Expert’s comment concerning Grand Rounds Case entitled “pancreatic fracture: a rare complication following scoliosis surgery” by Mélodie Juricic Jr. et al. (Eur Spine J; : doi: 10.1007/s00586-017-5318-x)
Open image in new window Open image in new window This is an interesting report of pancreatic fracture following spinal surgery for neuromuscular scoliosis . This is a complex surgical procedure with a number of recognized complications including acute pancreatitis; however, pancreatic fracture has not been described previously.
Traumatic injury to the pancreas is relatively rare when compared with other solid organ injury, occurring in 0.2–12% of instances of abdominal trauma , and most commonly results from penetrating injuries occurring in 20–30% of gunshot injuries or stab wounds in some series , but in less than 2% of blunt injuries . In the latter, it is associated with sudden force to the abdomen or acceleration–deceleration injury resulting in compression of the pancreas against the vertebral column . Of note, such injuries usually occur from penetrating trauma or blunt force to the anterior part of the abdomen rather than from trauma occurring posterior to the pancreas as in this case.
The diagnosis of pancreatic injury is not always straightforward, and a high index of suspicion is required taking into account the mechanism of injury or damage to adjacent structures. Alternatively, a patient may present with non-specific abdominal symptoms or features of acute pancreatitis. Diagnosis may be confirmed with cross-sectional imaging using computed tomography (CT) scanning, although the reported sensitivity varies from 65 to 80% and the pancreas may appear normal in the early stages following trauma [5, 6]. CT features suggestive of pancreatic injury include fracture or laceration of the pancreas, intrapancreatic haematoma, fluid separating the splenic vein from the pancreas, fluid surrounding the superior mesenteric artery, and inflammatory changes in the peripancreatic fat and mesentery [5, 7]. Delayed findings include pancreatic ductal dilatation, peripancreatic fluid collection, or pseudocyst formation. Magnetic resonance cholangiopancreatography (MRCP), particularly with secretin stimulation, allows imaging of the parenchyma as well as the pancreatic ducts, thus providing similar information to CT whilst allowing better assessment of ductal injuries and identification of leaks [8, 9].
Operative assessment of the pancreas may be necessary to determine the optimal management of major injuries identified on cross-sectional imaging, but may also be the only way to identify an injury where it has not been apparent on CT or where preoperative CT has not been possible. Findings suggestive of a pancreatic injury at laparotomy include retroperitoneal bile staining, fluid in the lesser sac, haematoma overlying the pancreas and fat saponification. Entry into the lesser sac allows direct inspection of the anterior surface of the pancreas. This manoeuvre with the placement of surgical drains may be the optimal approach during damage control laparotomy in an unstable patient or where an experienced HPB surgeon is not available. A more detailed assessment may be achieved by mobilization of the hepatic flexure with Kocherisation of the duodenum allowing inspection of the head and uncinate process. Mobilization of the splenic flexure and spleen allows inspection of the pancreatic tail and mobilization of the pancreas from the retroperitoneum, together with the spleen and splenic vessels if necessary, allows complete assessment of the posterior surface.
The management of pancreatic injury depends on the extent and location of parenchymal injury, the presence of injury to the main pancreatic duct, and any associated injuries to other structures. Isolated pancreatic contusion or superficial lacerations in the absence of main duct disruption may be managed conservatively or with simple drainage. Conservative management always requires close monitoring of the patient with a low threshold for repeat imaging to detect later complications such as pancreatic fistula. This may be managed with radiologically placed drains and endoscopic retrograde cholangiopancreatography (ERCP) with stenting . Secondary haemorrhage is a life-threatening complication, which is best managed by interventional radiology but may require surgical exploration.
More severe injuries involving the main pancreatic duct require the input of an experienced HPB surgeon. Injuries involving the body or tail with main duct disruption may require drainage or distal pancreatectomy. Injuries to the head may be managed with washout and drainage, pancreatic head resection, or pancreaticoduodenectomy depending on the extent of the injury and the presence of damage to adjacent structures such as the duodenum.
The mechanism of injury in this case is unclear, although the authors present two hypotheses involving either blunt injury secondary to forces applied to the pancreas during reduction of the spinal deformity or a penetrating injury resulting from the pedicle screws. Having developed non-specific abdominal symptoms, the patient was investigated appropriately with CT, which demonstrated a pancreatic fracture. As occurs frequently in the trauma setting, suspected injury to other structures, in this case bowel perforation, prompted surgical exploration. The placement of surgical drains around the pancreas seems appropriate and appears to have led to a satisfactory outcome albeit with the development of a pseudocyst. Had there not been any suspicion of other injuries, it may have been possible to manage this case conservatively, with MRCP to assess more fully the pancreatic duct and insert radiologically placed drains and ERCP with stenting, as necessary.
Pancreatic injury is associated with a significant morbidity and mortality and so early detection, and appropriate management is essential. Whilst pancreatic injury would appear to be rare following scoliosis surgery, it is possible that postoperative acute pancreatitis, which is a well-recognized complication, may, in some cases, be the result of an undetected pancreatic injury. This case demonstrates the potential for posterior injury to the pancreas and highlights the need for surgeons undertaking this type of surgery to have a high index of suspicion in patients developing unexplained abdominal symptoms in the postoperative period. In the absence of other evidence, it is likely that the management of such injuries in a similar manner to pancreatic injuries following abdominal trauma will provide the best outcome.
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Conflict of interest
None to declare.