A Posttraumatic Pancreatic-Dural Fistula: A Big Challenge Necessitating a Multidisciplinary Approach

Posttraumatic pancreatic fistula is a common complication following high-energy trauma. The diagnosis in most of the cases is, however, delayed, which leads to a high complication and mortality rate. Although many types of fistulas have been described, we report to our knowledge the first pancreatic-dural fistula. Our patient is a 21-year-old male, who presented post a motor vehicle accident to the emergency room with paraplegia and a sensory level at T10, associated with significant abdominal trauma. Initial stabilization with abdominal packing and splenectomy was necessary, followed by thoracolumbar instrumentation for posterior fixation of a T11–T12 transdiscal fracture, with anterior subluxation of T11. Subsequent management was complicated by persistence of pseudomeningocele, despite multiple surgical drainages. Because of a progressive increase of retroperitoneal collections on follow-up CT, along with a pancreatic injury, we suspected the presence of a pancreatic-dural fistula, confirmed by the presence of high levels of amylase within the pseudomeningocele collection. A Wirsung duct rupture was diagnosed and treated by ERCP. The delay in diagnosis of the fistula resulted in multiple unsuccessful essays to drain the abdominal and paravertebral collections. Once the diagnosis was made, the stenting of the Wirsung duct allowed closure of the fistula and eventually complete resolution of the collections on follow-up imaging. The importance of this case is to demonstrate that in posttraumatic conditions, we should keep high index of suspicion for pancreatic fistulas, because of the gravity of the consequences if not diagnosed promptly. Treating the collections in the traditional manner will be highly unsuccessful and endanger the life of the patient as further deterioration will ensue due to the aggressiveness of the pancreatic secretions and the breach of the normal anatomic barriers. This combination allowed the pancreatic secretions to penetrate the musculofascial plane that usually separates the retroperitoneal and paravertebral spaces. Therefore, whenever a pancreatic injury is suspected, based on clinical background or imaging, a pancreatic fistula should be ruled out.