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Jain R, Gupta A, Kandasamy D, Jana M. Imaging in Pediatric Obstructive Jaundice. Indian J Pediatr 2022; 89:899-907. [PMID: 35653074 DOI: 10.1007/s12098-022-04171-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 01/25/2022] [Indexed: 01/16/2023]
Abstract
Cholestatic jaundice characterized by elevated conjugated bilirubin can be due to multitude of factors in neonates and childhood. Extrahepatic biliary atresia (EHBA), choledochal cyst, neonatal hepatitis, cytomegalovirus (CMV), and biliary plug are some of the common causes in neonate and early infancy. Causes in late infancy and childhood comprises viral hepatitis, choledochal cyst, cholelithiasis, worm infestation, and biliary compression secondary to extrinsic causes (node, collection, tumor). Some serious disorders like biliary atresia must be considered with the emphasis on early diagnosis of treatable causes. In the modern era, with multiple diagnostic modalities available including high-resolution ultrasonography, magnetic resonance imaging (MRI), CT scan, and nuclear imaging [hepatobiliary iminodiacetic acid (HIDA) scan], rapid diagnosis can be made in many surgically treatable cases. The authors will discuss the imaging modality available with advantages, disadvantages, and common indications of each modality, and overview of obstructive jaundice discussing the wide spectrum of causes in neonates and late childhood. Combining available knowledge with careful and meticulous search can help narrow down the diagnosis and initiate prompt treatment.
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Affiliation(s)
- Rupali Jain
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Amit Gupta
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Devasenathipathy Kandasamy
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Manisha Jana
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Abstract
The management of pediatric liver trauma has evolved significantly over the last few decades. While surgical intervention was frequently and mostly unsuccessfully practiced during the first half of the last century, the 1960s were witness to the birth and gradual acceptance of non-operative management of these injuries. In 2000, the American Pediatric Surgical Association (APSA) Trauma Committee disseminated evidenced-based guidelines to help guide the non-operative management of pediatric blunt solid organ injury. The guidelines significantly contributed to conformity in the management of these patients. Since then, a number of well-designed studies have questioned the strict categorization of these injuries and have led to a renewed reliance on clinical signs of the patient's hemodynamic status. In 2019, APSA introduced an updated set of guidelines emphasizing the use of physiologic status rather than radiologic grade as a driver of clinical decision making for these injuries. This review will focus on liver injuries, in particular blunt injury, as this mechanism is by far the most commonly seen in children. Procedures required when non-operative management fails will be detailed, including surgery, angioembolization, and less commonly employed interventions. Finally, the updated inpatient and post-discharge aspects of care will be reviewed, including hemoglobin monitoring, bedrest, length of hospital stay, and activity restriction.
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Affiliation(s)
- Vincent Duron
- Assistant Professor of Surgery, Division of Pediatric Surgery, Columbia University Vagelos College of Physicians & Surgeons, 3959 Broadway, CHN 215, New York, NY 10032.
| | - Steven Stylianos
- Chief, Division of Pediatric Surgery, Rudolph N Schullinger Professor of Surgery, Columbia University Vagelos College of Physicians & Surgeons, Surgeon-in-Chief, Morgan Stanley Children's Hospital, 3959 Broadway - Rm 204 N, New York, NY 10032.
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Grosek J, Čebron Ž, Janež J, Tomažič A. Bicycle handlebar injury in a child resulting in complex liver laceration with massive bleeding and bile leakage: A case report. Int J Surg Case Rep 2020; 72:386-390. [PMID: 32563827 PMCID: PMC7306525 DOI: 10.1016/j.ijscr.2020.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Bicycle accidents are a significant cause of traumatic morbidity in the paediatric population. The handlebar injuries are usually isolated and remain a major source of bicycle related morbidity. We present a case of severe liver laceration with left hepatic duct transection caused by handlebar trauma in a 13-year-old boy. CASE PRESENTATION An otherwise healthy 13-year-old Caucasian male patient was rushed to the hospital following a blunt abdominal trauma from a bicycle handlebar. An ultrasound revealed extensive free intraperitoneal fluid with accompanying features of hemodynamic instability. Operative findings included massive haemoperitoneum, a deep laceration almost separating left and right liver lobes, and a near-complete interruption of the left hepatic duct. Interestingly, the vascular anatomy of the left liver lobe was preserved. After haemostasis was established a duct-to-duct anastomosis of the ruptured left hepatic duct was performed. A T-tube biliary drainage was inserted, and intraoperative cholangiography showed no extraluminal spillage of contrast. During the recovery phase, cholangiography was performed several times revealing leakage from left hepatic duct. The leakage was managed conservatively and finally stopped. DISCUSSION Management of blunt hepatic injuries has remarkably changed from mandatory operation to mostly nonoperative interventions with selective operative management. Hemodynamic instability remains the main reason for exploratory laparotomy. Near-isolated laceration of main hepatic ducts is an extremely rare finding, and immediate reconstruction is the best option if an experienced surgeon is available. CONCLUSION Due to limited evidence, we recommend consultation with an experienced HPB surgeon on a case-by-case basis for every paediatric biliary injury.
