A 19-year-old man fell off his skateboard, reporting blunt injury to his upper abdomen. Abdominal CT and magnetic resonance cholangiopancreatography (MRCP) confirmed he suffered transection of the main pancreatic duct at the middle of the pancreatic body.
Which of the following would be the most appropriate next step in management?
A. Nonoperative treatmentOptimal management of pancreatic trauma is determined by where the parenchymal damage is located and whether the intrapancreatic common bile duct and main pancreatic duct remain intact. Patients with pancreatic contusions (defined as injuries that leave the ductal system intact) can be treated nonoperatively or with closed suction drainage if undergoing laparotomy for other indications. Patients with proximal pancreatic injuries, defined as those that lie to the right of the superior mesenteric vessels, are also managed with closed suction drainage. In contrast, distal pancreatic injuries are managed based upon ductal integrity. Pancreatic duct disruption can be identified through direct exploration of the parenchymal laceration, operative pancreatography, endoscopic retrograde pancreatography (ERCP), or magnetic resonance cholangiopancreatography (MRCP). Patients with distal ductal disruption undergo distal pancreatectomy, preferably with splenic preservation. An alternative, which preserves both the spleen and distal transected end of the pancreas, is either a Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy. If the patient is physiologically compromised, distal pancreatectomy with splenectomy is the preferred approach.