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Sedai H, Poddar E, Shrestha S, Koirala D, Gautam A. Delayed presentation of isolated ductal rupture of pancreatic head from blunt abdominal trauma managed conservatively: A case report. Ann Med Surg (Lond) 2022; 80:104249. [PMID: 36045849 PMCID: PMC9422292 DOI: 10.1016/j.amsu.2022.104249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction and Importance: Blunt abdominal injury causing significant and isolated major pancreatic injury is rare in adolescents and young adults, with a controversial approach to its management. Case presentation We present our experience of diagnosis and management of the ductal injury of the pancreatic head (Grade III) in the setting of blunt abdominal trauma in a 20-year-old male diagnosed by a series of various tests including magnetic resonance cholangiopancreatography (MRCP) and managed by pigtail drainage and octreotide alone; contrary to the previous recommendations of management of high-grade pancreatic trauma through surgical approach or endoscopic retrograde cholangiopancreatography (ERCP) and stenting. Clinical discussion Isolated ductal rupture of the pancreatic head can have delayed presentation within a window of time and can be diagnosed by a series of tests including hematological, biochemical, and radiological investigations. Conservative treatment is generally recommended for Grade I and II whereas a surgical approach is preferred for higher grade pancreatic injury. Conclusions Pancreatic ductal injury must be kept in mind when present with vague symptoms in the setting of blunt abdominal trauma. Magnetic resonance cholangiopancreatography (MRCP) is the investigation of choice for the diagnosis of pancreatic ductal injury. Even higher-grade pancreatic injury (grade III) can be managed with a conservative approach with pigtail drainage and an appropriate dosage of octreotide. Isolated ductal rupture of the pancreatic duct is very rare with delayed manifestations. MRCP is the investigation of choice for diagnosis. Conservative approach with pigtail drainage and octreotide can be successful in grade III injury.
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Affiliation(s)
- Hari Sedai
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Elisha Poddar
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Suraj Shrestha
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
- Corresponding author. Maharajgunj Medical Campus, Institute of Medicine, P.O.Box: 1524, Kathmandu, Nepal.
| | - Dinesh Koirala
- Department of Gastroenterology and Hepatology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Abishkar Gautam
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
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Kopljar M, Ivandić S, Mesić M, Bakota B, Žiger T, Kondža G, Pavić R, Milan M, Čoklo M. Operative versus non-operative management of blunt pancreatic trauma in children: Systematic review and meta-analysis. Injury 2021; 52 Suppl 5:S49-S57. [PMID: 32089286 DOI: 10.1016/j.injury.2020.02.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/09/2020] [Indexed: 02/07/2023]
Abstract
AIM Blunt abdominal trauma is the major cause of abdominal injury in children. No clear guidelines exist for the initial management of blunt pancreatic trauma in children. The aim of this study was to perform a systematic review and meta-analysis of initially non-operative versus initially operative treatment in children with blunt pancreatic injury. METHODS Studies including children (<18 years) with blunt pancreatic injuries published in any language after year 1990 were included. Total of 849 studies were identified by searching PubMed, Scopus, CINAHL and Cochrane Database. After review, 42 studies met inclusion criteria and were included in this systematic review. There were 1754 patients, of whom 1095 were initially managed non-operatively (NOM), and 659 operatively (OM). Primary outcome was non-operative management success rate, and secondary outcomes were mortality, complications (including specifically pseudocysts and pancreatic fistulas), percent of patients and days on total parenteral nutrition (TPN), length of hospital stay and readmissions. RESULTS There was no difference in mortality between NOM and OM groups. The incidence of pseudocysts was significantly higher in NOM group compared to OM (P<0.001), especially for AAST grade III or higher (P<0.00001). Overall incidence of pancreatic fistulas was significantly lower for NOM group (p = 0.02) but no difference was observed for AAST grades III or higher (p = 0.49). There was no difference in the length of hospital stay (P = 0.31). Duration of total parenteral nutrition was not different for all AAST grades (P = 0.35), but was significantly shorter for OM group for AAST grades III and higher (p = 0.0001). There was no overall difference in readmissions (P = 0.94). Overall success rate of initial non-operative treatment was 87%. CONCLUSIONS Most patients with pancreatic trauma can initially be treated non-operatively, while early surgical treatment may benefit patients with lesions of the main pancreatic duct. ERCP offers both highly accurate diagnosis and potential treatment of ductal injuries.
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Affiliation(s)
- Mario Kopljar
- Medical Faculty Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; University Hospital Center "Sestre milosrdnice", Zagreb, Croatia.
| | - Stjepan Ivandić
- University Hospital Center "Sestre milosrdnice", Zagreb, Croatia
| | | | - Bore Bakota
- Trauma and Orthopaedics Department, Medical University Hospital LKH Graz, Austria
| | - Tihomil Žiger
- University Hospital Center "Sestre milosrdnice", Zagreb, Croatia; Faculty of Dental Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Goran Kondža
- Medical Faculty Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; University Hospital Center Osijek, Croatia
| | - Roman Pavić
- Medical Faculty Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; University Hospital Center "Sestre milosrdnice", Zagreb, Croatia
| | | | - Miran Čoklo
- Institute for Anthropological Research, Zagreb, Croatia
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Richards MK, Clifton MS. Minimally invasive surgery of the pancreas: a narrative review of current practice. Transl Gastroenterol Hepatol 2021; 6:38. [PMID: 34423159 DOI: 10.21037/tgh-20-220] [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: 05/13/2020] [Accepted: 08/11/2020] [Indexed: 11/06/2022] Open
Abstract
Minimally invasive surgery has moved from the fringe of pediatric surgery to the mainstream to address a variety of problems. Pancreatic pathology, though uncommon and complex, is frequently amenable to laparoscopic intervention. Indications for pediatric pancreatic operative intervention includes trauma, congenital hyperinsulinemia and neoplasm. Children may require distal pancreatectomy, subtotal pancreatectomy, enucleation, lateral pancreaticojejunostomy and pancreaticoduodenectomy. Of these operations, all but pancreaticoduodenectomy have been successfully described in children using a minimally invasive approach. Traumatic transection of the main pancreatic duct may require operative intervention if endoscopic techniques are unsuccessful. Distal pancreatectomy has been successfully utilized in this circumstance. Additionally, near total pancreatectomy may also be performed laparoscopically although successful reports are limited. Enucleation, especially with the use of intraoperative ultrasound may avoid a large laparotomy for isolated benign masses. Finally, chronic pancreatitis resulting in a dilated main pancreatic duct may benefit from a lateral pancreaticojejunostomy. This operation has also successfully been performed in children. Included is a review of pediatric pancreatic minimally invasive operations paired with corresponding pathology.
