitted to another hospital after sustaining blunt abdominal trauma from a bicycle handlebar. Upper abdominal pain and hyperamylasemia were suggestive of pancreatic injury. On day 1, ultrasound examination showed fluid collection in the body of the pancreas. Despite conservative treatment consisting of complete bowel rest with nasogastric suction and hyperalimentation, the pseudocyst increased in size. On day 51, PED was applied under ultrasound guidance. Because the drainage was poor, he was transferred to Fukuoka Children’s Hospital for further treatment, on day 62. At the time of admission, he complained of abdominal pain, and showed vomiting and a high fever. Catheter fistulogram did not show any specific findings, but diagnostic modalities showed a large pseudocyst measuring 11 cm in diameter (Fig 1). The drainage was confirmed to be ineffective, and additional PED through another route was applied on day 70. All the symptoms disappeared after this procedure was begun. The drainage flow was as high as 447 mL per day under subsequent conservative treatment. During management, both serial catheter fistulograms and endoscopic retrograde cholangiopancreatogram (ERCP) showed abrupt disruption of the pancreatic duct (Fig 2). Although we recommended operative options to the patient’s parents, they expressed a strong desire that the PED be continued because the patient was otherwise healthy.
Journa~ofPedjatr;cSurge~
Vol3O,Nol2
(December),l995:ppl741-1742
Fig 1. CT scene.. (A) CT scan on day 6 suggests transection of the body of the pancreas (arrows). (B) A large pseudocyst of the pancreas body displaces the stomach anteriorly (day 63).
Oral intake was started on day 105, and the drainage flow ceased on day 139. The drainage catheter was removed on day 161, and he was discharged on day 200. Although routine ultrasonography showed slight dilatation of the distal pancreatic duct, the boy remains asymptomatic, with normal growth. Follow-up ERCP has not been conducted because
From the Department of Pediattic SurgeT, Fukuoka Childrenk Hospital, Fukuoka, Japan. Address reprint requests to Yasuham Ohno, MD, Second Depatiment of Surgery, Nagasaki University School of Medicine, I-7-1 Sakamoto-machi, Nagasaki 852, Japan. Copyright Q 1995 by WB. Saunders Company 0022-3468i95l3012-0031$03.00l0
1741
OHNO
both endocrine and exocrine pancreatic normal for the 2 years since discharge.
functions
have
ET AL
remained
DISCUSSION
Traumatic pancreatic pseudocyst is a rather severe sequela of pancreatic injury in children. Because it often resolves spontaneously, the conditions and timing of surgical intervention remain controversial. PED is currently used with increasing frequency for pancreatic pseudocyst, even in children.3,4 However, there is widespread belief that the procedure cannot be applied if there is a complete ductal disruption without proximal drainage.s Early laparotomy has been advocated because of the concern of PED failure. However, we showed the effectiveness of PED even in a patient with complete disruption of the main pancreatic duct. With respect to the use of PED, the two points to be emphasized are that the original drainage catheter should be placed through a confirmed access route under ultrasound guidance and that the drainage catheter should always be positioned in the optimal drainage site under serial follow-up fistulograms. Proper catheter placement not only accelerates the drainage effect but also minimizes the risk of inappropriate ductal obstruction relating to compression of the catheter itself. Amelioration of the inflammatory process would promote recanalization of the major ductal system in children. To our knowledge, this is the first report of major ductal disruption successfully managed by PED. The observations in this case may extend the indications for PED in the treatment of traumatic pancreatic pseudocyst in children. REFERENCES 1. MacErlean DP, Bryan DJ, Murphy JJ: Pancreatic pseudocyst: Management by ultrasonographically guided aspiration. Gastrointest Radio1 5:255-257,198O 2. Torres WE, Evert aspiration and drainage genoll47:1007-1009,1986
MB, Baumgartner BR, et al: Percutaneous of pancreatic pseudocysts. Am J Roent-
3. Bass J, Lorenzo MDi, Desjardins JG, et al: Blunt pancreatic injuries in children: The role of percutaneous external drainage in the treatment of pancreatic pseudocysts. J Pediatr Surg 23:721-724, 1988
Fig 2. (A) ERCP on day 79 shows complete disruption of the main pancreatic duct (arrow). (B) Fistulogram on day 84 defines residual cyst with distal ductal communication. No opacification of the proximal duct is seen. (C) Fistulogram on day 100 shows a minute communication to the distal duct. There is complete resolution of the cyst, without opacification of the proximal duct.
4. Jaffe RB, Arata traumatic pancreatic 152:591-595, 1989
JA Jr, Matlak pseudocysts
ME: Percutaneous in children. Am
5. Rescorla FJ, Cory D, Vane DW, et al: Failure ous drainage in children with traumatic pancreatic Pediatr Surg 25:1038-1042,199O
drainage of J Roentgen01 of percutanepseudocysts.
J
Ohno,
Hiroshi
Ohgami, Akira Nagasaki, Fukuoka, Japan
and Ryuichiro
Duct: Drainage Hirose
0 The authors report on a 7-year-old boy who sustained blunt abdominal trauma on a bicycle handlebar. A large traumatic pancreatic pseudocyst developed, for which percutaneous external drainage under ultrasound guidance was performed. Both the catheter fistulogram and endoscopic retrograde cholangiopancreatogram showed complete disruption of the main pancreatic duct. During continuous external drainage, the pseudocyst disappeared. The drainage flow decreased gradually and ceased. The patient is well, with normal endocrine and exocrine pancreatic functions, 2 years after discharge. Copyright o 1995 by W. B. Saunders Company INDEX WORDS: Pancreatic injury; major percutaneous external drainage, treatment.
ductal
disruption;
ERCUTANEOUS external drainage (PED) is one of the therapeutic procedures for traumatic pancreatic pseudocyst. la2PED may facilitate the resolution of a pseudyocyst and shorten the hospital stay. Even in an emergency patient with impending risk, PED can be performed easily, with minimal complication. In this report the authors describe a case of complete disruption of the main pancreatic duct successfully managed by PED.
