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Katsura M, Ikenoue T, Aoki M, Kuriyama A, Takahashi K, Schellenberg M, Martin MJ, Inaba K, Matsushima K. Recent Changes in the Management of High-Grade Blunt Pancreatic Injury in Children: A Nationwide Trend Analysis. J Am Coll Surg 2024; 238:1106-1114. [PMID: 38323622 DOI: 10.1097/xcs.0000000000001033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND The optimal management of pediatric patients with high-grade blunt pancreatic injury (BPI) involving the main pancreatic duct remains controversial. This study aimed to assess the nationwide trends in the management of pediatric high-grade BPI at pediatric (PTC), mixed (MTC), and adult trauma centers (ATC). STUDY DESIGN This is a retrospective observational study of the National Trauma Data Bank. We included pediatric patients (age 16 years or less) sustaining high-grade BPI (Abbreviated Injury Scale 3 or more) from 2011 to 2021. Patients who did not undergo pancreatic operation were categorized into the nonoperative management (NOM) group. Trauma centers were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric), and ATC (level I/II adult only). Primary outcome was the proportion of patients undergoing NOM, and secondary outcomes included the use of ERCP and in-hospital mortality. A Cochran-Armitage test was used to analyze the trend. RESULTS A total of 811 patients were analyzed. The median age was 9 years (interquartile range 6 to 13), 64% were male patients, and the median injury severity score was 17 (interquartile range 10 to 25). During the study period, there was a significant upward linear trend in the use of NOM and ERCP among the overall cohort (range 48% to 66%; p trend = 0.033, range 6.1% to 19%; p trend = 0.030, respectively). The significant upward trend for NOM was maintained in the subgroup of patients at PTC and MTC (p trend = 0.037), whereas no significant trend was observed at ATC (p trend = 0.61). There was no significant trend in in-hospital mortality (p trend = 0.38). CONCLUSIONS For the management of pediatric patients with high-grade BPI, this study found a significant trend toward increasing use of NOM and ERCP without mortality deterioration, especially at PTC and MTC.
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Affiliation(s)
- Morihiro Katsura
- From the Department of Surgery, University of Southern California, Los Angeles, CA (Katsura, Takahashi, Schellenberg, Martin, Inaba, Matsushima)
| | - Tatsuyoshi Ikenoue
- Data Science and AI Innovation Research Promotion Center, Shiga University, Shiga, Japan (Ikenoue)
| | - Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan (Aoki)
| | - Akira Kuriyama
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan (Kuriyama)
| | - Kyosuke Takahashi
- From the Department of Surgery, University of Southern California, Los Angeles, CA (Katsura, Takahashi, Schellenberg, Martin, Inaba, Matsushima)
| | - Morgan Schellenberg
- From the Department of Surgery, University of Southern California, Los Angeles, CA (Katsura, Takahashi, Schellenberg, Martin, Inaba, Matsushima)
| | - Matthew J Martin
- From the Department of Surgery, University of Southern California, Los Angeles, CA (Katsura, Takahashi, Schellenberg, Martin, Inaba, Matsushima)
| | - Kenji Inaba
- From the Department of Surgery, University of Southern California, Los Angeles, CA (Katsura, Takahashi, Schellenberg, Martin, Inaba, Matsushima)
| | - Kazuhide Matsushima
- From the Department of Surgery, University of Southern California, Los Angeles, CA (Katsura, Takahashi, Schellenberg, Martin, Inaba, Matsushima)
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Sukhotnik I, Cohen N. Management of Blunt Pancreatic Trauma in Children: A Persistent Controversy-Case Report and Comprehensive Literature Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:135. [PMID: 38275445 PMCID: PMC10814196 DOI: 10.3390/children11010135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
Blunt pancreatic injury (BPI) is relatively uncommon in children, and is associated with relatively high morbidity and mortality, especially if diagnosis is delayed. The aim of this report is to review the literature regarding controversial questions in the early diagnosis and management of pediatric BPI. A representative case of blunt pancreatic trauma in a six-year-old girl with delayed diagnosis and intraoperative and postoperative complications was described. A systematic search of databases and the grey literature in Scopus and Web of Science using relevant keywords was conducted. A total of 26 relevant articles published in last 5 years were found in PubMed. Although early CT performance is considered part of initial pancreatic trauma workup, the sensitivity of CT for detecting main pancreatic duct injuries in children is relatively low. MRCP and ERCP (if available) are useful for assessing ductal injury and should be performed when the status of the pancreatic duct is unclear on the CT. Most patients with low-grade pancreatic damage may be treated conservatively. Although surgery involving distal pancreatectomy remains the preferred approach for most children with high-grade pancreatic injury, there is growing evidence to suggest that non-operative management (NOM) is safe and effective. Most pancreatic pseudo cysts following NOM had relatively mild complications, and most resolved spontaneously. For those children who do require surgery, a conservative operative approach with the least risk is advocated. In conclusion, the optimal management for pediatric pancreatic trauma is controversial. Further clinical trials are required to generate clinical practice guidelines on pancreatic trauma in a child population.
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Affiliation(s)
- Igor Sukhotnik
- Department of Pediatric Surgery, Dana Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel
| | - Neta Cohen
- Pediatric Emergency Department, Dana Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel-Aviv 64239, Israel;
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Kwon HJ, Jung MK, Park J. Traumatic pancreatic ductal injury treated by endoscopic stenting in a 9-year-old boy: A case report. World J Clin Cases 2023; 11:3885-3890. [PMID: 37383128 PMCID: PMC10294148 DOI: 10.12998/wjcc.v11.i16.3885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/27/2023] [Accepted: 04/24/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Traumatic pancreatic injury is relatively rare in children, accounting for approximately 3%-12% of blunt abdominal trauma cases. Most traumatic pancreatic injuries in boys are related to bicycle handlebars. Traumatic pancreatic injuries often result in delayed presentation and treatment, leading to high morbidity and mortality. The management of children with traumatic main pancreatic duct injuries is still under debate.
CASE SUMMARY We report the case of a 9-year-old boy who was presented at our institution with epigastric pain after being stuck with his bicycle handlebar at the upper abdomen and then treated with endoscopic stenting because of a pancreatic ductal injury.
CONCLUSION We believe that endoscopic stenting of pancreatic ductal injuries may be a feasible technique in certain cases of children with traumatic pancreatic duct injuries to avoid unnecessary operations.
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Affiliation(s)
- Hyung Jun Kwon
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, South Korea
| | - Min Kyu Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, South Korea
| | - Jinyoung Park
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, South Korea
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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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CT and MRI findings in pancreatic trauma in children and correlation with outcome. Pediatr Radiol 2020; 50:943-952. [PMID: 32172401 DOI: 10.1007/s00247-020-04642-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/07/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND There are limited published data on pancreatic trauma imaging in children. OBJECTIVE To present our experience using computed tomography (CT) and magnetic resonance (MR) imaging of pancreatic trauma in children and to correlate the imaging grade of pancreatic injury with management and outcome. MATERIALS AND METHODS A retrospective cohort study of children with pancreatic injury presenting between Jan. 1, 2000, and Dec. 31, 2016, was performed. Patient charts were reviewed to note demographics, the mechanism of injury, associated abdominal injuries, management and outcome. All imaging was rereviewed by two radiologists blinded to clinical and laboratory information, and pancreatic injuries were graded according to the American Association for the Surgery of Trauma (AAST). RESULTS Of 3,265 patients presented as trauma team activations during the study period, only 28 (0.86%) children (19 boys, 9 girls; mean age: 7.14 years; age range: 1-15 years) had pancreatic injury. Of the available 27 CTs of the abdomen, 26 were performed on the day of trauma. Associated injuries were seen in 25/27 children, most frequently in the liver and lung, 16 (59.2%) each. There were 5 (19%) Grade I, 9 (33%) Grade II, 8 (30%) Grade III and 3 (11%) Grade IV. No patients had Grade V injury. No pancreatic parenchymal injury was identified in 2 (7%) patients with isolated fluid around the pancreas and mesentery. The pancreatic duct was visible in all 10 children (days: 0-330, median days: 41 post-trauma) who had MRI. Eight of these children, who had Grade III/IV injuries on CT and confirmed pancreatic duct injury on endoscopic retrograde cholangiopancreatography (ERCP) or surgery, showed either signal intensity difference in pancreatic parenchyma and/or caliber difference in the pancreatic duct proximal and distal to the injury site. Two patients died because of multiorgan injuries, 9 patients (mainly with Grade III and IV injuries) underwent surgery and/or ERCP, and 16 patients were managed conservatively. AAST grading of pancreatic injury on CT correlated with type of management (P=0.0001) with most of the Grade III and IV injuries treated with intervention and/or surgery while all of the Grade I and II injuries were treated conservatively. CONCLUSION Pancreatic injury is rare in children but often associated with other organ injuries most frequently involving the liver and lung. CT grading of injury correlates with management and guides intervention and/or surgery versus conservative treatment. MRI is useful for assessing pancreatic duct injury by demonstrating the pancreatic duct directly and/or secondary changes like signal intensity difference in pancreatic parenchyma and caliber difference in the pancreatic duct.