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Affiliation(s)
- Morgan K Richards
- Division of Pediatric Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew S Clifton
- Division of Pediatric Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Ravindranath A, Srivastava A, Yachha SK, Poddar U, Sarma MS, Saraswat VA, Mohindra S, Yadav RR, Kumar S. Childhood pancreatic trauma: Clinical presentation, natural history and outcome. Pancreatology 2020; 20:68-73. [PMID: 31706820 DOI: 10.1016/j.pan.2019.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/06/2019] [Accepted: 10/27/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To study the presentation, management strategies and long-term natural history of children with pancreatic trauma. METHODS Children admitted with pancreatic trauma were analyzed for their presentation, management and outcome. Management included nasojejunal feeds, total parenteral nutrition (TPN), octreotide, drainage (radiological and endoscopic), endoscopic retrograde cholangiopancreatography (ERCP) and surgery. Patients were assessed in follow-up for development of chronic pancreatitis (CP). RESULTS 36 children [29 boys, age 144 (13-194) months] presented at 30 (3-210) days after trauma. Most common cause of trauma was bicycle handle bar injury [n = 18,50%]. Presenting features were abdominal pain [n = 26,72%], lump [n = 16, 44.4%], ascites [n = 13,36%], pleural effusion [n = 9,25%] and anasarca [n = 3,8.3%]. All presented with sequelae of ductal disruption with pseudocyst, ascites or pleural effusion. Fifteen (41.6%) patients each had Grade III and IV injury, 4 (11%) had grade V, and grading was unavailable in 2. Other organs were injured in 4 (11%) cases. Management consisted of various combinations of nasojejunal feeds [n = 17,47.2%], TPN [n = 5,13.8%], octreotide [n = 13,36%], pseudocyst drainage [radiological (n = 18,50%), endoscopic (n = 3,8.3%)] and ERCP [n = 12,33.3%]. Surgical intervention was done in 2 (5.5%) cases [cystojejunostomy and peritoneal lavage in 1 each]. Two (5.5%) patients died due to sepsis. Of the 32 cases in follow-up, 19 (59.3%) recovered and 13 (40.6%) developed CP, with half (6/13) of them being symptomatic with recurrent pain. CONCLUSION Multi-disciplinary non-operative management is effective for managing pancreatic trauma in 94.4% of children, with 75% requiring radiological or endoscopic intervention. 40% developed structural changes later but only half were symptomatic.
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Affiliation(s)
- Aathira Ravindranath
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vivek A Saraswat
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Samir Mohindra
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajanikant R Yadav
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sheo Kumar
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Keil R, Drabek J, Lochmannova J, Stovicek J, Rygl M, Snajdauf J, Hlava S. What is the role of endoscopic retrograde cholangiopancreatography in assessing traumatic rupture of the pancreatic in children? Scand J Gastroenterol 2016. [PMID: 26200695 DOI: 10.3109/00365521.2015.1070899] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND STUDY AIMS Trauma is one of the most common causes of morbidity and mortality in the pediatric population. The diagnosis of pancreatic injury is based on clinical presentation, laboratory and imaging findings, and endoscopic methods. CT scanning is considered the gold standard for diagnosing pancreatic trauma in children. PATIENTS AND METHODS This retrospective study evaluates data from 25 pediatric patients admitted to the University Hospital Motol, Prague, with blunt pancreatic trauma between January 1999 and June 2013. RESULTS The exact grade of injury was determined by CT scans in 11 patients (47.8%). All 25 children underwent endoscopic retrograde cholangiopancreatography (ERCP). Distal pancreatic duct injury (grade III) was found in 13 patients (52%). Proximal pancreatic duct injury (grade IV) was found in four patients (16 %). Major contusion without duct injury (grade IIB) was found in six patients (24%). One patient experienced duodeno-gastric abruption not diagnosed on the CT scan. The diagnosis was made endoscopically during ERCP. Grade IIB pancreatic injury was found in this patient. One patient (4%) with pancreatic pseudocyst had a major contusion of pancreas without duct injury (grade IIA). Four patients (16%) with grade IIB, III and IV pancreatic injury were treated exclusively and nonoperatively with a pancreatic stent insertion and somatostatine. Two patients (8%) with a grade IIB injury were treated conservatively only with somatostatine without drainage. Eighteen (72 %) children underwent surgical intervention within 24 h after ERCP. CONCLUSION ERCP is helpful when there is suspicion of pancreatic duct injury in order to exclude ductal leakage and the possibility of therapeutic intervention. ERCP can speed up diagnosis of higher grade of pancreatic injuries.
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Affiliation(s)
- Radan Keil
- a 1 Departement of Internal Medicine, Motol University Hospital , Prague, Czech Republic
| | - Jiri Drabek
- a 1 Departement of Internal Medicine, Motol University Hospital , Prague, Czech Republic
| | - Jindra Lochmannova
- a 1 Departement of Internal Medicine, Motol University Hospital , Prague, Czech Republic
| | - Jan Stovicek
- a 1 Departement of Internal Medicine, Motol University Hospital , Prague, Czech Republic
| | - Michal Rygl
- b 2 Departement of Pediatric Surgery, Motol University Hospital , Prague, Czech Republic
| | - Jiri Snajdauf
- b 2 Departement of Pediatric Surgery, Motol University Hospital , Prague, Czech Republic
| | - Stepan Hlava
- a 1 Departement of Internal Medicine, Motol University Hospital , Prague, Czech Republic
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Vane DW, Keller MS, Sartorelli KH, Miceli AP. Pediatric Trauma: Current Concepts and Treatments. J Intensive Care Med 2016. [DOI: 10.1177/088506602237107] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Injured children represent a complex management problem for the trauma surgeon. Physiologic and psychological factors have been shown to influence outcome; however, more importantly, injury patterns and treatment algorithms differ from those recommended for adults. Children often do well after major injuries, but surgeons must use appropriate treatment to maximize the physiologic responses and the innate healing abilities of the growing child. Historically, surgeons have defined childhood as prepubertal, but a child's physiologic response to injury extends well into the third decade of life, making treatment of a 20-year-old similar to that of a 10-year-old, rather than that of a 40-year-old. The distribution of pediatric trauma facilities across the country has limited the access of the injured child to these centers. Adult centers more often serve as the first and definitive treatment provider for children. This article reviews the current concepts of trauma treatments for children. It is hoped that the adult trauma surgeons caring for injured children might gain information that will be of assistance in their daily practice.