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Affiliation(s)
- Jan Grosek
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia; Medical Faculty, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
| | - Žan Čebron
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia; Medical Faculty, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia.
| | - Jurij Janež
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia; Medical Faculty, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
| | - Aleš Tomažič
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia; Medical Faculty, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
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Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019; 14:56. [PMID: 31867050 PMCID: PMC6907251 DOI: 10.1186/s13017-019-0278-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.
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Lange B, Adam R, Kähler G, Wessel LM, Kubiak R. Experience with Stent Placement for Benign Pancreaticobiliary Disorders in Children. J Laparoendosc Adv Surg Tech A 2019; 29:839-844. [DOI: 10.1089/lap.2018.0663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Bettina Lange
- Department of Pediatric Surgery, Medical Faculty Mannheim, Heidelberg University, University Medical Center, Mannheim, Germany
| | - Rüdiger Adam
- Department of Pediatrics, Medical Faculty Mannheim, Heidelberg University, University Medical Center, Mannheim, Germany
| | - Georg Kähler
- Department of Central Interdisciplinary Endoscopy, Medical Faculty Mannheim, Heidelberg University, University Medical Center, Mannheim, Germany
| | - Lucas M. Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, Heidelberg University, University Medical Center, Mannheim, Germany
| | - Rainer Kubiak
- Department of Pediatric Surgery, Medical Faculty Mannheim, Heidelberg University, University Medical Center, Mannheim, Germany
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Pereira R, Vo T, Slater K. Extrahepatic bile duct injury in blunt trauma: A systematic review. J Trauma Acute Care Surg 2019; 86:896-901. [PMID: 31008893 DOI: 10.1097/ta.0000000000002186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Extrahepatic bile duct injuries (EHBDIs) are a rare consequence of blunt abdominal trauma. The purpose of this study was to establish mechanisms of injury, clinical indicators of EHBDI following blunt trauma (both with investigative modalities and intraoperatively), method and timing of injury detection, and definitive treatment options. METHODS A systematic review was performed to gather data on patients with an EHBDI secondary to blunt trauma. Three databases (MEDLINE, PubMed, and EMBASE) were searched to July 19, 2018. RESULTS Our systematic review included 51 studies, compromising a study population of 66 patients with EHBDIs sustained from blunt trauma. The three most common injuries included complete transection of the suprapancreatic common bile duct (29%, n = 19), complete transection of the intrapancreatic common bile duct (23%, n = 15) and partial laceration of the left hepatic duct (20%, n = 13). Of the hemodynamically stable group managed nonoperatively (n = 23), mean timing postinjury to diagnosis of EHBDI was 11 days. An EHBDI was recognized at initial laparotomy in 87% (n = 13) of hemodynamically stable patients. An EHBDI was recognized at initial laparotomy in 57% (n = 8) of hemodynamically unstable patients. CONCLUSION The EHBDIs are a rare yet serious consequence of blunt trauma. To establish a timely diagnosis and limit complications of missed injuries, a heightened awareness is required by the attending surgeon with particular attention to subtle yet important clinical indicators. These vary depending on the hemodynamic stability of the patient and decision to manage injuries conservatively or surgically on presentation. LEVEL OF EVIDENCE Systematic review, level III.
