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

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.