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Affiliation(s)
- Dennis W. Vane
- Division of Pediatric Surgery, University of Vermont College of Medicine, Burlington, VT,
| | | | - Kennith H. Sartorelli
- Division of Pediatric Surgery, University of Vermont College of Medicine, Burlington, VT
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8
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Kamath SU, Dharap SB. Non Operative Approach to Isolated Traumatic Pancreatic Duct Disruption. J Clin Diagn Res 2016; 10:PD08-10. [PMID: 27134933 DOI: 10.7860/jcdr/2016/16605.7451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/11/2015] [Indexed: 11/24/2022]
Abstract
Management of isolated traumatic pancreatic duct disruption remains challenging due to associated morbidity and mortality. Two children with isolated pancreatic ductal disruption were treated conservatively. Both developed a pseudocyst which resolved spontaneously due to the atrophy of the distal pancreas in a five-year-old girl while remained persistent and was treated by endoscopic cystogastrostomy in an eight-year-old boy. Non-operative management may be pursued in patients with pancreatic ductal injury in the hope of a pseudocyst formation which may spontaneously resolve or may be treated later with a minimally invasive procedure. However, the literature review precludes its practice as a standard due to high incidence of associated complications of non-operative management.
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Affiliation(s)
- Sheshang U Kamath
- Post Graduate Student, Lokmanya Tilak Municipal Medical College and General Hospital , Mumbai, Maharashtra India
| | - Satish B Dharap
- Professor, Department of General Surgery, Lokmanya Tilak Municipal Medical College and General Hospital , Mumbai, Maharashtra India
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9
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Girard E, Abba J, Arvieux C, Trilling B, Sage PY, Mougin N, Perou S, Lavagne P, Létoublon C. Management of pancreatic trauma. J Visc Surg 2016; 153:259-68. [PMID: 26995532 DOI: 10.1016/j.jviscsurg.2016.02.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Pancreatic trauma (PT) is associated with high morbidity and mortality; the therapeutic options remain debated. MATERIAL AND METHODS Retrospective study of PT treated in the University Hospital of Grenoble over a 22-year span. The decision for initial laparotomy depended on hemodynamic status as well as on associated lesions. Main pancreatic duct lesions were always searched for. PT lesions were graded according to the AAST classification. RESULTS Of a total of 46 PT, 34 were grades II or I. Hemodynamic instability led to immediate laparotomy in 18 patients, for whom treatment was always drainage of the pancreatic bed; morbidity was 30%. Eight patients had grade III injuries, six of whom underwent immediate operation: three underwent splenopancreatectomy without any major complications while the other three who had simple drainage required re-operation for peritonitis, with one death related to pancreatic complications. Four patients had grades IV or V PT: two pancreatoduodenectomies were performed, with no major complication, while one patient underwent duodenal reconstruction with pancreatic drainage, complicated by pancreatic and duodenal fistula requiring a hospital stay of two months. The post-trauma course was complicated for all patients with main pancreatic duct involvement. Our outcomes were similar to those found in the literature. CONCLUSION In patients with distal PT and main pancreatic duct involvement, simple drainage is associated with high morbidity and mortality. For proximal PT, the therapeutic options of drainage versus pancreatoduodenectomy must be weighed; pancreatoduodenectomy may be unavoidable when the duodenum is injured as well. Two-stage (resection first, reconstruction later) could be an effective alternative in the emergency setting when there are other associated traumatic lesions.
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Affiliation(s)
- E Girard
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - J Abba
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - C Arvieux
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - B Trilling
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - P Y Sage
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - N Mougin
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - S Perou
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - P Lavagne
- Réanimation post-chirurgicale, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - C Létoublon
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France.
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Abstract
Trauma is the leading cause of death in children of all ages. The most common site of injury in pediatric patients is the head followed by the extremities and the abdomen. Though less than 10% of admissions to the hospital are secondary to intra-abdominal injuries, mortality related to these injuries is not insignificant. Pancreatic and duodenal trauma occurs in 3 to 12% of the patients with abdominal injuries and can be associated with significant morbidity. The management of pancreatic and duodenal trauma in children is based mostly on adult data, but there is an increasing volume of research on the subject.
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Affiliation(s)
- Aaron Lesher
- Division of Pediatric Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Regan Williams
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, United States
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11
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Management of blunt pancreatic trauma: what's new? Eur J Trauma Emerg Surg 2015; 41:239-50. [PMID: 26038029 DOI: 10.1007/s00068-015-0510-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/03/2015] [Indexed: 12/17/2022]
Abstract
Pancreatic injuries are relatively uncommon but present a major challenge to the surgeon in terms of both diagnosis and management. Pancreatic injuries are associated with significant mortality, primarily due to associated injuries, and pancreas-specific morbidity, especially in cases of delayed diagnosis. Early diagnosis of pancreatic trauma is a key for optimal management, but remains a challenge even with more advanced imaging modalities. For both penetrating and blunt pancreatic injuries, the presence of main pancreatic ductal injury is the major determinant of morbidity and the major factor guiding management decisions. For main pancreatic ductal injury, surgery remains the preferred approach with distal pancreatectomy for most injuries and more conservative surgical management for proximal ductal injuries involving the head of the pancreas. More recently, nonoperative management has been utilized, especially in the pediatric population, with the potential for increased rates of pseudocyst and pancreatic fistulae and the potential for the need for further intervention and increased hospital stay. This review presents recent data focusing on the diagnosis, management, and outcomes of blunt pancreatic injury.
