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pancreatic lesions are very infrequent after closed abdominal trauma ( 5% of cases ) with a complication rate that affects 3040% of patients , and a mortality rate that can reach 39% . in our experience ,
closed abdominal traumatisms occurring at typical popular horse - riding festivals in our region constitute a high risk of pancreatic trauma .
the purpose of the present paper is to raise awareness about our experience in the diagnosis and treatment of pancreatic lesions secondary to closed abdominal traumatism .
a 15-year - old female who suffered closed abdominal traumatism and abdominal crushing after falling from a horse presented to the emergency room ( er ) with abdominal pain and hemodynamic instability . a focused abdominal sonography for trauma ( fast ) was performed which revealed the presence of free liquid .
there was no clinical improvement , and high levels of amylase in the serum were observed .
the patient was transferred to our center where an urgent re - intervention was performed .
image findings were confirmed intraoperatively and , after checking the viability of the pancreatic tissue , a proximal closure was performed with mechanical suture and distal posterior pancreaticogastrostomy ( fig .
the pancreaticogastric anastomosis was performed on the back side of the greater curvature of the stomach with non - absorbable monofilament suture dashed through an anterior assistance gastrostomy , which was subsequently closed with a continuous monofilament suture . for the introduction of the pancreas into the stomach ,
the evolution was satisfactory reaching oral intake on the third postoperative day and the drainage was removed after ruling out postoperative pancreatic fistula ( popf ) .
after one and a half years of follow - up the patient is now asymptomatic .
a 16-year - old female came to the er after a closed abdominal trauma caused by a horse kick .
physical examination showed epigastric abdominal pain with no signs of peritoneal irritation , as well as significant blood amylase levels . suspecting pancreatic gland compromise , a ct was performed with unspecific report and ,
subsequently , a magnetic resonance cholangiography ( mrcp ) was also performed where a complete pancreatic fracture at the pancreatic isthmus was observed . during the exploratory laparotomy the radiological findings
2 ) and a closure of the cephalic pancreatic portion was performed with non - absorbable monofilament suture and distal posterior pancreaticogastrostomy . reconstruction was performed following the same steps as those described in section 2.1 .
three days after the operation , she presented low - output of type a popf , which was handled conservatively .
seventeen days after the operation the patient was discharged and eight months after the operation , she is currently asymptomatic .
a 15-year - old female who suffered closed abdominal traumatism and abdominal crushing after falling from a horse presented to the emergency room ( er ) with abdominal pain and hemodynamic instability . a focused abdominal sonography for trauma ( fast ) was performed which revealed the presence of free liquid .
there was no clinical improvement , and high levels of amylase in the serum were observed .
the patient was transferred to our center where an urgent re - intervention was performed .
image findings were confirmed intraoperatively and , after checking the viability of the pancreatic tissue , a proximal closure was performed with mechanical suture and distal posterior pancreaticogastrostomy ( fig .
the pancreaticogastric anastomosis was performed on the back side of the greater curvature of the stomach with non - absorbable monofilament suture dashed through an anterior assistance gastrostomy , which was subsequently closed with a continuous monofilament suture . for the introduction of the pancreas into the stomach ,
the evolution was satisfactory reaching oral intake on the third postoperative day and the drainage was removed after ruling out postoperative pancreatic fistula ( popf ) .
after one and a half years of follow - up the patient is now asymptomatic .
a 16-year - old female came to the er after a closed abdominal trauma caused by a horse kick .
physical examination showed epigastric abdominal pain with no signs of peritoneal irritation , as well as significant blood amylase levels . suspecting pancreatic gland compromise , a ct was performed with unspecific report and ,
subsequently , a magnetic resonance cholangiography ( mrcp ) was also performed where a complete pancreatic fracture at the pancreatic isthmus was observed . during the exploratory laparotomy the radiological findings
2 ) and a closure of the cephalic pancreatic portion was performed with non - absorbable monofilament suture and distal posterior pancreaticogastrostomy . reconstruction was performed following the same steps as those described in section 2.1 .
three days after the operation , she presented low - output of type a popf , which was handled conservatively .
seventeen days after the operation the patient was discharged and eight months after the operation , she is currently asymptomatic .
abdominal high energy traumas , such as those caused by horse - riding accidents may provoke the transection of the pancreatic gland by crushing the retroperitoneal structures against the spinal column .
the retroperitoneal location of the pancreas means that the signs and symptoms caused by the lesion are unspecific and difficult to objectify .
evidence suggesting a potential pancreatic injury includes a history of high - energy trauma in the epigastrium .
regarding other initial complementary tests , we acted in accordance with advanced trauma life support protocols in er .
40% of patients with pancreatic injury present normal serum amylase levels . with some limitations ,
ct is the imaging test of choice for diagnosis and staging in the acute phase . if the suspicion of pancreatic injury persists and the ct findings are negative , endoscopic retrograde cholangiopancreatography ( ercp ) and/or mrcp can prove useful .
mrcp seems to be more effective than ct in assessing the integrity of the pancreatic duct in differential diagnosis but not in the acute phase .
the ercp is the best imaging technique to visualize the wirsung , but its availability is limited .
once diagnosed , we stage the pancreatic injury according to the american association for the surgery of trauma .
the most extended surgical procedure for a complete traumatic pancreatic section in the neck is the resection of pancreatic body , tail , and spleen . on average ,
while endocrine and/or exocrine failure of the pancreas is uncommon after pancreatic trauma if more than 20% of the glandular tissue is conserved , it is all the more important to conserve as much pancreatic tissue and spleen as possible in the case of young patients . in the case of distal pancreas preservation , it is common to perform a pancreaticojejunal anastomosis and roux y. in our experience , with evidence of the complete lesion of the main duct at the neck level and after checking the viability of the pancreatic tissue intraoperatively , we chose to perform distal pancreatic preservation with pancreaticogastric anastomosis .
after a thorough review of existing literature , we found no clear consistency in the choice of the surgical reconstruction technique after type iii pancreatic trauma .
the two most important determining prognostic factors are the state of the main pancreatic duct and the time from the injury to definitive treatment .
in conclusion , a safer option may be the distal pancreatic preservation with pancreaticogastric anastomosis in grade iii lesions with healthy pancreatic tissue .
we believe that further studies with larger series are needed to achieve greater evidence for this surgical technique .
this work has the approval of the ethical committee of the hospital son espases where the patients were treated .
written informed consent was obtained from the patient for publication of this case report and accompanying images .
a copy of the written consents is available for review by the editor - in - chief of this journal on request .
all authors contributed to treat the cases presented . all authors contributed in gathering information , studying the literature , and writing this paper .
highlightsclosed abdominal traumatisms occurring at typical popular horse - riding festivals in our region constitute a high risk of pancreatic traumatism.we describe our experience in the diagnosis and treatment of pancreatic lesion secondary to closed abdominal traumatism.facing a complete traumatic pancreatic section in the neck the most extended surgical procedure is the resection of pancreatic body , tail , and spleen.a safer option may be the distal pancreatic preservation with pancreaticogastric anastomosis in grade iii lesions with healthy pancreatic tissue .