Total pancreas-preserving pancreatic injury-site jejunostomy for traumatic pancreatic head injury with main pancreatic duct transection: feasibility and decision algorithm

Abstract

Background

Traumatic pancreatic head injury with complete main pancreatic duct (MPD) transection is rare and associated with high morbidity. For the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade IV injuries, pancreaticoduodenectomy is often considered the only definitive option; however, its invasiveness and risk of long-term endocrine and exocrine dysfunction create a major dilemma when pancreaticoduodenectomy may be disproportionate to the anatomic injury. Practical pancreas-preserving strategies remain poorly defined.

Case presentation

A 25-year-old male sustained a self-inflicted stab wound causing hemorrhagic shock, generalized peritonitis due to gastric perforation, and AAST-OIS Grade IV pancreatic head injury with complete MPD transection. Initial management consisted of staged damage-control surgery with peri-pancreatic gauze packing and negative-pressure therapy for hemorrhage and contamination control. After physiological stabilization, delayed reconstruction was performed using total pancreas-preserving pancreatic injury-site jejunostomy (PP-PIJ), in which viable pancreatic tissue surrounding the injury site was anastomosed to a Roux-en-Y jejunal limb without pancreatic resection. The postoperative course was complicated by a subfascial abdominal wall abscess with wound dehiscence requiring drainage and abdominal wall re-closure; however, no pancreatic fistula or anastomotic failure occurred, and pancreatic function was preserved.

Conclusions

This report describes the first adult application of PP-PIJ and proposes a pancreas-preserving reconstructive option for traumatic pancreatic head injury with MPD transection. Staged damage-control surgery may serve as a platform for delayed reconstruction. The accompanying decision algorithm may assist operative selection when pancreaticoduodenectomy may be disproportionate to the anatomic injury.

Introduction

Traumatic pancreatic injury is uncommon, accounting for approximately 0.2% to 12% of all abdominal trauma^{1 2}; however, pancreatic head injuries with main pancreatic duct (MPD) disruption are associated with disproportionately high morbidity and mortality.^3–6 Leakage of pancreatic enzymes leads to pancreatic fistula, intra-abdominal sepsis, hemorrhage, and organ failure, making operative management particularly challenging.^{3 4 7}

For high-grade pancreatic head injuries classified as American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade IV, pancreaticoduodenectomy (PD) has traditionally been considered the definitive surgical option.^8–10 However, PD in trauma is frequently performed under physiologically unstable conditions with contamination and hemorrhagic shock,^{9 11} and it may be associated with long-term endocrine and exocrine insufficiency, although the reported incidence varies widely according to the indication for resection, baseline pancreatic condition, patient comorbidities, and operative factors.^{12 13} Consequently, surgeons often face a critical operative dilemma when the patient is physiologically salvageable but local ductal reconstruction is not technically feasible.

External drainage alone is inadequate for complete MPD disruption because persistent pancreatic leakage frequently results in prolonged fistula formation and delayed complications.^{4 7} Pancreas-preserving reconstructions, such as Roux-en-Y pancreaticojejunostomy, have been reported as alternatives to resection^14–16; however, these procedures are typically performed after resection of the injured pancreatic segment, and they are largely limited to injuries of the pancreatic neck or body-tail region. For pancreatic head injuries, even limited resection generally necessitates PD, leaving no established non-resectional reconstructive strategy.

Herein, we report the first application of a total pancreas-preserving pancreatic injury-site jejunostomy (PP-PIJ) in an adult with a traumatic pancreatic head injury and MPD transection, performed after staged damage control surgery (DCS), with peri-pancreatic gauze packing and negative-pressure therapy. In addition, a clinical decision algorithm is proposed to define indications for this pancreas-preserving reconstructive option.

Case presentation

A 25-year-old male presented with a self-inflicted stab wound to the upper abdomen. A physician-staffed emergency vehicle responded. The patient presented in hemorrhagic shock. Although the initial focused assessment with sonography for trauma (FAST) was negative, a repeat FAST during transport was positive. On arrival, the patient was in hypotensive shock, and he was transferred to the hybrid emergency room in the trauma center. The hybrid emergency room is an integrated trauma resuscitation unit that combines the functions of an emergency room, CT suite, angiography suite, and operating room, allowing CT imaging and immediate operative intervention without patient transfer.¹⁷ Because the patient was judged able to tolerate rapid CT under ongoing resuscitation, contrast-enhanced CT was performed to define the injury pattern and bleeding source, whereas the surgical team remained prepared to proceed immediately to laparotomy if hemodynamic deterioration occurred. Contrast-enhanced CT revealed massive hemoperitoneum, pneumoperitoneum, full-thickness gastric injury, active extravasation along the anterior surface of the pancreatic head, and hematoma formation predominantly anterior to the pancreatic head, with a low-density area in the ventral aspect of the pancreatic head, confirming pancreatic head injury with peritonitis (figure 1a, b).