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Haugaard MV, Wettergren A, Hillingsø JG, Gluud C, Penninga L. Non-operative versus operative treatment for blunt pancreatic trauma in children. Cochrane Database Syst Rev 2014; 2014:CD009746. [PMID: 24523209 PMCID: PMC10907977 DOI: 10.1002/14651858.cd009746.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pancreatic trauma in children is a serious condition with high morbidity. Blunt traumatic pancreatic lesions in children can be treated non-operatively or operatively. For less severe, grade I and II, blunt pancreatic trauma a non-operative or conservative approach is usually employed. Currently, the optimal treatment, of whether to perform operative or non-operative treatment of severe, grade III to V, blunt pancreatic injury in children is unclear. OBJECTIVES To assess the benefits and harms of operative versus non-operative treatment of blunt pancreatic trauma in children. SEARCH METHODS We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (Issue 5, 2013), MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED and CPCI-S) and ZETOC. In addition, we searched bibliographies of relevant articles, conference proceeding abstracts and clinical trials registries. We conducted the search on the 21 June 2013. SELECTION CRITERIA We planned to select all randomised clinical trials investigating non-operative versus operative treatment of blunt pancreatic trauma in children, irrespective of blinding, publication status or language of publication. DATA COLLECTION AND ANALYSIS We used relevant search strategies to obtain the titles and abstracts of studies that were relevant for the review. Two review authors independently assessed trial eligibility. MAIN RESULTS The search found 83 relevant references. We excluded all of the references and found no randomised clinical trials investigating treatment of blunt pancreatic trauma in children. AUTHORS' CONCLUSIONS This review shows that strategies regarding non-operative versus operative treatment of severe blunt pancreatic trauma in children are not based on randomised clinical trials. We recommend that multi-centre trials evaluating non-operative versus operative treatment of paediatric pancreatic trauma are conducted to establish firm evidence in this field of medicine.
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Affiliation(s)
- Michael V Haugaard
- Rigshospitalet, Copenhagen University HospitalDepartment of Surgery and Transplantation C2122Blegdamsvej 9CopenhagenDenmarkDK‐2100 Ø
| | - André Wettergren
- Kirurgisk Klinik HvidovreHvidovrevej 342, 1. salHvidovreDenmark2650
| | - Jens Georg Hillingsø
- Rigshospitalet, Copenhagen University HospitalDepartment of Surgery and Transplantation C2122Blegdamsvej 9CopenhagenDenmarkDK‐2100 Ø
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Luit Penninga
- Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812Blegdamsvej 9CopenhagenDenmarkDK‐2100
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13
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Abstract
Blunt trauma to the abdomen accounts for the majority of abdominal injuries in children. Pancreatic injury is the fourth most common solid organ injury, following injuries to the spleen, liver and kidneys. The most common complications are the formation of pancreatic fistulae, pancreatitis and the development of pancreatic pseudocysts, which usually present several weeks after injury. The nonoperative management of minor pancreatic injury is well accepted; however, the treatment of more serious pancreatic injuries with capsular, ductal or parenchymal disruption in pediatric patients remains controversial. Based on the data presented in this literature review, although children with pancreatic injuries (without ductal disruption) do not appear to suffer increased morbidity following conservative management, patients with ductal disruption may benefit from operative intervention.
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Affiliation(s)
- Kosaku Maeda
- Division of Pediatric Surgery, Department of Surgery, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan,
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Klin B, Abu-Kishk I, Jeroukhimov I, Efrati Y, Kozer E, Broide E, Brachman Y, Copel L, Scapa E, Eshel G, Lotan G. Blunt pancreatic trauma in children. Surg Today 2011; 41:946-54. [PMID: 21748611 DOI: 10.1007/s00595-010-4369-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Accepted: 04/20/2010] [Indexed: 12/25/2022]
Abstract
PURPOSE To report our experience with blunt pancreatic trauma in pediatric patients and evaluate several various management strategies. METHODS Ten children admitted over the last 10 years with pancreatic blunt trauma were included in the present series. RESULTS The average time from injury to hospital admission was 2.4 days. All injuries resulted from accidents: bicycle handlebar injuries (5), being kicked by a horse (2), falls from a height (2), and injury sustained during closure of an electric gate (1). Additional systemic and abdominal injuries were recorded in 7 patients. The amylase levels at the time of patient admission were normal in 3 patients, mildly raised in 4 patients, and elevated in 3 patients. Abdominal computed tomography was performed in 10 patients, ultrasonography in 5, and endoscopic retrograde cholangiopancreatography (ERCP) in 4. Pancreatic injuries comprised 4 grade I, 3 grade II, and 3 grade III injuries. Grade I and II injuries were successfully managed by conservative treatment. The 3 children with grade III trauma and pancreatic ductal injury in the neck (1), body (1), and tail (1) of the gland were surgically treated, having an uneventful postoperative stay of 8-14 days and no complications during the 1-year follow-up period. CONCLUSION The present study supports early ERCP as an essential part of the initial patient evaluation when pancreatic transection is highly suspected.
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Affiliation(s)
- Baruch Klin
- Department of Pediatric Surgery, Assaf Harofeh Medical Center, Zerifin, 70300, Israel
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Rutkoski JD, Segura BJ, Kane TD. Experience with totally laparoscopic distal pancreatectomy with splenic preservation for pediatric trauma--2 techniques. J Pediatr Surg 2011; 46:588-93. [PMID: 21376217 DOI: 10.1016/j.jpedsurg.2010.07.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 06/23/2010] [Accepted: 07/13/2010] [Indexed: 12/21/2022]
Abstract
PURPOSE Blunt pancreatic traumatic injury in children, although rare, can be managed with a variety of methods from nonoperative, early operative, or delayed operative strategies. In the appropriate setting, early operative intervention has been associated with shorter hospitalization and decreased morbidity for these patients. Case reports describe laparoscopic distal pancreatectomy for isolated pancreatic laceration in children. This article presents the experience and results of the first series of totally laparoscopic, spleen-preserving distal pancreatectomies for trauma in children. METHODS Three children aged 8 to 13 years underwent laparoscopic distal pancreatectomy with splenic preservation for traumatic pancreatic transection within 72 hours of initial injury. Computed tomography imaging in all patients demonstrated complete pancreatic transection. The details of 2 operative techniques used for totally laparoscopic distal pancreatectomy are described. The data for associated injuries, amylase/lipase levels, operative management, postoperative course, length of stay, complications, and follow-up were collected for all patients. RESULTS All 3 children aged 8, 10, and 13 years underwent laparoscopic distal pancreatectomy without splenectomy within 72 hours of injury (23, 48, and 72 hours). The mechanism of injury was from a bicycle handle, knee to abdomen, and dirt bike handle, respectively. The length of hospital stay was 6, 15, and 7 days with follow-up of 12, 35, and 34 months. The 2 older children underwent pancreatic transection with an endostapler, and the 8-year-old had the pancreatic remnant oversewn by hand. Use of postoperative total parenteral nutrition continued for 0, 13, and 7 days. Complications included an abdominal wall hematoma and prolonged ileus with mild pancreatitis. There were no pancreatic fistulae or insufficiency. All patients are doing well and are asymptomatic from prior injury and laparoscopic distal pancreatectomy. CONCLUSIONS In the appropriate pediatric patient with traumatic pancreatic transection, a laparoscopic distal pancreatectomy with splenic preservation can be performed safely, with low morbidity and good outcomes. Further studies with larger series of patients with these injuries would be useful.
