Aiming for the "surgical soul"? – A penetrating pancreatic injury in a victim of multiple stab wounds

Abstract text (incl. references and figure legends)

CASE HISTORY: A 43-year-old male was admitted to the emergency room with multiple stab wounds.

CLINICAL FINDINGS: On admission, he was normotensive but tachycardic, with abdominal pain. The physical examination revealed fourteen stab wounds – to the chest, abdomen and other superficial body lacerations.

INVESTIGATION/RESULTS: Chest X-ray: right pneumothorax – drained with a chest tube. FAST: free fluid in four quadrants - fluid resuscitation, transfusion and emergency surgery.

DIAGNOSIS: Exploratory laparotomy: hemoperitoneum, full-thickness perforating stomach injury, transverse mesocolon lacerations and a zone 1 retroperitoneal hematoma resulting from a pancreatic laceration.

THERAPY AND PROGRESSION: Gastric and mesocolic lacerations were repaired and haemostasis of the bleeding vessels was achieved with sutures and haemostatic agents. A drain was placed in the pancreatic bed. The patient was admitted to the ICU. On the third day, an abdominal CT was performed which confirmed a 22mm laceration in the pancreatic body, near the neck – Grade II on AAST classification. Complications: grade B pancreatic fistula and an intraabdominal fluid collection that required antibiotic therapy and percutaneous drainage. The patient progressed well and was discharged after 23 days.

COMMENTS: Pancreatic injuries occur in less than 10% of all abdominal trauma. Grade I or II can generally be managed conservatively, while higher grades require resection or stenting. Ductal injuries restricted to side-branches have high success rates for conservative treatment. Penetrating injuries to the "surgical soul", around the pancreatic head, are highly lethal and control of the bleeding is paramount. Stab wounds are associated with lower mortality than gunshot wounds (<5%vs20%) but the morbidity is high, with a risk of pancreatic fistula over 10%.

REFERENCES: Søreide K, Weiser TG, Parks RW. Clinical update on management of pancreatic trauma. HPB (Oxford). 2018 Dec;20(12):1099-1108

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