Figure 1. Initial imaging findings of traumatic pancreatic head injury and complete main pancreatic duct transection. (a) Contrast-enhanced CT showing active extravasation along the anterior surface of the pancreatic head (arrow). (b) Contrast-enhanced CT showing a low-density area in the ventral aspect of the pancreatic head, indicating the pancreatic injury site (arrowhead). (c) Endoscopic retrograde pancreatography showing contrast extravasation from the main pancreatic duct at the pancreatic head (arrow). The distal pancreatic duct was not visualized, consistent with complete main pancreatic duct transection. (d) Intraoperative photograph during pancreas-preserving pancreatic injury-site jejunostomy showing suturing between the injured pancreatic head and the elevated jejunal limb. (e) Intraoperative photograph after completion of the pancreatic injury-site jejunostomy, showing reconstruction between the injured pancreatic head and the elevated jejunal limb.

Damage control surgery (day 0)

Based on the findings of gastric perforation, pancreatic head injury, and active intra-abdominal hemorrhage, an emergency laparotomy was performed (operative time, 55 min). The intraoperative findings included severe intra-peritoneal contamination from full-thickness anterior and posterior gastric body lacerations, which were repaired by primary closure using 4–0 absorbable sutures. In addition, active hemorrhage from injuries to the anterior superior pancreaticoduodenal artery and vein resulted in hemorrhagic shock. Hemostasis was achieved using suture ligation. A deep penetrating injury of the pancreatic head was identified, raising strong suspicion of MPD disruption. Given persistent shock physiology, peri-pancreatic gauze packing was performed for hemorrhage control and pancreatic containment. Temporary abdominal closure was achieved using an AbThera negative-pressure open abdomen system. Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) confirmed complete MPD transection (figure 1c), and cannulation of the distal pancreatic duct was not possible. The patient was subsequently transferred to the intensive care unit for continued resuscitation and stabilization during approximately 24 hours.

Planned re-operation for contamination control (day 1)

On postoperative day (POD) 1, severe peritoneal contamination due to gastric perforation necessitated a re-laparotomy. Extensive abdominal lavage was performed, and peri-pancreatic packing was reinforced to prevent pancreatic enzyme activation and autodigestion. Negative-pressure therapy was continued.

Definitive reconstruction (day 2)

On POD 2, after physiological stabilization, definitive reconstructive surgery was performed in a conventional operating room. Removal of the peri-pancreatic packing revealed adequate hemostasis and a 2 cm pancreatic head defect with active leakage of pancreatic juice. Intraoperative ERCP was performed to reassess the MPD. Cannulation of the proximal MPD was successful; however, cannulation of the distal pancreatic duct beyond the injury site was not possible, indicating complete ductal disruption. Endoscopic sphincterotomy was not performed because complete MPD transection with failure of distal duct cannulation made bridging stent placement impossible. Sphincterotomy alone was not expected to control pancreatic juice leakage from the disconnected distal ductal system, and additional endoscopic intervention was considered unlikely to provide sufficient benefit. Careful intraoperative inspection of the pancreatic injury cavity failed to identify the injured distal pancreatic duct. In addition, intraoperative pancreatic ultrasonography demonstrated the pancreatic duct; however, its diameter was less than 2 mm; therefore, localization and access from the injury site were not possible. Based on these findings, endoscopic or surgical ductal cannulation and stenting were deemed to be not feasible, and conventional duct-to-mucosa reconstruction could not be performed. In this setting, the duodenum and bile duct were intact, and PD was considered to be excessively invasive. Therefore, PP-PIJ was selected to achieve definitive internal drainage while preserving the entire pancreas.

The jejunum was divided 30 cm distal to the ligament of Treitz. The distal limb was elevated through a retrocolic route, and an approximately 2 cm jejunal enterotomy was created. A circumferential PIJ was constructed by anastomosing the viable pancreatic parenchyma surrounding the injury cavity to the jejunal wall using interrupted full-thickness sutures with 3–0 absorbable material, forming a wide side-to-side internal drainage channel (figure 1d, e). A standard Roux-en-Y reconstruction was completed (figure 2). Drains were placed cranial and ventral to the anastomosis, and in the foramen of Winslow, followed by definitive abdominal closure.