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Affiliation(s)
- John D Rutkoski
- Division of Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh Medical Center, Pittsburgh, PA 15224, USA
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Shimoda M, Park KW, Mori S, Kato M, Kubota K. Traumatic pancreatic injury during playing sports. BMJ Case Rep 2009; 2009:bcr04.2009.1772. [PMID: 21857875 DOI: 10.1136/bcr.04.2009.1772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The patient was a 33-year-old man. He had severe upper abdominal pain after a rugby game and he was diagnosed with traumatic pancreatic injury. Since intra-abdominal bleeding became severe, laparotomy was performed for haemostasis. On operation, venous bleeding from the upper edge of the head of the pancreas was found and the haemorrhage was stopped. The whole pancreas had severe inflammation with oedematous tissue spreading into the meso-colon and meso-jejunum. On the same day, the patient was transferred to our hospital for further treatment of acute pancreatitis. On admission, the amylase level in the drainage fluid was high and, thus, we started continuous arterial infusion treatment via the superior mesenteric artery, in addition to subcutaneous administration of octreotide. Enteral nutrition was started on postoperative day 6, oral intake was started on postoperative day 15. The patient recovered successfully and was discharged on postoperative day 30.
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Affiliation(s)
- Mitsugi Shimoda
- Dokkyo Medical University, Second Department of Surgery, 880 Kitakobayashi, Mibu, 321-0293, Japan
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Bixby SD, Callahan MJ, Taylor GA. Imaging in pediatric blunt abdominal trauma. Semin Roentgenol 2008; 43:72-82. [PMID: 18053830 DOI: 10.1053/j.ro.2007.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Sarah D Bixby
- Department of Radiology, Children's Hospital Boston, Boston, Massachusetts 02115,
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Potoka DA, Saladino RA. Blunt Abdominal Trauma in the Pediatric Patient. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2005. [DOI: 10.1016/j.cpem.2005.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Abstract
Abstract
Background
Pancreatic trauma is rare in children, and management strategies are diverse and controversial. The aim of this study was to report the outcome of a consecutive series of children with pancreatic injury seen at a single regional centre over a decade.
Methods
All children under 14 years of age referred with pancreatic injury between January 1995 and June 2004 were reviewed retrospectively.
Results
Nine children (six boys) aged 3–13 years sustained pancreatic injuries: one grade I (minor contusion), two grade II (major contusion without duct injury or tissue loss), five grade III (distal transection and duct injury) and one grade IV (proximal transection). Grade I and II injuries were successfully managed without surgery. The five children with grade III injuries were initially treated without operation, but each developed a large symptomatic pseudocyst that failed to resolve with percutaneous drainage. Four underwent a spleen-sparing distal pancreatectomy and one boy with a transected pancreatic neck was treated by Roux-en-Y jejunostomy drainage. A 6-year-old boy who sustained severe pancreatobiliary trauma (grade IV) was treated by Roux-en-Y drainage. All children made a full recovery.
Conclusion
The management of pancreatic injuries in children should be individualized depending on the site of injury, timing of referral, presence of associated injuries and institutional expertise.
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Affiliation(s)
- M D Stringer
- Children's Liver and Gastrointestinal Unit, St James's University Hospital, Leeds LS9 7TF, UK.
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Abstract
BACKGROUND/PURPOSE The aim of this study was to determine the etiology, associated injuries, and outcome of children with pancreatic injuries. METHODS A retrospective review was conducted of children under 16 years with pancreatic trauma admitted to the Children's Hospital at Westmead (CHW) from January 1983 to September 2002. Deaths were reported to the New South Wales Paediatric Trauma Death Registry (State Registry) from January 1988 to September 2002. RESULTS Sixty-five cases were identified: 46 patients were admitted to CHW, and 22 deaths were reported to the State Registry (including 3 deaths at CHW). The median age was 6 years (range, 1 to 14 years). Boys accounted for 60% (n = 40) of cases, decreasing to 50% (n = 11) of those that died. Motor vehicle injuries (MVI) were the most common mechanism, accounting for 40% of survivors and 77% of those who died. Children were restrained incorrectly in 48% of all cases and in 67% of those who died. Significantly more children who died had head, chest, and abdominal visceral injuries, compared with those who survived. Death occurred as a result of head injuries in 68%, with only 3 deaths directly attributed to pancreatico-duodenal injuries. CONCLUSIONS Pancreatic injuries remain uncommon in children. The most frequent mechanism was MVI, with incorrect use of passenger restraints an important contributing factor. Whereas mortality was mainly caused by other injuries, 3 deaths were directly attributable to pancreato-duodenal trauma.
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Affiliation(s)
- A S W Jacombs
- Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, The University of Sydney, Sydney, NSW, Australia
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Abstract
Laparoscopic pancreatic surgery has been discussed but remains relatively limited to resection for benign disease. Laparoscopic intervention for pancreatic trauma has been documented briefly, and the authors now report a case of traumatic pancreatic transection managed by laparoscopic distal pancreatectomy.
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Aherne NJ, Kavanagh EG, Condon ET, Coffey JC, El Sayed A, Redmond HP. Duodenal perforation after a blunt abdominal sporting injury: the importance of early diagnosis. THE JOURNAL OF TRAUMA 2003; 54:791-4. [PMID: 12707547 DOI: 10.1097/01.ta.0000061514.05103.7b] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Noel J Aherne
- Department of Academic Surgery, Cork University Hospital, Wilton, Ireland.
