A 28-year-old man sustains a steering wheel injury to the epigastrium during a high-speed motor vehicle collision. He is haemodynamically stable with mild epigastric tenderness. CT abdomen with IV contrast shows a laceration of the pancreatic body with ductal injury. Which complication is most common in pancreatic injuries with ductal disruption?

## Pancreatic Ductal Injury: Most Common Complication **Key Point:** Pancreatic pseudocyst formation is the most common complication of pancreatic ductal disruption, occurring in 30–50% of patients with ductal injuries, particularly when the injury is managed conservatively or when ductal repair is incomplete. [cite:Sabiston Textbook of Surgery 21e Ch 19] ### Pathophysiology of Pseudocyst Formation 1. **Ductal disruption** → pancreatic juice leaks into the retroperitoneum and peripancreatic tissues. 2. **Inflammatory response** → granulation tissue and fibrosis wall off the fluid collection. 3. **Encapsulation** → forms a pseudocyst (lacks true epithelial lining, unlike a true cyst). 4. **Timeline** → typically develops 4–6 weeks post-injury; may be asymptomatic or symptomatic. ### Classification of Pancreatic Injuries | Injury Grade | Pancreatic Involvement | Ductal Status | Management | |---|---|---|---| | I–II | Contusion/superficial laceration | Intact | Conservative; observe | | III | Laceration without duct injury | Intact | Drain or observe | | IV | Laceration with duct injury | Disrupted | Distal pancreatectomy (distal duct) OR ERCP + stent (proximal duct) | | V | Pancreatic head injury | Disrupted | Whipple (if unstable) or ERCP + stent | **High-Yield:** In haemodynamically stable patients with ductal injury to the pancreatic body or tail, **distal pancreatectomy** is the gold standard. For proximal duct injuries, **ERCP with sphincterotomy and stent placement** can bridge the ductal gap and reduce fistula/pseudocyst risk. [cite:ATLS 10th Edition Ch 7] ### Why Pseudocyst is Most Common ```mermaid flowchart TD A[Pancreatic ductal disruption]:::outcome --> B[Pancreatic juice leaks]:::outcome B --> C[Retroperitoneal inflammation]:::outcome C --> D{Ductal continuity restored?}:::decision D -->|No| E[Persistent juice leak]:::action D -->|Yes| F[Minimal leak]:::action E --> G[Pseudocyst formation 4-6 weeks]:::outcome F --> H[Lower pseudocyst risk]:::outcome G --> I{Symptomatic?}:::decision I -->|Yes| J[Percutaneous/endoscopic drainage]:::action I -->|No| K[Observe, serial imaging]:::action ``` **Clinical Pearl:** A pseudocyst that is **>6 cm, symptomatic, or expanding** requires drainage. Endoscopic transpapillary drainage is preferred if the cyst communicates with the main pancreatic duct; percutaneous drainage is used for non-communicating or inaccessible cysts. **Mnemonic:** **PANCREATIC PSEUDOCYST** — **P**ersistent **A**cute **N**ecrosis **C**aused by **R**uptured **E**pithelia **A**nd **T**issue **I**nflammation **C** — forms a **P**seudocyst (walled-off fluid without epithelium).