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Omura T, Matsushita K, Arase M, Yagi T. Three cases of paediatric pancreatic injury involving the main pancreatic duct. Trauma Case Rep 2019; 24:100253. [PMID: 31872024 PMCID: PMC6911926 DOI: 10.1016/j.tcr.2019.100253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/22/2019] [Accepted: 09/19/2019] [Indexed: 12/26/2022] Open
Abstract
We report on 3 patients aged 9–12 years with pancreatic injury involving the main pancreatic duct. None of them presented with shock. They were initially transported to secondary emergency care facilities, leading to delays in diagnosis and treatment. Two patients underwent organ (spleen and pancreatic tail)-preserving surgery and one underwent non-operative management (NOM). They recovered and were discharged without major complications. Although the indications for NOM for paediatric pancreatic injury might increase in the future, we believe that it is preferable for patients to be transferred to the tertiary care hospital from the very beginning to recieve appropriate diagnosis and treatment.
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Affiliation(s)
- Takeshi Omura
- Department of Surgery, Tokushima Prefectural Central Hospital, Kuramotocho, 1-10-3, Tokushima-city, Tokushima, Japan.,Emergency Surgery and Trauma Center, Tokushima Prefectural Central Hospital, Kuramotocho, 1-10-3, Tokushima-city, Tokushima, Japan
| | - Kenta Matsushita
- Department of Surgery, Tokushima Prefectural Central Hospital, Kuramotocho, 1-10-3, Tokushima-city, Tokushima, Japan
| | - Miharu Arase
- Department of Emergency Medicine, Tokushima Prefectural Central Hospital, Kuramotocho, 1-10-3, Tokushima-city, Tokushima, Japan
| | - Toshiyuki Yagi
- Department of Surgery, Tokushima Prefectural Central Hospital, Kuramotocho, 1-10-3, Tokushima-city, Tokushima, Japan
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Hyser E, Sahhar HS, Woollen C. Modified Whipple on an 18-month-old with traumatic pancreatic transection and duodenal rupture. Trauma Case Rep 2019; 23:100241. [PMID: 31517015 PMCID: PMC6727103 DOI: 10.1016/j.tcr.2019.100241] [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] [Accepted: 08/11/2019] [Indexed: 11/18/2022] Open
Abstract
The emergence of the Whipple procedure revolutionized operative management of pancreatic disease since its introduction (Fernandez-del Castillo et al., 2012 [1]). This operation classically involves removal of the head of the pancreas along with the duodenum, gallbladder, a portion of the bile duct, and part of the stomach (Warshaw and Thayer, 2004; Evans et al., 2007 [2,3]). We report a beneficial outcome of a modified Whipple on a paediatric trauma patient post- motor vehicle accident (MVA). After Advanced Trauma Life Support (ATLS) was initiated and haemodynamic stability was achieved, exploratory laparotomy revealed pancreatic transection and duodenal rupture. Partial pancreaticoduodenectomy, pancreaticoduodenostomy, cholecystojejunostomy, and pyloric-sparing gastrojejunostomy were performed. Post-operative acute pancreatitis resolved with antibiotics and supportive care. While paediatric abdominal trauma does not typically warrant a Whipple, patients with severe injury to the pancreas and neighboring organs with major vascular injury may offer no other intra-operative choice (Adams, 2014; Thatte and Vaze, 2014; Debi et al., 2013 [[4], [5], [6]]). Our patient's growth was followed post-operatively. At a 20-year post-operative follow-up, he reported no further hospitalizations or complications such as diabetes, biliary stricture, gallstones, or growth retardation. We review the literature to expose the novelty of using a Whipple to treat paediatric abdominal trauma, and the advantages of a pylorus-preserving Whipple. Indications for damage control surgery and non-operative management were contrasted with those for definitive surgery to reconstruct the biliary tree to further elucidate why the latter option was chosen.
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Affiliation(s)
- Elise Hyser
- Edward Via College of Osteopathic Medicine (VCOM)-Carolinas Campus, United States of America
| | - Hanna S Sahhar
- Edward Via College of Osteopathic Medicine (VCOM)-Carolinas Campus, United States of America.,Spartanburg Regional Healthcare System, United States of America
| | - Claude Woollen
- Spartanburg Regional Healthcare System, United States of America
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Rosenfeld EH, Vogel AM, Jafri M, Burd R, Russell R, Beaudin M, Sandler A, Thakkar R, Falcone RA, Wills H, Upperman J, Burke RV, Escobar MA, Klinkner DB, Gaines BA, Gosain A, Campbell BT, Mooney D, Stallion A, Fenton SJ, Prince JM, Juang D, Kreykes N, Naik-Mathuria BJ. Management and outcomes of peripancreatic fluid collections and pseudocysts following non-operative management of pancreatic injuries in children. Pediatr Surg Int 2019; 35:861-867. [PMID: 31161252 DOI: 10.1007/s00383-019-04492-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes. METHODS A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests. RESULTS One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75). CONCLUSIONS Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery. LEVEL OF EVIDENCE III STUDY TYPE: Case series.
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Affiliation(s)
- Eric H Rosenfeld
- Department of Surgery, Baylor College of Medicine, 6701 Fannin Street # 1210, Houston, TX, 77030, USA
| | - Adam M Vogel
- Department of Surgery, Saint Louis University Children's Hospital, St. Louis, MO, USA
| | - Mubeen Jafri
- Department of Surgery, Randall Children's Hospital at Legacy Emmanuel, Portland, OR, USA.,Doernbecher Children's Hospital Oregon Health and Science University, Portland, OR, USA
| | - Randall Burd
- Department of Surgery, Children's National Medical Center, Washington, DC, USA
| | - Robert Russell
- Department of Surgery, Children's of Alabama, Birmingham, AL, UK
| | - Marianne Beaudin
- Department of Surgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Alexis Sandler
- Department of Surgery, Children's National Medical Center, Washington, DC, USA
| | - Rajan Thakkar
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard A Falcone
- Department of Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Hale Wills
- Department of Surgery, Hasbro Children's Hospital, Providence, RI, USA
| | - Jeffrey Upperman
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Rita V Burke
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Mauricio A Escobar
- Department of Surgery, MultiCare Mary Bridge Children's Hospital and Health Center, Tacoma, WA, USA
| | | | | | - Ankush Gosain
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Brendan T Campbell
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, CT, USA
| | - David Mooney
- Department of Surgery, Boston Children's, Boston, MA, USA
| | - Anthony Stallion
- Department of Surgery, Carolinas HealthCare System, Charlotte, NC, USA
| | - Stephon J Fenton
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Jose M Prince
- Department of Surgery, Cohen's Children's Hospital, Aurora, CO, USA
| | - David Juang
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | | | - Bindi J Naik-Mathuria
- Department of Surgery, Baylor College of Medicine, 6701 Fannin Street # 1210, Houston, TX, 77030, USA.