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Affiliation(s)
- Ryan Pereira
- From the Hepatobiliary and Pancreatic Surgery Unit (R.P., T.V., K.S.), The Princess Alexandra Hospital, Woolloongabba, QLD; and The Whiteley-Martin Research Unit, Discipline of Surgery (R.P.), University of Sydney, Sydney, Australia
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Muftah M, Shah R, Fritzen C, Sauer CG, Freeman AJ, Willingham FF. Endoscopic Retrograde Cholangiopancreatography in Pediatric Populations. ACTA ACUST UNITED AC 2019; 17:165-170. [PMID: 30756232 DOI: 10.1007/s11938-019-00225-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Mayssan Muftah
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Rushikesh Shah
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Chris Fritzen
- Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Cary G Sauer
- Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Alvin J Freeman
- Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Field F Willingham
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA. .,Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
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Wong YC, Wang LJ, Wu CH, Chen HW, Fu CJ, Yuan KC, Lin BC, Hsu YP, Kang SC. Detection and characterization of traumatic bile leaks using Gd-EOB-DTPA enhanced magnetic resonance cholangiography. Sci Rep 2018; 8:14612. [PMID: 30279434 PMCID: PMC6168538 DOI: 10.1038/s41598-018-32976-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 09/19/2018] [Indexed: 02/07/2023] Open
Abstract
Expanding bile leaks after blunt liver trauma require more aggressive treatment than contained bile leaks. In this retrospective study approved by institution review board, we analyzed if non-invasive contrast-enhanced magnetic resonance cholangiography (CEMRC) using hepatocyte-specific contrast agent (gadoxetic acid disodium) could detect and characterize traumatic bile leaks. Between March 2012 and December 2014, written informed consents from 22 included patients (17 men, 5 women) with a median age of 24.5 years (IQR 21.8, 36.0 years) were obtained. Biliary tree visualization and bile leak detection on CEMRC acquired at 10, 20, 30, 90 minutes time points were independently graded by three radiologists on a 5-point Likert scale. Intraclass Correlation (ICC) was computed as estimates of interrater reliability. Accuracy was measured by area under receiver operating characteristic curves (AUROC). Biliary tree visualization was the best on CEMRC at 90 minutes (score 4.30) with excellent inter-rater reliability (ICC = 0.930). Of 22 CEMRC, 15 had bile leak (8 expanding, 7 contained). The largest AUROC of bile leak detection by three radiologists were 0.824, 0.914, 0.929 respectively on CEMRC at 90 minutes with ICC of 0.816. In conclusion, bile leaks of blunt liver trauma can be accurately detected and characterized on CEMRC.
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Affiliation(s)
- Yon-Cheong Wong
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan. .,Center for Advanced Molecular Imaging and Translation, Taoyuan City, Taiwan.
| | - Li-Jen Wang
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Cheng-Hsien Wu
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Huan-Wu Chen
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Chen-Ju Fu
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Kuo-Ching Yuan
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Being-Chuan Lin
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Yu-Pao Hsu
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Shih-Ching Kang
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
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Guanà R, Giulia C, Brunati A, Garofalo S, Schleef J. Biliary Complications after Hepatic Trauma in Children. J Emerg Trauma Shock 2017; 10:211-214. [PMID: 29097861 PMCID: PMC5663141 DOI: 10.4103/jets.jets_136_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Aim of the Study: In pediatric patients with liver trauma and hemodynamic stability, conservative treatment is acknowledged as the gold standard. Patients and Methods: We conducted a retrospective analysis of 116 consecutive pediatric patients (<14-year-old) observed at our institution for closed abdominal trauma from January 2010 to January 2016. Among these, 16 patients (13%) had hepatic trauma Grade II or more, according to Moore liver trauma injury score. Results: Only one patient underwent surgery for hemodynamic instability; all others children received conservative treatment according to the American Paediatric Surgical Association guidelines. Three patients had a biliary complication (2, 5%). two patients treated surgically by drainage insertion and one was managed conservatively. Conclusions: Biliary complications of liver trauma in children may require aggressive surgical approach in selective patients.
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Affiliation(s)
- Riccardo Guanà
- Division of Pediatric Surgery, Regina Margherita Children's Hospital, Turin, Italy
| | - Carbonaro Giulia
- Division of Pediatric Surgery, Regina Margherita Children's Hospital, Turin, Italy
| | - Andrea Brunati
- Division of Pediatric Surgery, Regina Margherita Children's Hospital, Turin, Italy
| | - Salvatore Garofalo
- Division of Pediatric Surgery, Regina Margherita Children's Hospital, Turin, Italy
| | - Jurgen Schleef
- Division of Pediatric Surgery, Regina Margherita Children's Hospital, Turin, Italy
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Issa I, Modica Alameddine V, Fadous Khalife MC, Al Ojaimi M, Ghorayeb Z. Isolated and stable gallbladder perforation in a 5 year old child after blunt abdominal trauma. Trauma Case Rep 2017; 9:27-29. [PMID: 29644320 PMCID: PMC5883222 DOI: 10.1016/j.tcr.2017.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2017] [Indexed: 10/25/2022] Open
Abstract
Isolated gallbladder injury, secondary to a blunt abdominal trauma, is a rare finding in children. The presence of vague symptoms and the unknown dynamic of the trauma may increase the diagnostic challenge especially in pediatrics. A conservative management has been proposed in some particular cases in adults, but remains controversial in children. We report a case of a 5 year old boy who presented an isolated gallbladder lesion secondary to a blunt abdominal trauma. The surgical treatment was delayed for non-medical reasons, which gave us the possibility to try a conservative approach.
