Endoscopic Ultrasound-Guided Drainage of a Pancreatic Pseudocyst after a Bicycle Trauma

Abstract

Blunt pancreatic injuries are rare as they only comprise 1–5% of abdominal trauma, and half of the cases are seen in combination with multiple injuries. More than 60% of pancreatic injuries are located in the body and tail of the gland (Krige JE et al. Pancreatology. 2017;17(4):592–598). \n \nPancreatic trauma often entails severe lesions with a high morbidity and mortality if treatment is delayed or inadequate (Mohseni S et al. Injury. 2018;49(1):27–32). Treatment is controversial and depends on whether the main pancreatic duct has been injured. Grade I and II trauma is usually managed conservatively, while grade III to V trauma is generally managed operatively either with drainage or resection of major parts of the gland (Ho VP et al. J Trauma Acute Care Surg . 2017;82(1):185–99). However, an increasing number of studies suggest that non-operative management with drainage alone rather than resection may provide acceptable outcomes (Menahem B et al. Hepato Biliary Surg Nutr. 2016;5(6):470–77). \n \nWe present an acute case with a grade III lesion of the pancreatic neck in an adult treated with surgical drainage and subsequent drainage of a pseudocyst with a lumen-apposing metal stent (LAMS) with conservation of the gland. \n \nCase presentation \nA 27-year-old healthy female suffered a grade III lesion of her pancreas after she fell from a bicycle and landed on the handlebar. At a local hospital a pancreatic contusion was found on a trauma CT scan, and the patient was referred to a level 1 trauma center with specialized HPB function. A reassessment of the CT scan revealed complete rupture of the pancreatic neck with a retroperitoneal hematoma without signs of other abdominal injuries. An MRCP confirmed rupture of the main duct with a diastasis measuring 2\u2009cm ( Fig. 1 ). A conservative approach was chosen, and the patient was treated with a nasogastric tube with continuous suction, intravenous proton pump inhibitor (pantoprazole 40\u2009mg b.i.d.), subcutaneous octreotide 100 microgram t.i.d., intravenous cefuroxime 1500\u2009mg t.i.d., metronidazole 1500\u2009mg q.d. and parenteral nutrition. On the third day of admission an endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy of the pancreatic duct was performed to ease the flow to the duodenum and diminish the leakage from the severed duct. Due to the considerable diastasis of the duct ends and the large hematoma with displacement of the fractured parts, an attempt to insert a bridge prosthesis over the contused area was not attempted. On the fourth day the patient’s condition deteriorated with increasing abdominal pain, inflammatory parameters and on free intraperitoneal fluid seen on ultrasonography. A laparotomy was performed with removal of 2000\u2009ml ascites, but the surgeon refrained from resection of the distal part of the gland due to a large retroperitoneal hematoma in the retroperitoneal space. Instead two external 18 Fr tubes were placed along the superior and inferior pancreatic border, respectively, and the abdomen was closed. The patient’s general condition quickly improved with no need for pain killers, the systemic inflammatory response decreased, she started eating regular food and one abdominal tube was discontinued because of the decreasing amount of fluid. In the remaining tube the level of liquid was stable around 200\u2009ml/day with amylase of 10,000\u2009U/l. The patient was discharged on day 16 and followed up once a week at the outpatient clinic with intermittent retraction of the drain until a fistula to the skin had formed and the drain was removed 8 weeks later. Two weeks after removal of the drain, the discharge had ceased from the fistula and the patient complained of increasing discomfort and abdominal pain. A CT scan revealed a pseudocyst of 4.6×3.1×2.6\u2009cm ( Fig. 1 ) and an MRCP and MR angiography showed the severed pancreatic duct with a diameter of 6\u2009mm and both halves of the gland with arterial perfusion ( Fig. 2 ). Endoscopic ultrasonography was performed and a 10×10\u2009mm HOT AXIOS TM stent (Boston scientific, Marlborough, MA) was inserted between the stomach and the cyst ( Fig. 3 and \u200band4 ).4 ). A therapeutic Pentax echoendoscope (EG-3870UTK; Pentax, Tokyo, Japan) and Hitachi ultrasound workstation (EUB 7500, HI Vison Preirus; Hitachi Medical Corp., Tokyo, Japan) were used. The collection was punctured under EUS control using the electrocautery wire at the tip of the Hot AXIOS stent. Once the device was satisfactorily positioned within the cyst, the distal flange of the stent was deployed under EUS control. The device was then pulled back until the distal flange deformed against the cavity wall. The proximal flange was then deployed on the luminal side under direct endoscopic control. The same evening the patient could eat normally, the abdominal pain had ceased, and she was discharged the following day. Five weeks later a CT scan revealed a collapsed cyst and nine weeks from insertion the stent was removed by regular gastroscopy. Two weeks after removal of the stent, a CT scan showed no recurrence of the cyst, the pancreatic duct still measured 6\u2009mm and both halves of the pancreas had blood supply. The patient was doing well without signs of malabsorption or diabetes and the follow-ups were terminated but with open contact to our department. \n \n \n \n \nOpen in a separate window \n \n \nFig. 1 \n \n \nThe CT scan shows trauma to the neck of the pancreas with a 2\u2009cm diastasis between the head and body with retroperitoneal extravasation.