Middle Pancreatectomy for Traumatic Main Pancreatic Duct Injury with Delayed Presentation: Two Case Series

Abstract

Introduction: Pancreatic trauma is an uncommon, yet potentially lethal condition, with main pancreatic duct (MPD) disruption guiding surgical management. Middle pancreatectomy (MP) with Roux-en-Y pancreatojejunostomy (PJ) offers an organ-preserving alternative to distal pancreatectomy, particularly for young patients. However, the extent of its applicability and the specific surgical techniques-including key technical tips-remain unclear in the context of traumatic pancreatic injury. This is especially true in cases of delayed presentation, where severe intra-abdominal inflammation further complicates surgical intervention.

Case presentation: We report 2 cases of young patients with MPD injuries from blunt trauma, both presenting late with significant peripancreatic contamination. Case 1 included a 22-year-old male who sustained pancreatic and liver injuries while skiing. He was transferred 30 hours post-injury with stable hemodynamics. Endoscopic retrograde pancreatography (ERP) confirmed MPD disruption. Intraoperatively, saponification obscured the anatomical structures, but MP with PJ was successfully performed. The patient recovered without major complications. Case 2 involved a 17-year-old female who was initially observed at another hospital after a traffic accident. Three days later, she developed peritonitis, and a retrospective computed tomography review revealed a pancreatic body rupture. An ERP confirmed MPD disruption. During surgery, extensive inflammation and adhesions were noted, and the MPD was extremely small. Despite technical complexities, an MP with PJ was successfully completed. The pancreatic fistula from the pancreatic head stump required drainage treatment following spinal surgery for vertebral fractures, and the patient recovered without sequelae.

Conclusions: MP with Roux-en-Y PJ is a technically challenging but viable approach for MPD injuries in young patients, even with delayed presentation. It preserves the pancreatic and splenic functions, making it a valuable approach for young patients when performed by experienced surgeons. These cases demonstrate the clinical impact and potential implications of MP as a viable treatment approach for pancreatic trauma.

Keywords: central pancreatectomy; delayed presentation; endoscopic retrograde pancreatography; main pancreatic duct injury; middle pancreatectomy; pancreatic injury; pancreatic trauma; trauma.

Fig. 1. Images before surgical intervention in Case 1. (A) A contrast-enhanced CT scan after admission to the previous hospital revealing a laceration of the pancreatic body (arrowhead). (B) A contrast-enhanced CT scan after admission to the previous hospital showing a laceration and compression of the liver (arrowhead). (C) ERP showing the leakage of contrast agents from the MPD. (D) X-ray image showing a fracture of the left olecranon (arrowhead).

CT, computed tomography; ERP, endoscopic retrograde pancreatography; MPD, main pancreatic duct

Fig. 2. Surgical findings from Case 1. (A) The crushed and torn pancreatic body (arrowhead) and pancreatic head stump (arrow). (B) The crushed pancreatic body had been removed, and the distal resection margin was trimmed (arrowhead). (C) A modified Blumgart technique for pancreatojejunostomy was performed. (D) The lacerated liver was sutured with pledgets.

Fig. 3. Images before the surgical intervention in Case 2. (A) Contrast-enhanced CT scan after admission to the previous hospital. The arrowheads mark the kidney injury (AAST-OIS grade IIIb). (B) Contrast-enhanced CT scan after admission to the previous hospital. The arrowheads mark a slight abnormality of the pancreatic injury. (C) Contrast-enhanced CT scan after admission to our hospital (3 days after injury). The arrowheads mark the location of the pancreatic injury, which is more pronounced compared to (A). (D) ERP revealed the leakage of contrast agents from the MPD. (E) Sagittal CT scan of dislocation fracture of the 11th and 12th thoracic vertebrae.

AAST, American Association for the Surgery of Trauma; CT, computed tomography; ERP, endoscopic retrograde pancreatography; MPD, main pancreatic duct

Fig. 4. Surgical findings from Case 2. (A) The abdominal cavity exhibited peritonitis and adhesions with saponification (arrow). The pancreatic body was encircled by a yellow vessel loop. Pancreatic injury was observed without remarkable capsular rupture (arrowheads). (B) The MPD was scarcely identifiable due to its extremely small caliber. The arrowheads mark the location of the MPD. (C) An intravenous cannula was inserted into the MPD. (D) The MPD was successfully secured using an over-the-wire technique with a 0.025-inch guidewire. (E) Pancreatojejunostomy (duct-to-mucosa anastomosis) was performed using eight 6-0 PROLENE sutures.

MPD, main pancreatic duct

Fig. 5. Decision-making algorithm for the treatment of main pancreatic duct injury in the pancreatic body. This algorithm applies to hemodynamically stable patients with grade III pancreatic injury involving the pancreatic body. The initial assessment includes ERP, to evaluate the feasibility of nonoperative management via stenting of the distal MPD. If stenting is not feasible, surgical management is indicated. DP with splenectomy is the standard option, while MP with pancreatojejunostomy may be considered in young patients, provided the procedure is performed by an experienced surgical team.

DP, distal pancreatectomy; ERP, endoscopic retrograde pancreatography; MP, middle pancreatectomy; MPD, main pancreatic duct