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Kimura Y, Mukaiya M, Sasaki K, Nishimori H, Kihara C, Hirata K, Ura H, Asai Y. Traumatic transection of the pancreas head: report of a case with santorini duct injury treated by damage-control surgery. Pancreas 2003; 26:205-7. [PMID: 12604921 DOI: 10.1097/00006676-200303000-00019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Yasutoshi Kimura
- First Department of Surgery, Department of Traumatology and Critical Care Medicine, Sapporo Medical University, Sapporo, Japan
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Adamson WT, Hebra A, Thomas PB, Wagstaff P, Tagge EP, Othersen HB. Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic trauma. J Pediatr Surg 2003; 38:354-7; discussion 354-7. [PMID: 12632348 DOI: 10.1053/jpsu.2003.50107] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Injury to the pancreas is rare in pediatric trauma. Identification of pancreatic injury relies on clinical, radiographic, and laboratory data. Serum screening for pancreatic injury frequently is used but has not proven to correlate well with pancreatic injury. This study investigated utility and cost effectiveness of serum assessment of amylase and lipase. METHODS A retrospective study of 1,821 pediatric trauma patients over 64 months was conducted. A total of 293 (16%) of these patients suffered trauma to the torso 195 (11%) of whom had confirmed intraabdominal injury. Eight pancreatic injuries (4% of abdominal injuries) were identified; 5 underwent surgery for pancreatic ductal injury. One patient not operated on had a pseudocyst that required late drainage. RESULTS Serum amylase or lipase levels (AMY/LIP) were measured in 507 (28%) patients. A total of 116 (23%) had elevated AMY/LIP levels. Six of 8 with proven pancreatic injury underwent AMY/LIP testing; 5 had elevated values. Forty-eight percent of patients with elevated AMY/LIP levels had no evidence of intraabdominal injury. Seventy-four of 116 (64%) with elevated AMY/LIP levels underwent abdominal and pelvic computed tomography (CT) scanning, yet 38 (51%) of these had completely normal scans. Many patients with elevated AMY/LIP levels (cost, $6 per test) underwent screening CT scans (cost, $592 per test) based on AMY/LIP alone. No patient with elevated AMY/LIP levels but without clinical suspicion was proven to have pancreatic injury. Cost data are presented. CONCLUSIONS Serum amylase and lipase determinations may support clinical suspicion in the diagnosis of pediatric pancreatic trauma but are not reliable or cost effective as screening tools. Costs incurred from routine serum amylase and lipase or from imaging tests subsequent to elevated serum values may be significant and unjustified.
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Affiliation(s)
- William T Adamson
- Department of Surgery, Division of Pediatric Surgery, Medical University of South Carolina, Charleston, South Carolina 29425, USA
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Loungnarath R, Blanchard H, Saint-Vil D. [Blunt injuries of the pancreas in children]. ANNALES DE CHIRURGIE 2001; 126:992-5. [PMID: 11803637 DOI: 10.1016/s0003-3944(01)00639-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
STUDY AIM Conservative management is mainly proposed for pancreatic trauma without ductal injuries. The aim of this retrospective study was to assess our experience with traumatic pancreatic injuries and to compare patients with medical or surgical treatment. PATIENTS AND METHOD From January 1989 to December 1998, 21 children, 13 boys and 8 girls with a mean age of 8 years (range: 1 to 17 years) were treated for pancreatic injuries. Main mechanisms of injuries were bicycle's falls (n = 7), passengers in motor vehicle collision (n = 6), and other road collisions (n = 5). Diagnosis of pancreatic trauma in 17 patients was made through ultrasonography and/or CT scan. In 4 patients, the diagnosis was made intraoperatively. Associated injuries were splenic (n = 6), hepatic (n = 5) and duodenal (n = 5). Thirteen patients had only medical treatment and 8 patients required laparotomy. The two groups were comparable according to the rate of high grade pancreatic lesions. RESULTS Two complications, a pancreatic fistula and a pseudocyst, occurred in the operative group and improved spontaneously. One death due to a head trauma, one acute pancreatitis and seven pancreatic pseudocysts (six required percutaneous drainage), occurred after medical treatment. The mean hospital stay, shorter after medical treatment, was not significantly different between the two groups (26 days vs 32 days). During the follow-up, no late complications have been observed. CONCLUSION Traumatic pancreatic injuries are rarely lethal but are often associated with other intra-abdominal injuries. Conservative treatment is advocated for grade 1 to 4 isolated pancreatic injuries. This conservative approach may be associated with the development of post-traumatic pancreatic pseudocysts which are easily cured by percutaneous drainage.
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Affiliation(s)
- R Loungnarath
- Service de chirurgie générale pédiatrique, hôpital Sainte-Justine, 3175, Côte-Sainte-Catherine, H3T 1C5 Montréal, Québec, Canada
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Blunt Pancreatic Trauma by a Wheelchair User Restraint System During a Traffic Accident. J Forensic Sci 2001. [DOI: 10.1520/jfs15079j] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
BACKGROUND The operative versus nonoperative management of major pancreatic ductal injuries in children remains controversial. The computed tomographic (CT) scan may not be accurate for determination of location and type of injury. We report our experience with ductal injury including the recent use of acute endoscopic retrograde cholangiopancreatography (ERCP) for definitive imaging, and an endoscopically placed stent as definitive treatment. This has not been reported in children. METHODS In review of 14,245 admissions to a regional pediatric trauma center over a 14-year period, 18 patients with major ductal injuries from blunt trauma were noted. Records were reviewed for mechanism of injury, method of diagnosis, management, and outcome. RESULTS There were 10 girls and 8 boys, ranging in age from 2 months to 13 years. The most common mechanisms of injury were motor vehicle and bicycle crashes. Admission CT scan in 16 children was suggestive of injury in 11, and missed the injury in 5. Distal pancreatectomy was carried out in eight patients with distal duct injuries: one died of central nervous system injury. Nonoperative management in three proximal duct injuries suggested by initial CT scan and in three missed distal duct injuries resulted in pseudocyst formation in five survivors; one patient died of central nervous system injuries. Two children with minimal abdominal pain, normal initial serum amylase, and no initial imaging developed pseudocysts. Two of seven pseudocysts spontaneously resolved and five were treated by delayed cystogastrostomy. Two recent children with suggestive CT scans were definitively diagnosed by acute ERCP and treated by endoscopic stenting. Clinical and chemical improvement was rapid and complete and the stents were removed. Follow-up ERCP, CT scan, and serum amylase levels are normal 1 year after injury. CONCLUSION Pancreatic ductal injuries are rare in pediatric blunt trauma. CT scanning is suggestive but not accurate for the diagnosis of type and location of injury. Acute ERCP is safe and accurate in children, and may allow for definitive treatment of ductal injury by stenting in selected patients. If stenting is not possible, or fails, distal injuries are best treated by distal pancreatectomy; proximal injuries may be managed nonoperatively, allowing for the formation and uneventful drainage of a pseudocyst.
