Traumatic pancreatic injury successfully bridged through a giant pancreatic pseudocyst

Abstract

Figures

Computed tomography revealed disconnected pancreatic duct syndrome secondary to handlebar trauma (arrow). a Axial image. b Coronal image.

Fluoroscopic images of endoscopic retrograde cholangiography. Endoscopic pancreatic duct stenting was not achieved after two attempts. a First attempt, day 1 post-injury. b Second attempt, day 20 post-injury.

Magnetic resonance cholangiopancreatography demonstrated a pancreatic pseudocyst at the site of the trauma. a A small pancreatic pseudocyst was formed shortly after the injury. ( b ) The pseudocyst enlarged to 45 mm by the time the patient was transferred to our hospital.

Fluoroscopic images during pancreatic stenting in the first session. a EUS-guided pancreatic duct drainage was performed from the distal pancreatic duct. b The stricture was dilated using a drill dilator. c From the papillary side, the stricture was dilated with a balloon dilator. d Two pancreatic stents were placed in the pancreatic pseudocyst.

Fluoroscopic images of endoscopic retrograde cholangiography during the second session. a A guidewire was successfully advanced into the distal pancreatic duct through the shrunk pancreatic pseudocyst. b Transpapillary bridging with a single stent was achieved, and the transgastric stent was removed.

Full text

Pancreatic injury is a rare form of abdominal trauma and usually requires surgery for deep damage with axial deviation 1 2 . Recently, endoscopic pancreatic stenting for the disconnected pancreatic duct syndrome (DPDS) has been attempted as a minimally invasive treatment 3 4 5 , but difficult situations are often encountered. Here, we present a case of successful rendezvous stenting through a giant pancreatic pseudocyst ( Video 1 ). A 9-year-old boy fell off his bicycle and had handlebar trauma. He had a duodenal perforation and severe damage to the pancreas, resulting in DPDS ( Fig. 1 ). He first underwent mesh repair surgery for duodenal perforation, and endoscopic treatment for DPDS was unsuccessful on two attempts ( Fig. 2 ). Two weeks later, MRCP revealed a small pseudocyst, and conservative management was chosen. The patient developed postprandial abdominal pain and maintained on total parenteral nutrition (TPN) for 2 months. He was transferred to our hospital 2 months after the injury, still on TPN. MRCP performed at our hospital revealed that the pancreatic pseudocyst had enlarged to 45 mm ( Fig. 3 ). Because single-session bridging was considered impossible, two stents were placed in the pseudocyst – one via the transpapillary route and one via EUS-guided pancreatic duct drainage – to establish two points of communication between the pseudocyst and the main pancreatic duct ( Fig. 4 ). In the second session, after balloon dilation of the distal connecting part of the pancreatic duct, a guidewire inserted from the papilla of Vater was advanced across the pseudocyst into the pancreatic duct of the tail, and a transpapillary pancreatic stent was successfully placed through the pseudocyst ( Fig. 5 ). To the best of our knowledge, this is the first report of successful stent bridging through a giant pancreatic pseudocyst caused by trauma.

Traumatic pancreatic injury successfully bridged through a giant pancreatic pseudocyst.Video 1

Computed tomography revealed disconnected pancreatic duct syndrome secondary to handlebar trauma (arrow). a Axial image. b Coronal image.

Fluoroscopic images of endoscopic retrograde cholangiography. Endoscopic pancreatic duct stenting was not achieved after two attempts. a First attempt, day 1 post-injury. b Second attempt, day 20 post-injury.

Magnetic resonance cholangiopancreatography demonstrated a pancreatic pseudocyst at the site of the trauma. a A small pancreatic pseudocyst was formed shortly after the injury. ( b ) The pseudocyst enlarged to 45 mm by the time the patient was transferred to our hospital.

Fluoroscopic images during pancreatic stenting in the first session. a EUS-guided pancreatic duct drainage was performed from the distal pancreatic duct. b The stricture was dilated using a drill dilator. c From the papillary side, the stricture was dilated with a balloon dilator. d Two pancreatic stents were placed in the pancreatic pseudocyst.

Fluoroscopic images of endoscopic retrograde cholangiography during the second session. a A guidewire was successfully advanced into the distal pancreatic duct through the shrunk pancreatic pseudocyst. b Transpapillary bridging with a single stent was achieved, and the transgastric stent was removed.

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