Successful treatment of blunt trauma involving complete laceration of the pancreas and duodenum in a 7-year-old child: report of a case

Surgical reconstruction and endoscopic pancreatic stent for traumatic pancreatic duct disruption

Nonoperative management is acceptable treatment for minor pancreatic injuries. However, management of major pancreatic duct injury in children remains controversial. We present our experience in treating isolated pancreatic duct injury. We describe the cases of three male patients treated for complete pancreatic duct disruption in the past 5 years at our institution. We performed pancreatic duct repair to avoid distal pancreatectomy and to maintain normal pancreatic function. All patients underwent enhanced computed tomography and endoscopic retrograde cholangiopancreatography in the early period. The injuries were classified as grade III according to the American Association for the Surgery of Trauma classification. In two cases, we performed end-to-end anastomosis of the pancreatic duct during the delayed period. In the third case, we placed a stent across the disruption to the distal pancreatic duct. The patients' postoperative courses were uneventful, and the average hospitalization was 25.6 days after the procedure. At a median follow-up of 36 months (range 14-54 months), all patients remain asymptomatic, with normal pancreatic function, but with persistent distal pancreatic duct dilatation. We suggest that distal pancreatectomy should not be routinely performed in patients with isolated pancreatic duct injury.

Management of blunt pancreatic trauma in children

PURPOSE

Blunt abdominal trauma is the major cause of abdominal injury in children. Because of the retroperitoneal location, insidious signs and symptoms and the lack of sensitivity with common imaging modalities often lead to difficulties in making an accurate diagnosis. The most common complication is the formation of a pancreatic fistula, pancreatitis and a pancreatic pseudocyst, which usually manifests within 3 or 4 weeks after injury.

METHODS

The case records of seven children (4 male, 3 female) treated for blunt pancreatic injury in the department of pediatric surgery, University Hospital, Split were reviewed.

RESULTS

The treatment modalities were selected according to the grade of the pancreatic injury, hemodynamic status and associated injuries. Because all of the patients were classified as grade I or II according to the American Association for the Surgery of Trauma (AAST) classification, a conservative treatment was selected for all seven patients. In four patients the conservative treatment resulted in the total regression of the clinical, biochemical and radiological signs within four weeks (AAST grade I). In the other three patients, pancreatic pseudocysts arose within 3 or 4 weeks after the injury (AAST grade II).

CONCLUSIONS

The status of the main pancreatic duct and the location of the pancreatic injury constitute the basis of the AAST scoring system. This scale should be used as a guide to selecting a surgical or conservative strategy. Based on these data, two factors appear to be the most important determinants of the treatment strategy for children with pancreatic injury: the grade of the pancreatic injury, which is determined according to the status of the main pancreatic duct and the clinical status of the patient.

Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis

Injuries of the pancreas, gallbladder, and bile ducts due to blunt trauma are relatively uncommon and difficult to detect but are associated with high morbidity and mortality, especially if diagnosis is delayed. Accurate and early diagnosis is imperative, and imaging plays a key role in detection. Knowledge of the mechanisms of injury, the types of injuries, and the roles of various imaging modalities is essential for prompt and accurate diagnosis. Early recognition of disruption of the main pancreatic duct is important because such disruption is the principal cause of delayed complications. Computed tomography (CT) can demonstrate pancreatic parenchymal injuries and complications such as abscess, fistula, pancreatitis, and pseudocyst. CT findings can also suggest disruption of the pancreatic duct; however, the ability of CT to indicate this finding depends on the degree of parenchymal injury. Magnetic resonance (MR) cholangiopancreatography allows direct imaging of the pancreatic duct and sites of disruption. Gallbladder injuries can be detected with CT, ultrasonography, hepatobiliary scintigraphy, or MR cholangiopancreatography. CT findings include a collapsed gallbladder, wall thickening, inhomogeneous mural enhancement, and pericholecystic fluid. Bile duct injuries can be suggested with CT, which may show ascites and associated liver injuries, and can be confirmed with hepatobiliary scintigraphy.