P
CASE REPORT A 7-year-old boy was admitted to another hospital after sustaining blunt abdominal trauma from a bicycle handlebar. Upper abdominal pain and hyperamylasemia were suggestive of pancreatic injury. On day 1, ultrasound examination showed fluid collection in the body of the pancreas. Despite conservative treatment consisting of complete bowel rest with nasogastric suction and hyperalimentation, the pseudocyst increased in size. On day 51, PED was applied under ultrasound guidance. Because the drainage was poor, he was transferred to Fukuoka Children’s Hospital for further treatment, on day 62. At the time of admission, he complained of abdominal pain, and showed vomiting and a high fever. Catheter fistulogram did not show any specific findings, but diagnostic modalities showed a large pseudocyst measuring 11 cm in diameter (Fig 1). The drainage was confirmed to be ineffective, and additional PED through another route was applied on day 70. All the symptoms disappeared after this procedure was begun. The drainage flow was as high as 447 mL per day under subsequent conservative treatment. During management, both serial catheter fistulograms and endoscopic retrograde cholangiopancreatogram (ERCP) showed abrupt disruption of the pancreatic duct (Fig 2). Although we recommended operative options to the patient’s parents, they expressed a strong desire that the PED be continued because the patient was otherwise healthy.
Journa~ofPedjatr;cSurge~
Vol3O,Nol2
(December),l995:ppl741-1742
Fig 1. CT scene.. (A) CT scan on day 6 suggests transection of the body of the pancreas (arrows). (B) A large pseudocyst of the pancreas body displaces the stomach anteriorly (day 63).
Oral intake was started on day 105, and the drainage flow ceased on day 139. The drainage catheter was removed on day 161, and he was discharged on day 200. Although routine ultrasonography showed slight dilatation of the distal pancreatic duct, the boy remains asymptomatic, with normal growth. Follow-up ERCP has not been conducted because
From the Department of Pediattic SurgeT, Fukuoka Childrenk Hospital, Fukuoka, Japan. Address reprint requests to Yasuham Ohno, MD, Second Depatiment of Surgery, Nagasaki University School of Medicine, I-7-1 Sakamoto-machi, Nagasaki 852, Japan. Copyright Q 1995 by WB. Saunders Company 0022-3468i95l3012-0031$03.00l0
1741
OHNO
both endocrine and exocrine pancreatic normal for the 2 years since discharge.
functions
have
ET AL
remained
DISCUSSION
Traumatic pancreatic pseudocyst is a rather severe sequela of pancreatic injury in children. Because it often resolves spontaneously, the conditions and timing of surgical intervention remain controversial. PED is currently used with increasing frequency for pancreatic pseudocyst, even in children.3,4 However, there is widespread belief that the procedure cannot be applied if there is a complete ductal disruption without proximal drainage.s Early laparotomy has been advocated because of the concern of PED failure. However, we showed the effectiveness of PED even in a patient with complete disruption of the main pancreatic duct. With respect to the use of PED, the two points to be emphasized are that the original drainage catheter should be placed through a confirmed access route under ultrasound guidance and that the drainage catheter should always be positioned in the optimal drainage site under serial follow-up fistulograms. Proper catheter placement not only accelerates the drainage effect but also minimizes the risk of inappropriate ductal obstruction relating to compression of the catheter itself. Amelioration of the inflammatory process would promote recanalization of the major ductal system in children. To our knowledge, this is the first report of major ductal disruption successfully managed by PED. The observations in this case may extend the indications for PED in the treatment of traumatic pancreatic pseudocyst in children. REFERENCES 1. MacErlean DP, Bryan DJ, Murphy JJ: Pancreatic pseudocyst: Management by ultrasonographically guided aspiration. Gastrointest Radio1 5:255-257,198O 2. Torres WE, Evert aspiration and drainage genoll47:1007-1009,1986
MB, Baumgartner BR, et al: Percutaneous of pancreatic pseudocysts. Am J Roent-
3. Bass J, Lorenzo MDi, Desjardins JG, et al: Blunt pancreatic injuries in children: The role of percutaneous external drainage in the treatment of pancreatic pseudocysts. J Pediatr Surg 23:721-724, 1988
Fig 2. (A) ERCP on day 79 shows complete disruption of the main pancreatic duct (arrow). (B) Fistulogram on day 84 defines residual cyst with distal ductal communication. No opacification of the proximal duct is seen. (C) Fistulogram on day 100 shows a minute communication to the distal duct. There is complete resolution of the cyst, without opacification of the proximal duct.
4. Jaffe RB, Arata traumatic pancreatic 152:591-595, 1989
JA Jr, Matlak pseudocysts
ME: Percutaneous in children. Am
5. Rescorla FJ, Cory D, Vane DW, et al: Failure ous drainage in children with traumatic pancreatic Pediatr Surg 25:1038-1042,199O
drainage of J Roentgen01 of percutanepseudocysts.
J