Intraoperative image was that necrosis developed in the anterior and lateral faces of pancreatic neck body tissues, and pancreatic duct was progressing towards necrosis in this area, but back wall was intact. Anterior Roux-en-Y pancreatico-jejunostomy was applied following the debridement of the wound area due to the intact posterior pancreatic parenchyma in the patient with proximal pancreatic duct injury in which pancreatic tissue was not transected. In a stable patients with isolated pancreatic duct injury, for not causing loss of organs such as the pancreas, spleen, duodenum, pancreatico-enterostomy is a safe option to reduce mortality and morbidity.
Isolated pancreas main duct injury, Pancreatico-enterostomy, Pancreatic trauma. It can present acutely or months later [ 2 ] As known CT is the major imaging method in the diagnosis of abdominal visceral injuries.
ERCP has also been used therapeutically with transpapillary stenting across the pancreatic duct disruption or simply across the sphincter of Oddi aiming at a reduction of the intrapancreatic pressure gradient [ 2 , 3 ]. There are several surgery options for which can be employed to manage this injuries. According to the settelement and grade; distal pancreatectomy with or without splenectomy, pancreatico-jejunostomy, pancreatico-gastrostomy, whipple procedure are the options.
In our case we preferred pancretico-jejunostomy [ 4 ]. Patient had a history about striking his lower back by slide transport vehicle in his workplace, and remaining stuck between the wall and the vehicle. The patient had no known history of chronic disease, there was no routine drug usage and the patient had no surgery history except anterior mesh herniorrhaphy due to left inguinal hernia 20 years ago. When the patient arrived, he was evaluated as conscious, oriented cooperative and Glasgow coma scale was Patient was admitted to the general surgery service for follow up and further investigations.
Figure 1: Laceration in left lobe of liver at CT. View Figure 1. Figure 2: Liquid collection in the vicinity of pancreas at CT. View Figure 2. Oral intake of the patient was closed, and he was continued to be followed with IV hydration at the 12 hour of patient's follow up, body temperature was increased to In left lobe of liver, a view compatible with grade 2 laceration was observed, and hypodense area in the neck of the pancreas was observed compared to surrounding pancreatic tissue.
It was interpreted aspancreaticlaceration. Then, informed consent was obtained from the patient, and explorative laparotomy was planned with "acute abdomen" and "pancreatic laceration"? Figure Hypodense area in the neck of the pancreas was observed compared to surrounding pancreatic tissue. View Figure During the exploration, cc hemorrhagic collection was obresved in the abdomen, and it was aspirated. No signs of active bleeding were observed in laceration area in liver.
Posterior of stomach was explored by openning gastrocolic ligament. Peripancreatic collection, ischemic foci and peripancreatic calcified fat necrosis were present in whole pancreas.
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However, major laceration area and necrotic regions were not detected in pancreas. Approximately cc organized hematoma which was significant in paracaval and para-aortic region in retroperitonel field was observed. Hemostasis control was performed by draining hematoma.
Upon absence of active bleeding, abdominal drain was placed to the patient, and the operation was ended. In post-operative follow-up, approximately cc fluid per day came from right and left drains of the patienton post-operative day 1 Figure 5. GJ Jurkovich. Venkatesh , John Mun Chin Wan. Diagnosis and management of blunt pancreatic ductal injury in the era of high-resolution computed axial tomography.
Mullins , Martin A. Schreiber , John C. Sequential CT evaluation of isolated non-penetrating pancreatic trauma. Paraskevas S Brestas , D. Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Avneesh Gupta , Joshua W. Stuhlfaut , Keith W. Fleming , Brian C. Lucey , Jorge A. Multi-detector row CT imaging of blunt abdominal trauma. Kathirkamanathan Shanmuganathan. Multidetector computed tomography and blunt thoracoabdominal trauma.
A Jason Mullinix , W. Dennis Foley. Blunt duodenal injuries in children. Blood from a splenic injury also goes to the right upper quadrant Although peritoneal lavage is a sensitive indicator of intraperitoneal haemorrhage, it is unable to detect the source or origin of the bleeding A large amount of blood may collect in the pelvis without much haemoperitoneum seen in the upper abdomen. Active haemorrhage can appear as a region Figure 1a: CT coronal MPR in year-old of extravasated contrast material and is indicated boy whose motorbike skidded.
Pancreatic trauma: A concise review
Splenectomy units HU Figure 1c The site of contrast was performed and about 2 litres extravasations noted on CT scans corresponds to of haemoperitoneum was noted the site of bleeding seen on angiography This image demonstrate the possible pathway of blood low, from the splenic injury Splenic injury to perihepatic single arrow regions and passes down the right paracolic The spleen is the most frequently injured gutter double arrows to the pelvic abdominal organ during blunt abdominal trauma cavity long arrow. CT scans can detect a variety of splenic injuries, including laceration, a non-perfused region, intra-parenchymal haematoma and subcapcular 30 www.