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Trinci M, Piccolo CL, Ferrari R, Galluzzo M, Ianniello S, Miele V. Contrast-enhanced ultrasound (CEUS) in pediatric blunt abdominal trauma. J Ultrasound 2018; 22:27-40. [PMID: 30536214 DOI: 10.1007/s40477-018-0346-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 12/02/2018] [Indexed: 12/15/2022] Open
Abstract
Baseline ultrasound is the first-choice technique in traumatic hemodynamically stable children, and is essential in the early assessment of unstable patients to detect hemoperitoneum or other potentially fatal conditions. Despite the technological advancements in new ultrasound equipment and the experience of the operators, it is not always possible to rule out the presence of parenchymal traumatic lesions by means of baseline ultrasound nor to suspect them, especially in the absence of hemoperitoneum. For this reason, in the last decades, basic ultrasound has been associated with contrast-enhanced ultrasound (CEUS) to evaluate the stable little patient in cases such as low-energy blunt abdominal trauma. Because it relies on second-generation contrast agents, the CEUS technique allows for better detection of parenchymal injuries. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients affected by low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. A very important point in favor of CEUS is its capacity to help distinguish the healthy patient, who can be discharged, from the one needing prolonged monitoring, operative management or hospitalization. Finally, we also have the ability to follow-up on low-grade traumatic lesions using CEUS, always keeping in mind patients' clinical conditions and their hemodynamics.
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Affiliation(s)
| | | | - Riccardo Ferrari
- Department of Emergency Radiology, S. Camillo Hospital, Rome, Italy
| | - Michele Galluzzo
- Department of Emergency Radiology, S. Camillo Hospital, Rome, Italy
| | | | - Vittorio Miele
- Department of Radiology, Careggi University Hospital, L.go G.A. Brambilla, 3, 50134, Florence, Italy.
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Ishihara T, Nishiyama K, Abe T, Matsuda S, Okamoto K, Tanaka H. Efficacy of stent and drainage for blunt pancreatic injury. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2017.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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12
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Garg RK, Mahajan JK. Blunt Trauma Pancreas in Children: Is Non-Operative Management Appropriate for All Grades? Pediatr Gastroenterol Hepatol Nutr 2017; 20:252-258. [PMID: 29302507 PMCID: PMC5750380 DOI: 10.5223/pghn.2017.20.4.252] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 09/06/2017] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Blunt trauma of pancreas in children is uncommon and its management varies from observational to early operative intervention. We analysed the feasibility and outcome of non-operative management in all grades of paediatric pancreatic injuries. METHODS A total of 15 patients of pancreatic trauma seen in a Paediatric Surgery Unit were retrospectively analyzed. RESULTS Age of the patients ranged from 3-11 years (mean, 7.7 years). The mode of injury was local trauma in 9 children. Only 3 patients had associated injuries and all were haemodynamically stable. Serum amylase levels were raised in 12 patients at admission which ranged from 400-1,000 IU. Computed tomography scan made a correct diagnosis in 14 patients. Grades of the injury varied from grade I-V (1, 3, 6, 4, 1 patients respectively). Fourteen patients were managed conservatively. One patient underwent laparotomy for suspected superior mesenteric hematoma. The average duration of enteral feeds was 3.7 days and of hospital stay was 9.4 days. Six patients formed pancreatic pseudocysts; two were managed conservatively while the other four underwent cystogastrostomy. The patients were followed up for a period of 1-12 years. All remained asymptomatic and none had exocrine or endocrine deficiencies. CONCLUSION Non-operative treatment for isolated blunt trauma of pancreas in children may be safely followed for all the grades of injury; if associated injuries requiring surgical intervention are ruled out with a good quality imaging and the patients are hemodynamically stable. It did not increase the hospital stay and morbidity and avoided operative intervention on acutely injured pancreas.
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Affiliation(s)
- Ravi Kumar Garg
- Department of General Surgery, Kalpna Chawla Govt. Medical College, Karnal, India
| | - Jai Kumar Mahajan
- Department of Pediatric Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Specialized Imaging and Procedures in Pediatric Pancreatology: A North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Clinical Report. J Pediatr Gastroenterol Nutr 2017; 64:472-484. [PMID: 28230608 DOI: 10.1097/mpg.0000000000001371] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES An increasing number of children are being diagnosed with pancreatitis and other pancreatic abnormalities. Dissemination of the information regarding existing imaging techniques and endoscopic modalities to diagnose and manage pancreatic disorders in children is sorely needed. METHODS We conducted a review of the medical literature on the use of the following imaging and procedural modalities in pediatric pancreatology: transabdominal ultrasonography (TUS), computed tomography (CT), magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP). Recommendations for current use and future research were identified. RESULTS TUS offers noninvasive images of the pancreas but has limitations to details of parenchyma and ductal structures. CT offers improved detail of pancreatic parenchyma, solid masses, and traumatic injuries, but requires relatively high levels of ionizing radiation and does not adequately assess ductal anatomy. MRI/MRCP offers detailed intrinsic tissue assessment and pancreatic ductal characterization, but requires longer image acquisition time and is relatively poor at imaging calcifications. EUS provides excellent evaluation of pancreatic parenchyma and ductal anatomy, but can be subjective and operator dependent and requires sedation or anesthesia. EUS offers the capacity to obtain tissue samples and drain fluid collections and ERCP offers the ability to improve drainage by performing sphincterotomy or placing pancreatic stents across duct injuries and strictures. CONCLUSIONS Various imaging modalities may be used in pediatric pancreatology, but TUS and MRI/MRCP are favored. Interventional therapeutic maneuvers primarily involve use of ERCP and EUS. Future research is necessary to optimize equipment, expertise, and appropriate indications.
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Abstract
Pancreatic trauma is relatively uncommon and although the surgical management is in many cases comparatively simple, occasionally complex technical surgery is required. Early diagnosis is paramount, although this remains difficult. The challenge of pancreatic trauma is compounded by a high incidence of associated injuries to adjoining organs and major vascular structures that may require damage control surgery and delayed definitive repair and add to the high frequency of postoperative complications, morbidity and mortality.
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Affiliation(s)
- A Brooks
- Department of General Surgery, Queens Medical Centre, Nottingham, UK
| | - A Shukla
- Department of Surgery, Edinburgh Royal Infirmary, Edinburgh, UK
| | - I Beckingham
- Department of General Surgery, Queens Medical Centre, Nottingham, UK
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Englum BR, Gulack BC, Rice HE, Scarborough JE, Adibe OO. Management of blunt pancreatic trauma in children: Review of the National Trauma Data Bank. J Pediatr Surg 2016; 51:1526-31. [PMID: 27577183 PMCID: PMC5142528 DOI: 10.1016/j.jpedsurg.2016.05.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 05/16/2016] [Accepted: 05/21/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE This study aims to examine the current management strategies and outcomes after blunt pancreatic trauma in children using a national patient registry. METHODS Using the National Trauma Data Bank (NTDB) from 2007-2011, we identified all patients ≤18years old who suffered blunt pancreatic trauma. Patients were categorized as undergoing nonoperative pancreatic management (no abdominal operation, abdominal operation without pancreatic-specific procedure, or pancreatic drainage alone) or operative pancreatic management (pancreatic resection/repair). Patient characteristics, operative details, clinical outcomes, and factors associated with operative management were examined. RESULTS Of 610,402 pediatric cases in the NTDB, 1653 children (0.3%) had blunt pancreatic injury and 674 had information on specific location of pancreatic injury. Of these 674 cases, 514 (76.3%) underwent nonoperative pancreatic management. The groups were similar in age, gender, and race; however, pancreatic injury grade>3, moderate to severe injury severity, and bicycle accidents were associated with operative management in multivariable analysis. Children with pancreatic head injuries or GCS motor score<6 were less likely to undergo pancreatic operation. Overall morbidity and mortality rates were 26.5% and 5.3%, respectively. Most outcomes were similar between treatment groups, including mortality (2.5% vs. 6.7% in operative vs. nonoperative cohorts respectively; p=0.07). CONCLUSION Although rare, blunt pancreatic trauma in children continues to be a morbid injury. In the largest analysis of blunt pancreatic trauma in children, we provide data on which to base future prospective studies. Operative management of pancreatic trauma occurs most often in children with distal ductal injuries, suggesting that prospective studies may want to focus on this group.