Figure 2. Reconstruction diagram of total pancreas-preserving pancreatic injury-site jejunostomy. A Roux-en-Y jejunal limb was elevated through a retrocolic route and directly anastomosed to the viable pancreatic parenchyma surrounding the pancreatic head injury site, without pancreatic resection. The procedure created a wide circumferential internal drainage channel while preserving the entire pancreas.

Postoperative course

After PP-PIJ, the drain amylase level remained consistently low, with no evidence of pancreatic fistula or anastomotic failure. On POD 5, a midline surgical site infection was observed and initially managed conservatively. CT on POD 7 demonstrated an intact pancreatic injury-site jejunostomy without leakage, but revealed a localized subfascial abdominal wall abscess (figure 3a). After extubation on POD 8, increased abdominal strain was followed by wound dehiscence associated with the subfascial abdominal wall abscess, necessitating abscess drainage and abdominal wall re-closure.

Figure 3. Postoperative contrast-enhanced CT after total pancreas-preserving pancreatic injury-site jejunostomy. (a) Contrast-enhanced CT on postoperative day 7 showing an intact anastomosis between the pancreas and elevated jejunal limb, with no evidence of anastomotic leakage. (b) CT on postoperative day 75 showing a stable pancreatic injury-site jejunostomy with no peri-pancreatic fluid collection or dilatation of the distal main pancreatic duct in the pancreatic body and tail.

This abdominal wall complication was considered related to severe intra-abdominal contamination from gastric perforation and subsequent surgical site infection, rather than to PP-PIJ leakage. The abscess was localized to the subfascial abdominal wall, with no abscess formation around the PP-PIJ anastomosis and no pancreatic enzyme leakage. A tracheostomy was performed on POD 10 because prolonged postoperative ileus and aspiration pneumonia required extended respiratory management. The prolonged acute care surgical treatment period was mainly attributable to these abdominal wall and respiratory complications.

Thereafter, the patient recovered without additional complications, and there was no evidence of pancreaticojejunostomy leakage. On POD 49, after resolution of the acute surgical problems, the patient was transferred to the psychiatry department for further management of the underlying psychiatric condition. Abdominal CT performed on POD 75 demonstrated a stable pancreatic injury-site jejunostomy, with no peripancreatic fluid collection or anastomotic failure (figure 3b). In addition, there was no dilatation of the MPD in the pancreatic body or tail, suggesting that pancreatic juice from the injured pancreas was adequately drained through the elevated jejunal limb. At the latest follow-up 7 months after PP-PIJ, the patient remained free of abdominal symptoms and had no clinical features suggestive of chronic pancreatitis or exocrine insufficiency, such as steatorrhea or pancreatic diarrhea. No glucose intolerance was observed on follow-up laboratory assessment. Follow-up CT showed no atrophy of the pancreatic body or tail and no dilatation of the distal MPD. No PP-PIJ-related complications were observed during this follow-up period.

Discussion

Traumatic pancreatic head injury with MPD disruption, particularly an AAST-OIS Grade IV injury, is one of the most complex scenarios in emergency surgery.⁴ Although PD has traditionally been selected as definitive management, this approach largely reflects the absence of established alternatives rather than clear superiority.¹⁰ In physiologically salvageable patients, PD imposes a substantial operative burden and may be associated with long-term endocrine and exocrine insufficiency. Reported rates of endocrine and exocrine insufficiency after PD vary widely according to the indication for resection, baseline pancreatic condition, patient comorbidities, and operative factors.^{12 13} Therefore, when the duodenum and bile duct are intact and the pancreatic head is not globally crushed or devascularized, the decision to proceed directly to PD remains difficult if a less invasive reconstructive alternative may be technically feasible.

PP reconstruction has been described primarily in the setting of resection-based management for injuries to the pancreatic neck or body-tail.^14–16 These techniques are not applicable to pancreatic head injuries, where even limited resection generally necessitates PD. Consequently, pancreatic head injury with MPD transection has not had a non-resectional reconstructive option, leaving surgeons to choose between highly invasive resection and prolonged external drainage. Letton and Wilson described Roux-en-Y anastomosis to the distal pancreas after traumatic pancreatic transection.¹⁸ This approach reconstructs the distal pancreas but does not provide direct internal drainage of the pancreatic head injury site.^{5 19} Thus, currently available PP strategies do not address the core pathophysiology of uncontrolled pancreatic juice leakage from a disrupted duct within the pancreatic head.