Subcapsular haematoma star appears as a region of low attenuation that compresses the normal splenic parenchyma. Note also multiple lacerations of the Figure 1b: CT scan showing haemoperitoneum spleen. Splenectomy was performed from liver injury in a year- in this patient.
Liver injury was conirmed surgically with estimated blood loss of 3 litres. Figure 2b: CT scan showing splenic laceration in a year-old boy, a pillion rider Figure 1c: CT scan demonstrating active of a skidded motorbike. Splenic haemorrhage in a year-old man laceration is seen as irregular, linear following MVA. CT shows contrast region of low attenuation arrows. A extravasation long arrows and 4-cm laceration was identiied at the pooling of the extravasated contrast tip of the spleen during surgery and in the dependant area short arrows.
This patient died 2 days after surgery from excessive blood loss. CT demonstrates a subcapsular haematoma that Figure 2c: CT scan demonstrating a shattered appears as a hypodense collection, spleen in a year-old male compressing on the underlying liver motorcyclist following MVA. Multiple parenchyma arrows. This patient had failed conservative treatment and splenectomy was performed 2 days following the trauma which conirmed the CT indings of shattered spleen. Liver injury The liver is the second most frequently injured intra-abdominal viscus 2.
The worldwide incidence of liver injuries is not known Figure 3b: CT scan of liver injury in a year- 9 , although penetrating injuries gunshots and old man with MVA. Liver laceration stab wounds account for the majority of liver is shown on CT as a non-enhancing injuries in North America and South Africa while irregular, linear low attenuation blunt injuries cause the majority of liver injuries area arrow with associated in Europe and Australasia 8. He diagnostic modality of choice. CT scans can be was managed surgically.
CT grading criteria have been proposed for liver injuries, but, as with splenic injury, these criteria do no correlate well with the need for surgical intervention or risk of subsequent complications. CT can provide a precise delineation of renal laceration, haematoma and perinephric collection 29 ; in addition, CT scans can be used to differentiate trivial injuries from those requiring intervention 28 Figures 4a, 4b and 4c.
To evaluate bladder injuries, CT cystography with retrograde bladder illing can be added to the routine CT abdominal examination Bladder injuries have characteristic CT cystographic features that can be used to accurately classify Figure 4b: CT of renal laceration in a year- injuries and plan treatment Figures 5a, 5b and old man with MVA. The right renal 5c. CT differentiates between extraperitoneal lacerations are shown as irregular, and intraperitoneal bladder ruptures and helps linear low attenuation areas within determine the management of these injuries.
He was managed conservatively with an uneventful recovery. A right contusion year-old girl with MVA. A liver laceration CT as a supericial, crescentic, low is present adjacent to the kidney. He attenuation area that compresses was managed conservatively with an the adjacent renal parenchyma. She uneventful recovery.blacksmithsurgical.com/t3-assets/of/dont-fence-me-in.php
Imaging findings OR Procedure details
There is extravasation of contrast arrow in the perivesical fat indicating an Figure 5c: CT scan of urinary bladder injury in extraperitoneal bladder rupture. He fell and was run over by a tractor. This image shows extravasation of contrast from a urinary bladder injury, which outline the bowel loops arrows.
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This indicates an intraperitoneal bladder rupture. Note fracture on the right side of the sacrum and diasthesis of left sacroilliac joint. Urinary bladder perforation at 2 sites with about 1 litre of haemoperitoneum was conirmed at surgery. Figure 5b: CT scan showing fracture of the pelvic bone. A lower scan of the same patient in Figure 5a shows the pelvic Pancreatic injury fracture arrow. Pancreatic injury is more common in children and young adults, possibly because these individuals have less retroperitoneal fat to act as a protective buffer 2.
The identiication of blunt pancreatic injury may be dificult because image indings are often subtle Initial CT indings may be normal, even with pancreatic transaction, because the elastic pancreatic parenchyma resumes its normal contour A repeated CT abdominal scan at 24 to 48 hours can help reveal evolving injuries 2. A delay in diagnosis can often result in recurrent pancreatitis, pseudocyst, istula or abscess formation 27 Figure 6. Diagnosis was delayed and year-old man with MVA. Note CT scan performed 2 days after the subtle extraluminal air single incident showed a total transection white arrows with focal bowel of the body of pancreas arrow.
Also note air pockets in the urinary bladder black arrows.
Urinary bladder perforation and transection at the Bowel and mesenteric injury rectosigmoid junction were detected intraoperatively. CT indings can include focal bowel wall thickening, mesenteric iniltration, free air, the presence of intraperitoneal luid without solid organ injuries and extravasated contrast material 10,11,34,36 Figures 7a and 7b. CT images must be carefully examined to detect injuries and close attention should be paid to scanning techniques and optimal bowel contrast Injury to the retroperitoneum, spine, abdominal wall and lower chest Figure 7b: CT scan of bowel injury in a year- Before the use of CT, haemorrhage into the old lorry driver with MVA.