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Affiliation(s)
- Brian R Englum
- Department of Surgery, Duke University Medical Center, Durham, NC, United States.
| | - Brian C Gulack
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Henry E Rice
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, United States
| | - John E Scarborough
- Division of Trauma, Duke University Medical Center, Durham, NC, United States
| | - Obinna O Adibe
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, United States
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16
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Naik-Mathuria B. Practice variability exists in the management of high-grade pediatric pancreatic trauma. Pediatr Surg Int 2016; 32:789-94. [PMID: 27376827 DOI: 10.1007/s00383-016-3917-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Management of high-grade pancreatic trauma in children is controversial, although recent evidence supports early operation. We sought to evaluate whether practice variability exists regarding the management of these rare and complex injuries. METHODS A study group of pediatric trauma centers within the Pediatric Trauma Society completed a survey following a query of their institutional database. Results are presented using descriptive statistics. RESULTS Over a 3-year period (2012-2014), 123 pancreatic injuries (grades II-IV) were reported from 19 pediatric trauma centers (median 6, range 1-22). Sixty-two injuries involving injury to the pancreatic duct (clear/suspected) were reported (median 1, range 0-9). Of these, 49 % were managed with non-operative management (NOM) and 51 % with operative management. Surgeons at the majority (63 %) of institutions used both approaches. Of the operative cases, 21 % were laparoscopic. There was wide variability in clinical management of NOM patients: the most common feeding strategy was reported by 52 % of centers, percutaneous drainage of traumatic pseudocyst by 42 % and ERCP (early/after pseudocyst) by 72 %. CONCLUSION Wide practice variability exists among North American pediatric surgeons regarding both the initial approach to high-grade pancreatic injury and non-operative management. These results highlight the need for a prospective trial to determine the optimal strategy for these patients.
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Affiliation(s)
- Bindi Naik-Mathuria
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX, 77030, USA.
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17
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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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Mora MC, Wong KE, Friderici J, Bittner K, Moriarty KP, Patterson LA, Gross RI, Tirabassi MV, Tashjian DB. Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma: Evaluation of the National Trauma Data Bank. J Am Coll Surg 2016; 222:977-82. [DOI: 10.1016/j.jamcollsurg.2015.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022]
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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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Multi-institutional experience with penetrating pancreatic injuries in children. Pediatr Surg Int 2014; 30:1107-10. [PMID: 25240916 DOI: 10.1007/s00383-014-3599-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Penetrating pancreatic injuries in children are uncommon and are not well described in the literature. We report a multi-institutional experience with penetrating pancreatic injuries in children. METHODS A retrospective review of children sustaining penetrating pancreatic injuries was performed at eight pediatric trauma centers. RESULTS Sixteen patients were identified. Eleven patients were male; (mean ± SE) age was 11.7 ± 1.2 years. The mechanism of injury was gun-shot wound in 14 patients and mean injury-severity score was 18 ± 3. All patients had associated injuries, most frequently small bowel injuries (n = 9). Patients had either grade I (n = 4), grade II (n = 7), or grade III (n = 4) injuries; there was a single grade V injury. All patients underwent exploratory celiotomy. Drainage of the injured pancreas was performed in 11 patients, and 2 patients underwent pancreatorrhaphy in addition to drainage; 3 underwent resection for grade III (n = 2) and grade V (n = 1) injuries. Thirteen patients required other intra-abdominal procedures. All patients required intensive care over a mean 11.0 ± 3.0 days. Mean duration of stay was 30.1 ± 5.6 days. Post-operative morbidity was 62.5% with no mortalities. CONCLUSIONS Penetrating pancreatic injuries in children are uncommon and most often due to firearms. There is a high association with other injuries particularly hollow viscous perforation.
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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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Western Trauma Association critical decisions in trauma: management of pancreatic injuries. J Trauma Acute Care Surg 2014; 75:941-6. [PMID: 24256664 DOI: 10.1097/ta.0b013e3182a96572] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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23
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Iqbal CW, St Peter SD, Tsao K, Cullinane DC, Gourlay DM, Ponsky TA, Wulkan ML, Adibe OO. Operative vs nonoperative management for blunt pancreatic transection in children: multi-institutional outcomes. J Am Coll Surg 2013; 218:157-62. [PMID: 24440062 DOI: 10.1016/j.jamcollsurg.2013.10.012] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 10/18/2013] [Accepted: 10/23/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND The management of traumatic pancreatic transection remains controversial. STUDY DESIGN A multi-institutional review from 1995 to 2012 was conducted comparing operative with nonoperative management for grades II and III blunt pancreatic injuries in patients younger than 18 years. RESULTS Fourteen pediatric trauma centers participated, yielding 167 patients; 57 underwent distal pancreatectomy and 95 were managed nonoperatively. Fifteen patients treated with operative drain placement only were studied separately. Patients undergoing resection had a shorter time to goal oral feeds (7.8 ± 0.7 days vs 15.1 ± 2.5 days; p = 0.007) and a lower rate of pseudocyst formation (0% vs 18%; p = 0.001). Pseudocyst formation resulted in a greater need for endoscopic and interventional radiologic procedures (26% vs 2%; p = 0.002) in the nonoperative group, as well as a longer time to complete resolution (38.6 ± 6.4 days vs 22.6 ± 5.0 days; p = 0.05) compared with resection. When looking at those patients with clear evidence of main duct injury at presentation, those undergoing resection also had fewer complications (33% vs 61%; p = 0.05) and fewer total days in-hospital (12.6 ± 8.4 days vs 17.5 ± 9.7 days; p = 0.04) compared with nonoperative management. CONCLUSIONS In children with blunt pancreatic injury, distal pancreatectomy is superior to nonoperative management with more rapid resumption of diet, fewer repeat interventions, and a shorter period to complete resolution. When the main duct is involved, the benefits to operative resection also include lower morbidity and fewer days of hospitalization. Therefore, assessing the status of the pancreatic duct is paramount in determining management.
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Affiliation(s)
- Corey W Iqbal
- Division of General and Thoracic Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO.
| | - Shawn D St Peter
- Division of General and Thoracic Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO
| | - Kuojen Tsao
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | | | - David M Gourlay
- Division of Surgery, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Todd A Ponsky
- Department of Pediatric Surgery, Akron Children's Hospital, Akron, OH
| | - Mark L Wulkan
- Division of Pediatric Surgery, Children's Healthcare of Atlanta at Egleston, Atlanta, GA
| | - Obinna O Adibe
- Division Pediatric General Surgery, Duke University, Durham, NC
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Lv HX, Zhong XY, Cui YF. Diagnosis and treatment of traumatic pancreatic injuries. Shijie Huaren Xiaohua Zazhi 2013; 21:1817-1822. [DOI: 10.11569/wcjd.v21.i19.1817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pancreatic trauma accounted for 1%-5% of all blunt abdominal injuries and 12% of penetrating abdominal injuries. Although pancreatic trauma is uncommon, its mortality is high. Early accurate diagnosis, selection of suitable means of treatment based on the degree of injury, and management of complications are issues that should be stressed in the treatment of pancreatic trauma. This article discusses the clinical diagnosis, treatment and complications of pancreatic trauma.