The concept of PP-PIJ was partly inspired by our experience with longitudinal pancreaticojejunostomy, such as the Partington-Rochelle procedure, for chronic pancreatitis. Both approaches share the principle of internal drainage of pancreatic juice into the jejunum to avoid prolonged external pancreatic drainage. However, the technical setting is fundamentally different. In chronic pancreatitis, longitudinal pancreaticojejunostomy is performed by opening a dilated MPD within fibrotic pancreatic parenchyma. In contrast, PP-PIJ is performed in an acutely injured soft pancreas, in which pancreatic juice from both sides of the transected duct drains into the pancreatic injury cavity. The goal of PP-PIJ is therefore to anastomose the viable injured pancreatic parenchyma surrounding this cavity to a Roux-en-Y jejunal limb, thereby converting the traumatic ductal disruption into controlled internal drainage without pancreatic resection.

In the present case, PP-PIJ provided direct injury-site internal drainage, while preserving the entire pancreas. Rather than functioning solely as a technical innovation, PP-PIJ represents a decision-dependent reconstructive option that is feasible under specific physiological and anatomic conditions. A key factor in this case was staged DCS with peri-pancreatic gauze packing and negative-pressure therapy. Based on our previous experience with staged management of severe pancreatoduodenal injury, peri-pancreatic packing may help contain pancreatic and digestive juice contamination and maintain the local anatomic configuration until early re-operation.²⁰ However, the evidence supporting peri-pancreatic packing as a reconstructive adjunct remains limited. In the present case, packing and negative-pressure therapy appeared to help contain pancreatic juice leakage and permit delayed reassessment under improved physiological conditions. These factors may have contributed to the creation of an operative field suitable for circumferential anastomosis. Because successful transpapillary stent placement into the distal pancreatic duct may allow pancreatic parenchymal repair, external drainage, or other non-resectional management, the feasibility of this approach should be evaluated before considering PP-PIJ.

Based on this experience, PP-PIJ may be considered when the following conditions are met¹: MPD disruption is localized to the pancreatic head²; the injury is anteriorly accessible³; the duodenum and bile duct are preserved⁴; the pancreatic neck-to-tail region is preserved⁵; the pancreatic head is not globally crushed or devascularized⁶; physiological stabilization and contamination control are achieved through staged DCS with packing and negative-pressure therapy; and⁷ viable posterior pancreatic parenchyma remains. These criteria form the basis of the proposed decision algorithm (figure 4), which is intended to guide operative selection after evaluating the feasibility of transpapillary stent placement into the distal pancreatic duct and the anatomic and physiological eligibility criteria for PP-PIJ.

Figure 4. Proposed decision algorithm for selecting total pancreas-preserving pancreatic injury-site jejunostomy (PP-PIJ) for traumatic pancreatic head injury and main pancreatic duct (MPD) transection. The algorithm outlines a stepwise surgical decision-making process for high-grade pancreatic trauma. After confirming MPD disruption and pancreatic head involvement, the feasibility of transpapillary stent placement into the distal pancreatic duct is evaluated. If stent placement is feasible, pancreatic parenchymal repair, external drainage, or other non-resectional management may be considered. If stent placement is not feasible, anatomic and physiological criteria for PP-PIJ are evaluated, including anteriorly accessible injury, preserved duodenum and bile duct, preserved pancreatic neck-to-tail region, absence of global pancreatic head devascularization, viable posterior pancreatic parenchyma, controllable contamination, and physiological stabilization after staged damage control surgery (DCS). If these criteria are satisfied, PP-PIJ may be considered. If not, pancreaticoduodenectomy or external drainage should be considered. AAST, American Association for the Surgery of Trauma.

Limitations

A single adult case has been described, and broader applicability remains to be analyzed. Reproducibility across institutions and refinement of indications require further experience. Although no PP-PIJ-related complications, pancreatic body-tail atrophy, distal MPD dilatation, glucose intolerance, or clinical features suggestive of chronic pancreatitis or exocrine insufficiency were observed during the 7-month follow-up period, longer-term follow-up is required to assess late ductal changes, pancreatic atrophy, chronic pancreatitis, and endocrine and exocrine function. Therefore, PP-PIJ should currently be regarded as a carefully selected reconstructive option rather than a replacement for established surgical strategies, pending further clinical experience.

Conclusions

Total PP-PIJ may be a feasible non-resectional reconstructive option for carefully selected patients with traumatic pancreatic head injury and MPD transection. When physiological stabilization and contamination control are achieved through staged DCS, delayed injury-site internal drainage can become technically achievable. This report describes the first application of PP-PIJ in an adult, and the findings suggest that this approach may expand operative decision-making when PD may be disproportionate to the anatomic injury, particularly when the duodenum, bile duct, and pancreatic neck-to-tail region are preserved.