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Affiliation(s)
- I Issa
- Department of Pediatrics & Pediatric Surgery, UH Notre Dame De Secours, Jbeil, Lebanon.,Holy Spirit University of Kaslik, Lebanon
| | - V Modica Alameddine
- Department of Pediatrics & Pediatric Surgery, UH Notre Dame De Secours, Jbeil, Lebanon.,Holy Spirit University of Kaslik, Lebanon
| | - M C Fadous Khalife
- Department of Pediatrics & Pediatric Surgery, UH Notre Dame De Secours, Jbeil, Lebanon.,Holy Spirit University of Kaslik, Lebanon
| | | | - Z Ghorayeb
- Department of Pediatrics & Pediatric Surgery, UH Notre Dame De Secours, Jbeil, Lebanon.,Holy Spirit University of Kaslik, Lebanon
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Abstract
In the last decade, higher rates of nonoperative management of liver, spleen, and kidney injuries have been achieved. An algorithmic approach may improve success on a national level. Factors for success include management strategy based on physiologic status of the child, early attempt at resuscitation using blood products, and appropriate use of adjuncts. Shorter hospitalizations are appropriate for children who have not bled significantly, and discharge instructions facilitate the safety of early discharge. Although routine imaging is not required for liver or spleen injury, symptoms should prompt reevaluation. Reimaging of renal injuries remains in common use.
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Garvey EM, Haakinson DJ, McOmber M, Notrica DM. Role of ERCP in pediatric blunt abdominal trauma: a case series at a level one pediatric trauma center. J Pediatr Surg 2015; 50:335-8. [PMID: 25638632 DOI: 10.1016/j.jpedsurg.2014.08.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/22/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is no consensus regarding the appropriate use of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric trauma. We report our experience with ERCP for management of pediatric pancreatic and biliary injury following blunt abdominal trauma. METHODS A retrospective chart review was performed for pediatric patients with blunt abdominal trauma from July 2008 through December 2012 at our pediatric trauma center. For patients who underwent ERCP, demographics, injury characteristics, diagnostic details, procedures performed, length of stay, total parenteral nutrition use, and complications were reviewed. RESULTS There were 532 patients identified: 115 hepatic injuries, 25 pancreatic injuries and one gall bladder injury. Nine patients (mean age 7.8 years) underwent ERCP. Seven (78%) had pancreatic injuries, while two (22%) had bilateral hepatic duct injuries. The median time to diagnosis was one day (range, 0-12). Diagnostic ERCP only was performed in three patients, two of which proceeded to distal pancreatectomy. Five patients had stents placed (two biliary and three pancreatic) and four sphincterotomies were performed. Despite pancreatic stenting, one patient required distal pancreatectomy for persistent leak. Median length of stay was 11 days. CONCLUSIONS Pediatric pancreatic and biliary ductal injuries following blunt abdominal trauma are uncommon. ERCP can safely provide definitive treatment for some patients.
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Affiliation(s)
- Erin M Garvey
- Division of General Surgery, The Mayo Clinic, 5777 E Mayo Blvd. Phoenix, AZ 85255 USA
| | - Danielle J Haakinson
- Division of General Surgery, The Mayo Clinic, 5777 E Mayo Blvd. Phoenix, AZ 85255 USA
| | - Mark McOmber
- Pediatric Gastroenterology, Phoenix Children's Hospital, 1920 E Cambridge Ave. Phoenix, AZ 85006 USA
| | - David M Notrica
- Division of General Surgery, The Mayo Clinic, 5777 E Mayo Blvd. Phoenix, AZ 85255 USA; Pediatric Surgery, Phoenix Children's Hospital, 1920 E Cambridge Ave. Phoenix, AZ 85006 USA.
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