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25
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Okada N, Takada M, Ambo Y, Nakamura F, Kishida A, Kashimura N. Letton-Wilson procedure for blunt traumatic pancreatic transection in a 9-year-old child. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2013. [DOI: 10.1016/j.epsc.2013.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Beres AL, Wales PW, Christison-Lagay ER, McClure ME, Fallat ME, Brindle ME. Non-operative management of high-grade pancreatic trauma: is it worth the wait? J Pediatr Surg 2013; 48:1060-4. [PMID: 23701783 DOI: 10.1016/j.jpedsurg.2013.02.027] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 02/03/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND Whether children with pancreatic trauma should be managed non-operatively or operatively is controversial. We reviewed outcomes of high-grade pancreatic injuries at two high-volume pediatric surgical centres comparing non-operative and operative management strategies. METHODS All pancreatic traumas presenting from January 1993 to July 2010 were reviewed. Patients with high-grade pancreatic injuries were stratified based on early operative or non-operative therapy. Baseline characteristics and outcomes were compared. Regression analyses were performed to assess complication rates, length of stay, and TPN duration while controlling for injury severity score and associated injuries. RESULTS Of 77 patients with pancreatic injuries, 39 were grade 3 or higher. The mean ISS was 19.2 ± 10.8. Nineteen patients (50%) had associated injuries. Fifteen patients (38%) were managed operatively. Baseline characteristics were similar between groups other than ISS (p=0.03). Duration of hospitalization (p=0.01), days of TPN (p=0.003), and overall complications (p=0.007) were higher in non-operative patients. Controlling for both ISS and any associated injury, non-operative management was associated with more complications (OR 8.11; 95% CI 1.60-41.23) and was a significant predictor of prolonged TPN (13 days longer; p=0.024). CONCLUSION Primary non-operative management of high-grade pancreatic injuries is associated with a significant increase in complications and TPN dependency. Early operative intervention should be pursued whenever feasible.
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Affiliation(s)
- Alana L Beres
- The Hospital for Sick Children, Division of General and Thoracic Surgery, University of Toronto, Toronto ON, Canada
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27
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Clark W, Paidas CN, Germain D, Guidi C, Pinkas H, Kayton ML. Delayed presentation of complete pancreatic ductal transection in children: management of two cases without resection. Pediatr Surg Int 2013; 29:401-5. [PMID: 23242202 DOI: 10.1007/s00383-012-3233-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2012] [Indexed: 11/30/2022]
Abstract
Pancreatic ductal injuries in children are rare, and ductal transections presenting in a delayed or subacute fashion are seldom reported. We describe two cases of traumatic pancreatic ductal transection secondary to physical abuse, both of which presented late to medical care. Both were managed successfully without pancreatic resection. Judicious application of non-resectional management can yield favorable outcomes in this subset of pediatric patients.
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Affiliation(s)
- Whalen Clark
- Division of Pediatric Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 1 Tampa General Circle #G441, Tampa, FL 33606, USA
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Non-operative treatment versus percutaneous drainage of pancreatic pseudocysts in children. Pediatr Surg Int 2013; 29:305-10. [PMID: 23274700 DOI: 10.1007/s00383-012-3236-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE The objective of this study was to characterize the clinical course and outcomes of children with pancreatic pseudocysts that were initially treated non-operatively or with percutaneous drainage. METHODS A retrospective review of children with pancreatic pseudocysts over a 12-year period was completed. Categorical variables were compared using Fischer's exact method and the Student's t test was used to compare continuous variables. Analysis was done using logistic and linear regression models. RESULTS Thirty-six children met the criteria for pancreatic pseudocyst and 33 children were treated either non-operatively or with percutaneous drainage. Of the 22 children managed non-operatively, 17 required no additional intervention (77 %) and five required surgery. Operative procedures were: Frey procedure (3), distal pancreatectomy (1), and cystgastrostomy (1). Eight of the 11 children treated with initial percutaneous drainage required no additional treatment (72 %). The other three children underwent distal pancreatectomy. Success of non-operative management or percutaneous drainage was not dependent on size or complexity of the pseudocyst Logistic regression did not identify any patient demographic (gender, age, and weight), etiologic (trauma, non-traumatic pancreatitis) or pseudocyst characteristic (size, septations) that predicted failure of non-operative therapy. CONCLUSIONS In children, pancreatic pseudocysts can frequently be managed without surgery regardless of size or complexity of the pseudocyst. When an intervention is needed, percutaneous drainage can be performed successfully, avoiding the need for major surgical intervention in the majority of patients.
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29
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Lin TK, Barth BA. Endoscopic retrograde cholangiopancreatography in pediatrics. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2013. [DOI: 10.1016/j.tgie.2012.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Kang HJ, Choi SB, Choi SY. Surgical experience and clinical outcome of traumatic pancreatic injury. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2012; 16:160-6. [PMID: 26388928 PMCID: PMC4574994 DOI: 10.14701/kjhbps.2012.16.4.160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Revised: 10/23/2012] [Accepted: 10/24/2012] [Indexed: 11/29/2022]
Abstract
Backgrounds/Aims Traumatic pancreatic injury is rare and various surgical procedures can be applied according to the severity of injury. We reviewed our experience of pancreatic injury and investigated the clinical outcome. Methods Fifty-six patients were treated conservatively or with surgery for pancreatic injury at the Department of Surgery, Korea University Medical Center of Korea University College of Medicine from January 2001 to February 2012. Results Forty-one men and 15 women were included (mean age, 32 years; range, 5-66 years). Twelve patients were hypotensive at admission. According to the American Association for the Surgery of Trauma grade, 15 patients were grade I, 16 were grade II, 10 were grade III, 13 were grade IV, and one patient was grade V. A total of 41 patients underwent exploratory surgery. Complications developed in 35 patients, and 19 patients demonstrated intra-abdominal abscesses associated with pancreatic leakage. Four mortalities occurred. More adult patients (n=42) required intensive care than that of pediatric patients (n=14) (p=0.03). However, more pediatric patients had hyperamylasemia at admission (p=0.023). A significantly higher proportion of patients in the hypotensive group had blunt abdominal injuries, associated extra-abdominal injuries, combined intra-abdominal injuries, longer ICU stays, and a higher mortality rate. Conclusions Associated intra-abdominal and extra-abdominal injuries are frequent in patients with traumatic pancreatic injury. Despite the complication rate, most patients recovered. Mortalities were associated with combined injuries being placed into bleeding, hypovolemic shock, and multiorgan failure.
