Punctured Pancreas

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Greg Raver-Lampman

During a lacrosse practice in April 2006, Stuart Taylor, a 15-year-old freshman defender on Norfolk Academy’s junior varsity team, sprinted toward an opposing midfielder with the goal of dislodging the ball from his lacrosse stick, a typical checking drill.

“I was coming up at a good pace and he was going almost full speed,” Stuart recalls. The two players collided.

“I felt like I got the wind knocked out of me,” he said.

Punctured PancreasWhat he didn’t know then was that he had suffered a life-threatening injury. When the players ran into each other, a lacrosse stick jammed into Stuart’s abdomen, forcing his pancreas against his spine. The delicate organ split like a ripe peach. Enzymes meant to digest food gradually began to trickle into his abdominal cavity.

If left untreated, the crushed pancreas would digest itself.

Repairing a split pancreas ranks among the most technically difficult surgeries. At many hospitals around the nation, patients like Stuart would not have access to a pediatric surgeon. General hospitals seldom have pediatric surgeons on staff and patients often have to travel hundreds of miles to find one. CHKD has seven general pediatric surgeons who have built a formidable reputation. The team performs more complex pediatric surgeries than all but a few pediatric hospitals in the U.S. and Canada.

“We have a terrific team of pediatric surgeons complemented by pediatric anesthesiologists, nurses and other pediatric-trained providers,” said Dr. Arno Zaritsky, CHKD’s senior vice president for clinical services.

By the time Stuart Taylor went into surgery at CHKD, he needed a surgical superstar. In his case, that surgeon was Robert Obermeyer, who not only saved Stuart’s life but also repaired the boy’s pancreas in a way that would prevent life-long medical problems.

“What Bob Obermeyer did was a miracle,” said Stuart’s father, Tazewell Taylor. “Bob is our angel.”

To describe Stuart’s lacrosse injury as rare is an understatement. The pancreas is well protected, high enough in the abdomen to be shielded by the ribs and lodged behind the stomach and liver. Damage to the pancreas is most often caused by penetrating wounds from gunshots or by diseases such as cancer.

To injure a pancreas with a lacrosse stick requires both force and pinpoint precision. Such an injury can be especially dangerous because it seldom causes crippling pain, making it easy to overlook and tough to diagnose.

“The school trainer looked at Stuart right after the injury and told him not to go to practice for a while,” said Stuart’s mother, Katherine. “But he said he’d probably be okay.” The following day, when the pain continued, she took Stuart to a doctor, who said his discomfort was likely caused by bruising.

But five days after the injury, Stuart developed a fever. Worried, Katherine took her son directly to CHKD’s emergency center where a CT scan revealed that his pancreas had been damaged, either lacerated or severed.

“It was odd to hear that there was something serious going on almost a week after the injury,” Katherine recalled. Despite the time that had passed, Dr. Obermeyer wanted to hold off on surgery to make absolutely certain that the pancreas wasn’t in the process of healing itself.

“He looked healthy and I wanted to get a sense of whether this was healing or getting worse,” Dr. Obermeyer recalls.

While Stuart was in the hospital, the surgeon closely monitored his physical condition and the presence of two digestive enzymes, lipase and amylase, whose concentrations rise when the pancreas is inflamed or damaged. The levels of digestive enzymes continued to climb. The surgeon knew the pancreas would begin digesting itself. He decided surgery would be necessary.

Dr. Obermeyer didn’t sugarcoat the complexity of the surgery.

“Attempting to repair or remove a part of the pancreas is an extremely invasive operation with significant risk of complications, often including the need to remove the spleen,” he told the parents.

Without a pancreas, or with too much removed, Stuart would become a medically induced diabetic who would have to inject insulin normally produced by the organ. Without a spleen, Stuart would become highly susceptible to certain infections and would require antibiotics for life.

StuartTaylor2The goal of surgery would be to save Stuart’s spleen and enough of the pancreas that he could live a normal life.

As always, Dr. Obermeyer had a game plan when he started surgery. An examination with a laparoscope, a tiny camera mounted on a slender instrument, revealed that Stuart’s internal organs remained traumatized and badly swollen. Because of the swelling, the surgery couldn’t be done laparoscopically. The only way to reach the injury was with open surgery.

During surgery, Dr. Obermeyer had to tease the pancreas out of a crook in the intestines behind the liver and stomach. When he reached the pancreas, he could see a hole in the pancreatic duct that had developed as a result of the blunt trauma and the organ’s slow self-digesting enzymes. Like all pancreatic tissue, the healthy portion was frail and soft, the consistency of a yolk in an undercooked egg. It would be irreparably damaged by even a slight nudge.

Dr. Obermeyer had to remove the portion of the pancreas severed from the main body of the organ, but a web of blood vessels that feed the spleen ran through the dying tissue. Separating that pancreatic tissue from the web of vessels ranks among the most technically demanding procedures in surgery, analogous to digging through mucky soil without damaging tiny roots running through it.

“If you hit these roots, they bleed,” Dr. Obermeyer said. “They bleed a lot.”

The surgeon rejected the option of taking out the spleen along with the severed portion of the pancreas.

“Preserving those blood vessels was the best way to make certain that Stuart’s spleen would remain healthy,” Dr. Obermeyer said. He and one of his partners, Dr. Michael Goretsky, painstakingly removed the dying pancreatic tissue that clung to the web of blood vessels. With that accomplished, they delicately trimmed the jagged portion of the pancreas left by the injury, preserving as much healthy tissue as possible. The final step, closing the hole, was arduous, “like trying to stitch together the skin of an overripe peach,” the surgeon said.

Close to nine hours after Stuart went into the OR, Dr. Obermeyer came into the surgery waiting room to give the parents the good news.

StuartTaylor3“He told us that he left in a third to one half of the pancreas and that he was able to save the spleen,” Katherine said.

Now fully recovered, Stuart, 18, is headed to the University of Virginia in the fall. He still plays sports – both football and lacrosse – and enjoys kayaking on the river behind his home in Norfolk.

Dr. Obermeyer occasionally accompanies Stuart’s father to Kiwanis Club meetings where he tells Stuart’s incredible story and talks about the astonishing range of complex procedures performed by CHKD’s surgical team.

“It’s a wonderful blessing for families to know that they can stay here when their children require surgery,” Katherine said. “We have the best right here at CHKD.”

Drs. Obermeyer and Goretsky practice with CHKD’s pediatric surgery group.

This story was featured in the third 2009 issue of KidStuff, a publication of Children's Hospital of The King's Daughters. Click to read more patients' stories.

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