Conservative management in a case of pancreatic trauma with Wirsung duct injury

Abstract

Introduction:
The diagnosis of pancreatic injuries can be challenging. Although the FAST is efficient in detecting hemoperitoneum, one third of patients with pancreatic injury have normal FAST. Thus, the diagnosis is made by computed tomography (CT) or laparotomy. Complications of pancreatic injury occur in up to 50% of cases and include fistula, pseudocyst and abdominal abscesses. Appropriate management is essential in the outcome of morbidity and mortality. Case report: A 21-year-old male patient was admitted to the HEUE with a history of blunt abdominal trauma. CT showed hemoperitoneum and laceration of the pancreas head involving the Wirsung duct. At laparotomy, there wasn’t success in visualizing pancreatic lesions. He was referred to the HUCAM with a septic condition and antibiotic therapy, TPN and liquid diet were started. After 10 days ERCP showed stenosis of distal common bile duct, papillotomy was performed with placement of a biliary prosthesis, without success in accessing the pancreatic pathway. With impossibility of catheterizing the Wirsung duct via ERCP, a surgical approach was indicated, which showed firm adhesions in the upper abdomen, in addition to candle drippings in the omentum. In this scenario, tactical cholecystectomy and splenectomy for catheterization of the duct via the tail of the pancreas was performed. He was discharged with a Wirsung catheter and evolved with a pancreatic pseudocyst, which required transgastric drainage. Subsequently, the catheter was removed with no output, and CT showed resolution of the pseudocyst. Evolved without complaints. He is still being followed up at the HUCAM GIS outpatient clinic. Conclusion: The case in question shows the successful use of an exception tactic in the treatment of pancreatic trauma with involvement of the Wirsung duct. The conservative approach spared a large part of the pancreatic parenchyma that would be lost with an initial surgical approach, and the patient evolved favorably.