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Affiliation(s)
- T G Canty
- Division of Pediatric Surgery, General Thoracic Surgery, Children's Hospital, 3030 Children's Way, San Diego, CA 92123
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Lam JP, Eunson GJ, Munro FD, Orr JD. Delayed presentation of handlebar injuries in children. BMJ (CLINICAL RESEARCH ED.) 2001; 322:1288-9. [PMID: 11375234 PMCID: PMC1120385 DOI: 10.1136/bmj.322.7297.1288] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- J P Lam
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh EH9 1LF
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31
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Powis MR, Cord-Udy C, Walsh M. Non-operative management of solid organ trauma in children. TRAUMA-ENGLAND 2001. [DOI: 10.1177/146040860100300204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Trauma is the commonest cause of mortality in infancy and childhood. Injuries from blunt trauma predominate, with multisystem injury, the rule. Blunt abdominal injury represents the third commonest cause of death from injury in this age group. Initial management of the child combines assessment and resuscitation. If the child’s condition is stable then the injured organ should be definitively identified, usually by computerized tomography. Over 90% of children who are stable at this point can be managed conservatively, with a period of observation on an intensive care unit, followed by bed rest on a general ward. Instability at any point requires further resuscitation, reassessment and if necessary laparotomy. Repeated clinical assessment and radiological investigation are used to guide further management, mobilization and the return to normal activities.
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Affiliation(s)
- MR Powis
- Department of Paediatric Surgery
| | | | - M Walsh
- Department of General Surgery, Barts and the London NHS Trust, The Royal London Hospital, Whitechapel, UK.,
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Abstract
BACKGROUND Injuries to the pancreas from blunt abdominal trauma in children are rare. Most are minor and are best treated conservatively. The mainstay for treatment of major ductal injuries has been prompt surgical resection. Diagnostic imaging modalities are the key to the accurate classification of these injuries and planning appropriate treatment. Computed tomography (CT) scan has been the major imaging modality in blunt abdominal trauma for children, but has shortcomings in the diagnosis of pancreatic ductal injury. Endoscopic retrograde cholangiopancreatography (ERCP) has been shown recently to be superior in diagnostic accuracy. The therapeutic placement of stents in the trauma setting has not been described in children. METHODS Two children sustained major ductal injuries from blunt abdominal trauma that were suspected, but not conclusively noted, on initial CT scan. Both underwent ERCP within hours of injury. In case 1, a stent was threaded through the disruption into the distal duct. In case 2, a similar injury, the stent could only be placed through the ampulla, thereby reducing ductal pressure. In both cases, clinical improvement was rapid with complete resolution of clinical and chemical pancreatitis, resumption of a normal diet, and discharge from the hospital. The stents were removed at 10 and 12 days postinjury, and both children have remained well. Follow-up ERCP and CT scans show complete healing of the ducts and no evidence of pseudocyst formation 1 year post injury. CONCLUSIONS Acute ERCP should be the imaging modality of choice in suspected major pancreatic ductal injury. Successful treatment by placement of an intrapancreatic ductal stent may be possible at the same time. Surgical resection or reconstruction can then be reserved for cases in which stenting is impossible or fails.
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Affiliation(s)
- T G Canty
- Divisions of Pediatric Surgery and Trauma, Children's Hospital and Health Center, San Diego, CA, USA
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Nadler EP, Gardner M, Schall LC, Lynch JM, Ford HR. Management of blunt pancreatic injury in children. THE JOURNAL OF TRAUMA 1999; 47:1098-103. [PMID: 10608540 DOI: 10.1097/00005373-199912000-00020] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND METHODS Controversy persists regarding the management of pancreatic transection. Over the past 10 years, 51 patients admitted to the Children's Hospital of Pittsburgh sustained blunt pancreatic injuries. We reviewed their medical records to clarify the optimal management strategy and to define distinguishing characteristics, if any, of patients with pancreatic transection. RESULTS Patients who sustained pancreatic transection had a significantly higher Injury Severity Score, length of stay, serum amylase, and serum lipase, than those patients who sustained pancreatic contusion. Patients who underwent laparotomy within 48 hours of injury for pancreatic transection had a significantly shorter length of stay than those who underwent laparotomy more than 48 hours after injury. CONCLUSION Serum amylase greater than 200 and serum lipase greater than 1,800 may be useful clinical markers for major pancreatic ductal injury when combined with physical examination. Early operative intervention for pancreatic transection results in shorter length of stay and fewer complications.
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Affiliation(s)
- E P Nadler
- Children's Hospital of Pittsburgh, Department of Surgery, Pennsylvania 15213, USA
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Kouchi K, Tanabe M, Yoshida H, Iwai J, Matsunaga T, Ohtsuka Y, Kuroda H, Hishiki T, Ohnuma N. Nonoperative management of blunt pancreatic injury in childhood. J Pediatr Surg 1999; 34:1736-9. [PMID: 10591583 DOI: 10.1016/s0022-3468(99)90657-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE Nonoperative management for blunt pancreatic injury in children was performed between 1977 and 1998. The efficiency and safety of nonoperative management was examined. METHODS Pancreatic injury was diagnosed in 20 children. The surgical indication was determined by hemodynamic instability and the management of associated injuries. Children without surgical indications were treated initially by nonoperative management. RESULTS Nineteen of 20 children were treated initially nonoperatively, and 18 of the 19 survived. Surgical exploration was performed in only 1 child with perforation of the duodenum and bile duct. One child died of complications of total parenteral nutrition. Ultrasound scan and computed tomography scan showed pancreatic contusion in 9, laceration in 6, and injury of the main pancreatic duct (MPD) in 5. Pseudocysts were detected in 10 (5 laceration and 5 MPD injury). Pseudocysts smaller than 10 cm disappeared after nonoperative management, and those larger than 10 cm required operative management. Rupture of pseudocysts occurred in 2 children by rotating the upper torso. CONCLUSIONS Nonoperative management of pancreatic injuries is effective in children, although careful management is required to avoid complications. Pseudocysts smaller than 10 cm were treated successfully by nonoperative management, and those larger than 10 cm required surgical management.
