Healing a serious abdominal injury without surgery

In early October 2010, 15-year-old Ashton Fehr took a hard hit to the upper abdomen during a high school football game. Although he sat out the remaining quarters, no one — including Ashton himself — thought he was seriously injured. But shortly after showering, the running back developed acute abdominal pain that sent him to the local emergency department.

Despite some initial confusion, a CT scan eventually identified a laceration to the head of the pancreas with an associated fluid collection. After consulting with the family and other physicians, Ashton's doctors decided to transfer him to Saint Marys, one of Mayo Clinic's hospitals in Rochester, Minn., and a Level I pediatric trauma center. It would be a three-hour ambulance ride from the Fehr home in Algona, Iowa.

Reluctant to expose Ashton to more radiation, Mayo doctors reviewed the original CT scan and performed an endoscopic retrograde cholangiopancreatography (ERCP), which confirmed a grade V pancreatic injury with near total disruption of the pancreatic head and leaking from the accessory duct. The main duct remained intact.

Bret T. Petersen, M.D., of the Division of Gastroenterology and Hepatology at Mayo Clinic in Rochester, Minn., says that the traditional option for managing such a leak is complex surgery — possibly even a pancreatoduodenectomy (Whipple procedure), with significant associated morbidity.

"Most traumatic injuries occur in the middle of the pancreas, over the spine," he explains. "Often, we can resect the damaged portion of the pancreas and leave the connections to the intestine and bile duct intact. In this case, we would need to remove the pancreas head as well as part of the bile duct, the gallbladder and the duodenum."

Another treatment option, pseudocyst drainage, also carries significant risks and is more challenging early in the course of the injury.

"Because of his age and the location of the injury, we wanted to avoid operative management for Ashton," Dr. Petersen says. "Given the growing number of reports of successful endoscopic decompression for duct injuries in children and our own experience in adults, we decided to take that approach."

Two days after Ashton's injury, Dr. Petersen performed a pancreatic sphincterotomy and placed a stent in the main pancreatic duct, crossing the junction with the accessory duct, thereby diverting flow away from the leak.

2 weeks later, 20 pounds lighter

After two weeks at Saint Marys, Ashton was discharged with the stent still in place. He had lost 20 pounds, but he felt well, his liver enzymes were normal and a repeat CT showed that the pancreatic laceration was healing.

Within a week, however, he was back in Mayo's emergency department with renewed pain and a flare of his symptoms — the result of a pseudoaneurysm, a rare complication of the original injury and associated collection of pancreatic fluids. The pseudoaneurysm was successfully treated nonoperatively, and Ashton stayed in the hospital just one night.

In November, he returned to Mayo to have the stent removed. ERCP showed that the duct leak had closed and CT imaging confirmed continued improvement of the pancreatic laceration and near resolution of the fluid collection.

Although barred from contact sports for the rest of the season, Ashton spent much of the winter of 2011 lifting weights. He ran track in the spring and held down a strenuous landscaping job during the summer. This fall, he is playing football again and planning a career in organic agriculture.

"I'm pretty much perfect now," he says. "The only effect from the injury is that I'm still on a low-fat diet."

His mother adds, "At first, we weren't sure about taking Ashton to Mayo for treatment. But once we realized how serious the injury was and what the outcome might be, we wanted to give it a try. And now, I couldn't be more grateful that we did."