Perforation of a pancreatic duct during pancreatic stent placement is uncommon. Rashdan reported that only 3 of 2283 patients (0.1%) developed perforation of a pancreatic duct within 1–3 days after endoscopic retrograde cholangiopancreatography (ERCP) . However, there have been no cases of perforation of a pancreatic duct several months after pancreatic duct stenting. In the present case, we speculate that stent attachment to the wall of a pancreatic duct was one of the causes of the perforation. In addition, chemoradiotherapy for pancreatic cancer may have made the pancreatic parenchyma brittle.
Pancreatic injuries are not frequent and are often associated with intra-abdominal injuries , occurring in only 3 to 12% of all patients with severe abdominal injuries . Pancreatic injuries carry high mortality and morbidity rates, especially grade III (AAST scale) or worse injuries , so an early diagnosis and adequate therapy for pancreatic injuries is important.
CT is the most useful modality for diagnosing pancreatic injuries and can detect parenchymal lesions, but ductal disruption is commonly missed . Endoscopic retrograde pancreatography (ERP) is one of the most useful methods for demonstrating the main pancreatic duct (MPD). Many recent reports have stated that pancreatic stent placement after a diagnosis by ERP prevents surgical treatment . ERP has a high rate of complications (5–15%), such as pancreatitis, cholangitis, and duodenal perforation, but the importance of ERP is nevertheless increasing . In this case, a broad abscess was found to have formed and the patient’s condition was poor; therefore, we thought that a surgical approach would be better than ERP in order to ensure the patient’s survival.
Surgical treatments for pancreas lesions vary, and the site, type, and surgeon’s experience are important for determining the most appropriate strategy. For grade III injuries, surgical treatment, such as pancreatic resection, can be selected. In pancreatic head injuries, pancreatoduodenectomy (PD) can be considered . However, as PD may be accompanied by complications after surgery, we should select PD after consideration of the patient’s general condition and the surgical skill of the operator. In pancreatic body and tail injuries, distal pancreatectomy (DP) and splenectomy are the standard choice . Letton-Wilson’s procedure, which consists of the closure of the proximal pancreatic segment and pancreato-jejunal anastomosis for the distal pancreatic segment, is one method that preserves the pancreas. However, this procedure is not generally recommended, as it can easily cause anastomotic leakage and result in the formation of pancreatic cysts . The Bracy procedure, which is pancreato-gastric anastomosis, is said to cause less anastomotic leakage than other procedures because the pancreatic juice is not activated in the stomach . Suturing the pancreatic duct is the ideal surgical procedure, but it is very difficult, and there is a high risk of pancreatic fistula.
The concept of damage control surgery (DCS) has also been accepted. For example, the external drainage of the MPD and towel packing against the bleeding point can be performed. Patton et al.  reported that simplified external drainage was successful with low morbidity and mortality in cases of severe pancreatic injury.
In the present case, the pancreatic body was damaged, and while DP was indicated, we judged pancreatic resection to be unsuitable. First, we planned to perform PD for pancreatic head cancer in the future, so consequently, we wanted to preserve the distal pancreas. Second, because the patient was receiving chemoradiotherapy for cancer, we suspected that the pancreatic parenchyma and surrounding tissue might be fragile. Finally, panperitonitis due to pancreatic fistula occurred, and this patient’s general condition was poor. For these reasons, we selected the external drainage of a pancreatic duct. In addition, the distance between the posterior wall of the stomach and the perforated site of the pancreas was very small, and thus, it was easy to pass the tubes into the stomach, and we thought the perforated site was covered with the stomach. Therefore, we performed transgastric drainage. Regarding why the patient has had such a good postoperative course, we think that the size of the pancreatic tube matched that of the pancreatic duct well and the pancreatic tube passing through the stomach resulted in a setup similar to pancreato-gastric anastomosis. Although transgastric external drainage is not always useful in general pancreatic injuries, we think that this procedure should be considered as a choice in systemically unstable patients.