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Affiliation(s)
- Hyeok Jo Kang
- Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sae Byeol Choi
- Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sang Yong Choi
- Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Iqbal CW, Levy SM, Tsao K, Petrosyan M, Kane TD, Pontarelli EM, Upperman JS, Malek M, Burns RC, Hill S, Wulkan ML, St. Peter SD. Laparoscopic Versus Open Distal Pancreatectomy in the Management of Traumatic Pancreatic Disruption. J Laparoendosc Adv Surg Tech A 2012; 22:595-8. [DOI: 10.1089/lap.2012.0002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | - Shauna M. Levy
- University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Kuojen Tsao
- University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | | | | | | | | | - Marcus Malek
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Sarah Hill
- Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
| | - Mark L. Wulkan
- Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
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Abstract
PURPOSE OF REVIEW In this study we present a concise review of the evolving management of traumatic injury to the pancreas, including diagnostic approaches and options for operative and nonoperative intervention. RECENT FINDINGS New diagnostic adjuncts can be used for the evaluation of injury to the pancreas and pancreatic duct. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) are used as diagnostic modalities for duct evaluation. ERCP can be therapeutic with sphincterotomy and/or stenting for duct disruption. Computed tomography scan is the initial imaging study of choice for pancreatic injury, but is also used for drainage of pancreatic abscesses or pseudocysts. SUMMARY Nonoperative management of solid organ injuries is the recommended treatment in hemodynamically stable patients. This strategy is now being successfully applied to pancreatic injuries in specific situations. However, the mainstays of pancreatic injury remain the same. The identification of pancreatic duct injury is the top priority. Management includes distal resection, debridement, and closed suction drainage of pancreatic injuries.
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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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Paul MD, Mooney DP. The management of pancreatic injuries in children: operate or observe. J Pediatr Surg 2011; 46:1140-3. [PMID: 21683212 DOI: 10.1016/j.jpedsurg.2011.03.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 03/26/2011] [Indexed: 12/13/2022]
Abstract
PURPOSE The critical management decision in pediatric pancreatic injuries involves whether or not to operate on patients with grade II or III injuries. Because of the rarity of these injuries, no one hospital cares for enough patients to determine the outcome of this decision. Given this, the American Pediatric Surgical Association accrued a series of patients with pancreatic injuries from the members of its Trauma Committee. METHODS A retrospective review of concurrent pancreatic injuries from 9 level 1 pediatric trauma centers was performed. RESULTS Data on 131 children were submitted. Forty-three patients suffered grade II or grade III injuries. Twenty patients underwent an operation, and 23 were observed. Patients who underwent an operation had an average length of stay of 16.1 days compared with 14.2 days. Two in the operative group received total parenteral nutrition compared with 12 in the nonoperative group. Eight in the nonoperative group developed a pseudocyst compared with 3 in the operative group. CONCLUSIONS Children with grade II or grade III pancreatic injuries managed nonoperatively had a higher rate of pseudocyst, lower rate of reoperation, and a comparable length of stay compared with those who underwent surgery. These data will be used to help design a prospective study of pancreatic injury management.
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Affiliation(s)
- Michael D Paul
- Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
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Borkon MJ, Morrow SE, Koehler EA, Shyr Y, Hilmes MA, Miller RS, Neblett WW, Lovvorn HN. Operative Intervention for Complete Pancreatic Transection in Children Sustaining Blunt Abdominal Trauma: Revisiting an Organ Salvage Technique. Am Surg 2011. [DOI: 10.1177/000313481107700523] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Complete pancreatic transection (CPT) in children is managed commonly with distal pancreatectomy (DP). Alternatively, Roux-en-Y distal pancreaticojejunostomy (RYPJ) may be performed to preserve pancreatic tissue. The purpose of this study was to review our experience using either procedure in the management of children sustaining CPT after blunt abdominal trauma. We retrospectively reviewed the records of all children admitted to our institution during the last 15 years who were confirmed at operation to have CPT after blunt mechanisms. Summary statistics of demographic data were performed to describe children receiving either RYPJ or DP. CPT occurred in 28 children: 15 had DP, 10 had RYPJ, and three had cystogastrostomy. RYPJ children, compared with DP, were younger (7.5 vs 12.3 years, P = 0.039) and sustained more grade IV pancreatic injuries (70% vs 14%, P = 0.01). DP patients were 5.63 times more likely to tolerate full enteral feeds ( P = 0.009). Nevertheless, when controlling for age, injury severity score, and pancreatic injury grade, procedure type did not statistically affect total and postoperative lengths of stay and postoperative complications. In the operative management algorithm of children sustaining CPT, DP may afford an earlier return to full enteral feeds. RYPJ seems otherwise equivalent to DP and preserves significant pancreatic glandular tissue and the spleen.
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Affiliation(s)
- Matthew J. Borkon
- Department of Pediatric Surgery, Vanderbilt Medical Center, Nashville, Tennessee
| | - Stephen E. Morrow
- Department of Pediatric Surgery, Vanderbilt Medical Center, Nashville, Tennessee
| | - Elizabeth A. Koehler
- Department of Pediatric Surgery, Vanderbilt Medical Center, Nashville, Tennessee
| | - Yu Shyr
- Department of Pediatric Surgery, Vanderbilt Medical Center, Nashville, Tennessee
| | - Melissa A. Hilmes
- Department of Pediatric Surgery, Vanderbilt Medical Center, Nashville, Tennessee
| | - Richard S. Miller
- Department of Pediatric Surgery, Vanderbilt Medical Center, Nashville, Tennessee
| | - Wallace W. Neblett
- Department of Pediatric Surgery, Vanderbilt Medical Center, Nashville, Tennessee
| | - Harold N. Lovvorn
- Department of Pediatric Surgery, Vanderbilt Medical Center, Nashville, Tennessee
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Cigdem MK, Senturk S, Onen A, Siga M, Akay H, Otcu S. Nonoperative management of pancreatic injuries in pediatric patients. Surg Today 2011; 41:655-9. [PMID: 21533937 DOI: 10.1007/s00595-010-4339-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 03/23/2010] [Indexed: 12/13/2022]
Abstract
PURPOSE Nonoperative management of minor pancreatic injury is the generally accepted approach. However, the management of major pancreatic injury remains controversial in pediatric patients. The aim of the present study was to determine the safety and efficacy of nonoperative management of pancreatic injury in pediatric patients. METHODS Between 2003 and 2009, 31 patients, 28 male and 3 female, with pancreatic injury due to blunt abdominal trauma were treated in our clinic. All patients were evaluated by ultrasonography, computed tomography (CT), and evaluation of serum amylase levels. Patients with ongoing hemodynamic instability after resuscitation or signs of bowel perforation underwent immediate laparotomy, and the remaining patients were conservatively treated. Conservative treatment consisted of nasogastric tube replacement, total parenteral nutrition, monitoring of amylase levels, and serial clinical examination. RESULTS The most common mechanism of injury was a fall (35.4%). Ten patients (32.2%) had associated extra-abdominal injuries, and 18 patients (58.1%) had associated abdominal injuries. The spleen was the most common site of intra-abdominal injury that was associated with pancreatic trauma. Initial amylase levels were normal in 5 patients, whose CT scans revealed pancreatic injury. Twenty-five patients (80.6%) were conservatively treated. Six patients (19.4%) required surgical intervention because of a hollow viscus or diaphragmatic injury and hemodynamic instability. A pseudocyst developed in 11 of the 25 patients who were nonoperatively treated; 6 patients required intervention for the pseudocyst (percutaneous drainage and cystogastrostomy). No patient succumbed to injury. CONCLUSIONS The majority of the pancreatic injuries in pediatric patients can be successfully treated conservatively, unless there is hemodynamic instability and a hollow viscus injury. The most common complication is a pseudocyst.
