Asian Journal of Research in Surgery

Background: Pancreatic trauma is uncommon but may be associated with substantial morbidity, particularly when the main pancreatic duct is disrupted. Diagnosis may be difficult during the early phase after trauma, and a negative focused assessment with sonography for trauma (FAST) examination does not exclude significant intra-abdominal or retroperitoneal injury. We report a case of complete traumatic pancreatic transection following high-energy blunt abdominal trauma that was managed by spleen-preserving distal pancreatectomy, despite the inability to cannulate the very small main pancreatic duct directly.

Case Presentation: An 18-year-old man with no relevant medical or surgical history was admitted approximately 4 hours after a high-energy motorcycle crash. He was conscious, with a Glasgow Coma Scale score of 15/15, but presented with borderline haemodynamic instability, an arterial blood pressure of approximately 90/60 mmHg, and a traumatic abdominal wall wound measuring approximately 6 cm with evisceration. The initial FAST examination did not demonstrate significant free intraperitoneal fluid. Initial laboratory testing showed a decreased haematocrit, whereas the haemoglobin concentration was reportedly within the normal range. Contrast-enhanced whole-body computed tomography demonstrated a large-volume haemoperitoneum and complete transverse disruption of the pancreatic parenchyma at the level of the pancreatic isthmus and body, with associated retroperitoneal air. The spleen and splenic vessels were intact. Emergency exploratory laparotomy confirmed complete pancreatic transection at the level described on CT. A spleen-preserving distal pancreatectomy was performed, with preservation of the spleen and splenic vessels using a Kimura-type vessel-preserving approach. Intraoperative cannulation of the main pancreatic duct was attempted but was unsuccessful because of its very small calibre. The pancreatic stump was closed using a continuous double-pass PDS 3-0 suture without separate duct ligation, and a drain was placed adjacent to the stump. Postoperatively, the drain fluid showed an elevated amylase concentration exceeding 400 U/L. As the patient remained clinically stable, without sepsis, organ dysfunction, or the need for additional intervention, this finding was managed conservatively and was clinically consistent with a biochemical pancreatic leak. The drain was removed on postoperative day 15. Clinical follow-up at 1, 3, and 6 months showed no evidence of pancreatic endocrine or exocrine insufficiency; however, formal biochemical testing of endocrine or exocrine function was not performed.

Conclusion: Complete pancreatic transection is a rare and potentially life-threatening consequence of high-energy blunt abdominal trauma. A negative FAST examination and a reportedly normal early haemoglobin concentration should not be interpreted as excluding severe injury. In selected patients with distal pancreatic transection and intact splenic vessels, spleen-preserving distal pancreatectomy can provide definitive treatment while preserving splenic function. When the main pancreatic duct is too small to be identified or cannulated directly, secure closure of the pancreatic stump and adequate drainage may permit conservative management of a clinically insignificant postoperative pancreatic leak.