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Affiliation(s)
- K Kouchi
- Department of Pediatric Surgery, School of Medicine, Chiba University, Japan
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Abstract
BACKGROUND/PURPOSE Nonoperative management of low-grade pancreatic injury is widely accepted. Management of major pancreatic parenchymal or ductal injury in children remains controversial. This study will review management strategies as they relate to site and type of pancreatic injury and their outcomes. METHODS A total of 11,794 consecutive admissions to a regional pediatric trauma center from 1984 to 1997 were reviewed to identify children with pancreatic injury as documented by serum amylase; imaging by computed tomographic (CT) scan, ultrasonography (US), and endoscopic retrograde cholangiopancreatography (ERCP); and surgical or postmortem reports. RESULTS Pancreatic injury was documented in 56 children, age 2 months to 14 years, with blunt mechanisms of injury. Serum amylase level was elevated on admission in 40 (71%), and no correlation was found between admission amylase values and severity of pancreas injury. An admission CT scan was obtained in 44 (79%) patients and was positive for pancreatic injury in 25 (57%). Twelve children, who had diagnoses of other intraabdominal injury by CT scan, had pancreatic injuries discovered on exploratory laparotomy. Seven children with normal admission CT scans, and the 12 children who did not undergo imaging on admission, had pancreatic injuries that were later documented by imaging, exploration, or autopsy. Thirty children were treated with immediate exploration, 17 for nonpancreatic indications and 13 with pancreatic injuries on admission CT scan. Of 19 minor injuries noted in the operating room, only three were treated with external drainage. Seven patients with distal duct injuries underwent distal pancreatectomy with splenic preservation. Twenty-six children were treated nonoperatively, including 19 with minor pancreas injuries, three with proximal pancreatic duct injuries, and four with duct injuries that were missed at admission. There were no advantages or complications of external drainage versus nondrainage of minor pancreatic injuries. There were seven deaths (overall mortality rate, 12.5%), none related to pancreatic injury. Of the seven patients in whom pseudocysts developed (two not imaged at admission, two from known proximal duct injuries treated nonoperatively, and three from injuries missed by initial studies), five were treated by delayed internal drainage and recovered promptly, and two resolved spontaneously. Pancreas-related complications included one persistent fistula and one prolonged hyperamylasemia, both of which resolved. CONCLUSIONS Pancreatic injuries are uncommon in children. Initial serum amylase level does not correlate with the severity of pancreatic injury. The majority of pancreatic injuries can be managed nonoperatively. Initial nonoperative management of injuries of the proximal pancreatic duct allows for the formation and uneventful delayed drainage of a pseudocyst, rather than the risks of early radical interventions. Distal duct injuries are best managed by prompt spleen-sparing distal pancreatectomy. There is no benefit of closed drainage for management of minor pancreatic injuries discovered at laparotomy.
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Affiliation(s)
- M A Jobst
- Division of Trauma, Children's Hospital, San Diego, CA, USA
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Affiliation(s)
- A J Koestner
- Bronson Methodist Hospital, Kalamazoo, Michigan, USA
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Takishima T, Sugimoto K, Hirata M, Asari Y, Ohwada T, Kakita A. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg 1997; 226:70-6. [PMID: 9242340 PMCID: PMC1190909 DOI: 10.1097/00000658-199707000-00010] [Citation(s) in RCA: 121] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective of this study was to elucidate the significance and limitations of serum amylase levels in the diagnosis of blunt injury to the pancreas. SUMMARY BACKGROUND DATA Several recently published reports of analyses of patients with blunt abdominal trauma have indicated that determination of the serum amylase level on admission seemed to be of little value in the diagnosis of acute injury to the pancreas. Few previous reports have described clearly the significance and the limitations of the serum amylase level in diagnosing injury to the pancreas. METHODS Retrospective analysis of 73 patients with blunt injury to the pancreas during 16-year period from February 1980 to January 1996 was performed. The factors analyzed in the current study included age, gender, time elapsed from injury to admission, hypotension on admission, type of injury to the pancreas, intra-abdominal- and intracranial-associated injuries, and death. RESULTS The serum amylase level was found to be abnormal in all patients admitted more than 3 hours after trauma. Various comparisons between patients with elevated (n = 61, 83.6%) and nonelevated (n = 12, 16.4%) serum amylase levels showed the statistical significance solely of the time elapsed from injury to admission (7 +/- 1.5 hours vs. 1.3 +/- 0.2 hour, p < 0.001). The major factor that influences the serum amylase level on admission appeared to be the time elapsed from injury to admission. Determination of the serum amylase level is not diagnostic within 3 hours or fewer after trauma, irrespective of the type of injury. CONCLUSIONS To avoid failure in the detection of pancreatic injury, the authors advocate determination of serum amylase levels more than 3 hours after trauma.
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Affiliation(s)
- T Takishima
- Department of Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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Keller MS, Stafford PW, Vane DW. Conservative management of pancreatic trauma in children. THE JOURNAL OF TRAUMA 1997; 42:1097-100. [PMID: 9210548 DOI: 10.1097/00005373-199706000-00019] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Many adults and most children with a solid-organ abdominal injury can be managed nonoperatively. To date, however, little is known about the outcome of nonoperative management of pancreatic injury. To analyze current treatment patterns of pancreatic injury in children, all children (age < 19 years) identified in the National Pediatric Trauma Registry (49,540 patients) and admitted to two level I pediatric trauma centers with a diagnosis of injury to the pancreas (International Classification of Disease-9 codes 863.81-863.84 and 863.91-863.94) were reviewed. Over a 7-year period, 154 children were identified with pancreatic injury. Thirty-one (20%) sustained severe injuries (grades III, IV, or V) and 123 (80%) sustained lower-grade injuries (grades I and II). Sixteen (52%) of the children sustaining grades III, IV, or V injury required pancreatic procedures (9 distal resections, 3 simple repairs, 2 enteric anastomoses, 2 others). Only 26 (21%) of the grades I and II injuries required surgical intervention specific to the pancreas (11 resections, 9 catheter drainage of pseudocysts, 2 enteric anastomoses, 4 others). Ninety-seven (79%) grades I and II injuries were successfully managed conservatively. Overall, 15 (10%) children required drainage procedures for pseudocyst. The frequency of operative intervention decreased during the last 4 years of the study (18 vs. 26%, p > 0.05), coinciding with a decrease in the frequency of drainage procedures for pseudocysts. The need for surgical intervention was not influenced by age, Injury Severity Score, or Pediatric Trauma Score (p > 0.05). Associated abdominal injuries were common but did not influence operations on the pancreas (p > 0.05). No deaths were attributed to the pancreatic injury. These data indicate that early intervention for pancreatic injury, in the absence of clinical deterioration or major ductal injury (grades III, IV, or V), is unwarranted, and careful observation may supplant the conventional surgical therapy recommended for adults.
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Affiliation(s)
- M S Keller
- Department of Surgery, Children's Hospital of Philadelphia, Pennsylvania, USA
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