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Affiliation(s)
- Murat Kemal Cigdem
- Department of Pediatric Surgery, Dicle University Medical School, 21280, Diyarbakir, Turkey
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Herman R, Guire KE, Burd RS, Mooney DP, Ehlrich PF. Utility of amylase and lipase as predictors of grade of injury or outcomes in pediatric patients with pancreatic trauma. J Pediatr Surg 2011; 46:923-6. [PMID: 21616253 DOI: 10.1016/j.jpedsurg.2011.02.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 02/11/2011] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Grade of injury, serum amylase, and lipase are markers used to assess pancreatic injury. It is unclear how amylase and lipase relate to grade of injury or predict outcome. We hypothesize that serum amylase and lipase are good predictors of grade of injury and outcomes in patients with pancreatic trauma. METHODS This study is a multicenter review from 9 pediatric trauma centers of all children admitted to their institution over 5 years with a pancreatic injury. Initial as well as peak amylase and lipase values were analyzed with relation to pancreatic grade, length of stay, and outcomes. RESULTS One hundred thirty-one records were analyzed. There were 44 girls and 85 boys with an average age of 9.0 ± 0.4 years. The mean injury severity score (ISS) score was 15.5 ± 1.2 SE. The average length of stay (in days) was analyzed by grades 0 (3.93), 1 (7.73), 2 (13.4), 3 (18.4), 4 (31), and 5 (13.5). Neither initial nor peak amylase/lipase correlated with grade of injury. Neither amylase nor lipase predicted length of stay or mortality. Maximal amylase was highly predictive of developing a pseudocyst. CONCLUSION There seems to be limited value for repetitive routine amylase and lipase levels in the management of pediatric trauma patients with pancreatic injury.
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Affiliation(s)
- Richard Herman
- University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
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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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Nievelstein RAJ, Robben SGF, Blickman JG. Hepatobiliary and pancreatic imaging in children-techniques and an overview of non-neoplastic disease entities. Pediatr Radiol 2011; 41:55-75. [PMID: 20967540 PMCID: PMC3016234 DOI: 10.1007/s00247-010-1858-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 08/10/2010] [Accepted: 08/30/2010] [Indexed: 02/07/2023]
Abstract
Imaging plays a major role in the diagnostic work-up of children with hepatobiliary or pancreatic diseases. It consists mainly of US, CT and MRI, with US and MRI being the preferred imaging modalities because of the lack of ionizing radiation. In this review the technique of US, CT and MRI in children will be addressed, followed by a comprehensive overview of the imaging characteristics of several hepatobiliary and pancreatic disease entities most common in the paediatric age group.
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Affiliation(s)
- Rutger A. J. Nievelstein
- Department of Radiology E01.132, University Medical Center Utrecht, Wilhelmina Children’s Hospital, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Simon G. F. Robben
- Department of Radiology, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Johan G. Blickman
- Department of Imaging Sciences, Golisano Children’s Hospital, Rochester, NY USA
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Al-Jazaeri AH. Short hospitalization after early intervention in managing grade III pancreatic injuries in children: a possible new trend. Saudi J Gastroenterol 2011; 17:363-6. [PMID: 21912067 PMCID: PMC3178928 DOI: 10.4103/1319-3767.84500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The presence of ductal disruption in pancreatic trauma is a major indicator of severity leading to higher morbidities and prolonged hospital stay. However, the adoption of early interventional approach in selected cases of documented grade III pancreatic trauma could result in shorter hospitalization and early recovery. We are describing our approach of early presentation-tailored interventions in managing two consecutive children diagnosed with grade III pancreatic injuries, which constitute the two main ends of the presentations' spectrum. For the early presenter a spleen preserving distal pancreatectomy was performed, while for the late presenter with large symptomatic pseudocyst endoscopic drainage was attempted. Both early and late presenting children had quick and uneventful recoveries leading to 5 and 6 days of hospitalization, respectively. Both cases continued to be asymptomatic at 4 and 12 months post procedure. In the pseudocyst case, the gastro-cystostomy stents were removed after 10 weeks, and 2.5 months later a completely healed pancreas was demonstrated by magnetic resonance cholangio-pancreatography. Unlike other abdominal solid organ injuries in children, adopting early presentation-tailored intervention can be associated with quicker recovery and short hospitalization for grade III pancreatic injuries. While the series is still small, achieving such remarkable outcomes in two consecutive cases is possible and could set a new trend in managing these injuries in children.
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Affiliation(s)
- Ayman H. Al-Jazaeri
- Division of Pediatric Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Address for correspondence: Dr. Ayman Al-Jazaeri, Department of Surgery, King Saud University Riyadh 11472, PO Box 7805i, Saudi Arabia. E-mail:
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Sutherland I, Ledder O, Crameri J, Nydegger A, Catto-Smith A, Cain T, Oliver M. Pancreatic trauma in children. Pediatr Surg Int 2010; 26:1201-6. [PMID: 20803148 DOI: 10.1007/s00383-010-2705-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2010] [Indexed: 12/11/2022]
Abstract
PURPOSE To document the demographics, mechanisms and outcome of traumatic pancreatitis in children at a single large tertiary referral centre in Australia. METHODS We undertook a 10-year retrospective audit of children admitted to the Royal Children's Hospital, Melbourne, Australia with a hospital coded diagnosis which included pancreatic injury between 1993 and 2002. Data included patient demographics, source of admission, mechanism of injury, pancreatic complications, associated injuries, intensive care unit admission, results of any operative findings, results of any acute computed tomography and/or ultrasound imaging of pancreas, selected laboratory findings and length of stay. RESULTS We identified two distinct groups of patients in the 91 documented cases of pancreatic trauma (median age 8.0 years, range 0.6-15.8 years; M:F 2.5:1.0): 59 had a history of abdominal trauma and elevated serum lipase but no CT or ultrasound evidence of pancreatic injury (Group A); 32 had a history of abdominal trauma, elevated serum lipase but also had CT scan and/or ultrasound evidence of pancreatic injury (Group B). Patients with "less severe" injury based on normal imaging had a lower initial lipase level [Group A, median 651 U/L (interquartile range 520-1,324) vs. Group B, 1,608 U/L (interquartile range 680-3,526); p = 0.005] and shorter admission time [Group A, 9.0 days (interquartile range 5.5-15.5) vs. Group B, 13.4 days (interquartile range 6.8-23.8); p = 0.04]. There were no differences with respect to mortality (Group A, 13.5% vs. Group B, 12.5%), but patients with evidence of injury on imaging were more likely to have surgical intervention (p = 0.0001). The single most important overall cause of pancreatic trauma was involvement in a motor vehicle accident as a passenger or pedestrian. However, in children with high-grade ductal injury, bicycle handlebar injuries were most common. Associated injuries were common in both groups. CONCLUSION Significant pancreatic injury can occur in the absence of abnormality on medical imaging. Pancreatic trauma commonly occurs in the context of multiple injuries after motor vehicle accidents in children and bicycle handlebar injuries, especially in boys. Most children can be treated conservatively, with surgical intervention being limited to high-grade ductal injury.
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Affiliation(s)
- Ingrid Sutherland
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia
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42
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Fractura pancreática con ascitis masiva como manifestación clínica de maltrato. An Pediatr (Barc) 2010; 73:216-8. [DOI: 10.1016/j.anpedi.2010.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 12/16/2009] [Accepted: 02/22/2010] [Indexed: 11/18/2022] Open
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Wood JH, Partrick DA, Bruny JL, Sauaia A, Moulton SL. Operative vs nonoperative management of blunt pancreatic trauma in children. J Pediatr Surg 2010; 45:401-6. [PMID: 20152361 DOI: 10.1016/j.jpedsurg.2009.10.095] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2009] [Accepted: 10/27/2009] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of this study was to evaluate the outcome of nonoperative vs operative management of blunt pancreatic trauma in children. METHODS Retrospective review of pancreatic injuries from 1995 to 2006 at an urban level I regional pediatric trauma center. RESULTS Forty-three children with pancreatic injury were included in the analysis. Injuries included grade I (n = 18), grade II (n = 6), grade III (n = 17), and grade IV (n = 2). For grade II to IV injuries, patients managed operatively (n = 14) and nonoperatively (n = 11) had similar lengths of stay and rates of readmission, despite increased pancreatic complications (PCs) in the nonoperative cohort (21% vs 73%; P = .02). There was a trend toward increased non-PCs in patients managed with resection (P = .07). Twelve patients underwent successful diagnostic endoscopic retrograde cholangiopancreatography in which duct injury was identified. In this group, nonoperative management was pursued in 6 patients but was associated with increased rates of PC (86% nonoperative vs 29% operative; P = .02). CONCLUSIONS Operative management of children with grades II to IV pancreatic injury results in significantly decreased rates of PCs but fails to decrease length of stay in the hospital, possibly as a result of non-PCs. Endoscopic retrograde cholangiopancreatography may serve as a useful diagnostic modality for guiding operative vs nonoperative management decisions.
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Affiliation(s)
- James H Wood
- Department of Pediatric Surgery, The Children's Hospital, University of Colorado Health Science Center, Aurora, CO 80045, USA
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44
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Nonoperative Management of the Child With Severe Pancreatic and Splenic Injury: Should This Become Our Preferred Approach? ACTA ACUST UNITED AC 2010; 68:E44-8. [DOI: 10.1097/ta.0b013e31815edecd] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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45
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Martinez-Ramos D, Cifrián-Pérez M, García-Vila JH, Salvador-Sanchís JL, Hoashi JS. Percutaneous drainage treatment of traumatic pancreatic rupture with pancreatic transection. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 33:102-5. [PMID: 19896241 DOI: 10.1016/j.gastrohep.2009.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 09/07/2009] [Accepted: 09/15/2009] [Indexed: 10/20/2022]
Abstract
Management of traumatic pancreatic pseudocyst associated with pancreatic duct laceration is controversial. Surgical therapy has been clasically considered the treatment of choice for those pseudocysts. However, several authors have published good results with percutaneous drainage. Percutaneous drainage can be performed easily, with minimal complication and may facilitate the resolution of a pseudocyst. We present a case of a 16-year-old boy who sustained blunt abdominal trauma in a vehicle accident. A large pancreatic pseudocyst developed, with complete disruption of the main pancreatic duct. Percutaneous drainage under ultrasound guidance was performed and was associated with the administration of octreotide (to inhibit exocrine pancreatic secretion). The drainage flow decreased gradually until ceasing, and the pseudocyst disappeared.
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Affiliation(s)
- David Martinez-Ramos
- General Surgery and Digestive System Service, Castellón General Hospital, Castellón, Spain.
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46
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Extension of Nonoperative Management of Blunt Pancreatic Trauma to Include Grade III Injuries: A Safety Analysis. World J Surg 2009; 33:1611-7. [DOI: 10.1007/s00268-009-0082-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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47
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Abstract
OBJECTIVE Trauma is a leading cause of morbidity and mortality in children. The abdomen is the second most common site of injury. This article discusses abdominal trauma in children. CONCLUSION The clinical evaluation of children with potential blunt abdominal injury presents a challenging task. Therefore, imaging plays an essential role in the evaluation of such children.
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Vane DW, Kiankhooy A, Sartorelli KH, Vane JL. Initial resection of potentially viable tissue is not optimal treatment for grades II-IV pancreatic injuries. World J Surg 2009; 33:221-7. [PMID: 18404287 DOI: 10.1007/s00268-008-9569-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE This study was designed to ascertain the optimal therapy and diagnostics for children with pancreatic injury. METHODS From January 1, 2001 to January 1, 2007, all children (newborn to 17 years) who presented to this Level I trauma center with demonstrated pancreatic injury were prospectively entered into the TRACS IV system and reviewed for injury type, diagnostics, therapy, demographics, and outcome. RESULTS Fourteen children sustained grade II or higher pancreatic injury during this period. CT scan was performed for diagnosis in all cases. There were 11 boys and 3 girls, and mean age was 6.9 (range, 2-16) years. There were five grade II injuries, four grade III injuries, four grade IV injuries, and one grade V injury. All grade II injuries were treated successfully nonoperatively with observation. The nine grade III-IV injuries all underwent operative external drainage without pancreatectomy or stent placement. The single grade V injury died of multiple associated injuries after operative intervention. No pseudocysts developed in these children. All children have normal pancreatic function, and all except one have normal anatomy on follow-up scans. Early exploration and drainage directly reduces length of stay. CONCLUSION Grade II pancreatic injuries do not require routine surgical exploration in children. Grade III and IV injuries in this series were treated with expeditious drainage of the pancreatic bed and did not require routine pancreatectomy or endoscopic stent [corrected] placement as some have recommended. Early drainage shortens hospital stay, and outcomes from this therapy are excellent. Pancreatic resection of exocrine defunctionalized segments of pancreas may be performed safely electively after acute injury if necessary, but anecdotal information from this series indicates that too may not be necessary. Grade V injuries often are accompanied by multiple other organ injuries and are associated with a significant mortality rate. A multi-institutional investigation is warranted to reassess optimal therapy for pancreatic injury in children.
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Affiliation(s)
- Dennis W Vane
- Division of Pediatric Surgery, Vermont Children's Hospital, University of Vermont College of Medicine, FAHC, 267 FL4, MC Campus, 111 Colchester Avenue, Burlington, VT 05401, USA.
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Abstract
Generally speaking, isolated pancreatic injuries are rare after abdominal blunt trauma. However, the incidence of pancreatic injuries in children has risen in recent decades. Pancreatic pseudocyst represents a typical complication after acute pancreatitis due to blunt abdominal trauma. Spontaneous rupture of pseudocysts leading to acute abdominal pain has been described, however, it rarely occurs, especially in pediatric patients. We report the successful non-surgical management of a ruptured pancreatic pseudocyst in a 5-year-old girl which occurred 27 days after trauma. The traumatic acute pancreatitis was due to a handlebar injury.
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50
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de Blaauw I, Winkelhorst JT, Rieu PN, van der Staak FH, Wijnen MH, Severijnen RSVM, van Vugt AB, Wijnen RMH. Pancreatic injury in children: good outcome of nonoperative treatment. J Pediatr Surg 2008; 43:1640-3. [PMID: 18778999 DOI: 10.1016/j.jpedsurg.2008.03.061] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Revised: 02/19/2008] [Accepted: 03/21/2008] [Indexed: 12/26/2022]
Abstract
PURPOSE Treatment of blunt injury of the pancreas in children remains controversial. Some prefer nonoperative treatment, whereas others prefer operative management in selected cases. This report reviews the treatment of patients with blunt pancreatic trauma admitted to a level I pediatric trauma center in The Netherlands. METHODS Medical records of all children less than 15 years with blunt pancreatic trauma admitted to the University Medical Center St Radboud in the period 1975 to 2003 were retrospectively analyzed. RESULTS Thirty-four children were included, age 3 to 14 years. Most injuries were because of bicycle accidents (58%). On admission, amylase was raised in 90% of the patients. Five patients had pancreatic duct injuries identified by imaging (endoscopic retrograde cholangiopancreaticography was used once, magnetic resonance cholangiopancreaticography twice) or at surgery. Thirty-one children were initially managed nonoperatively. Pancreatic surgery was performed in 3 children (1 Roux-Y, 2 drainage only). Mean hospital stay was 29 days in the operative group and 24 days in the nonoperative group. Fluid collections developed in 2 operated patients. Both resolved spontaneously. In 14 of the 31 nonoperated patients, a pseudocyst developed. Only 6 of these needed secondary intervention. Of these, 3 were drained percutaneously. There was no mortality and no long-term morbidity in both groups. CONCLUSIONS Nonoperative management of pancreatic injury in children has good clinical outcome. Only 10% need secondary surgery. In 50%, pseudocysts develop of which half can be managed nonoperatively. The reliability of computed tomographic scan grading is of limited value to decide whether to operate primarily. There is little to gain with ERCP and stenting. The place of MRCP as a noninvasive diagnostic tool remains to be determined.
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Affiliation(s)
- Ivo de Blaauw
- Department of Pediatric Surgery, University Medical Center St Radboud, Nijmegen 6500 HB, The Netherlands
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