Blunt Trauma Pancreas in Children: Is Non-Operative Management Appropriate for All Grades?

Management of pancreatic and duodenal trauma in childhood: a university hospital experience over a 10-year period

PURPOSE

Duodenal/pancreatic injuries occur in less than 10% of intra-abdominal injuries in pediatric blunt trauma. Isolated duodenal/pancreatic injuries occur in two-thirds of cases, while combined injuries occur in the remaining. This study aimed to investigate pediatric patients with pancreatic and duodenal trauma.

METHODS

Data from 31 patients admitted to Atatürk University, Medical Faculty, Department of Pediatric Surgery for pancreatic/duodenal trauma between 2010 and 2019 were retrospectively analyzed. Age/gender, province of origin, duration before hospital admission, trauma type, injured organs, injury severity, diagnostic and therapeutic modalities, complications, hospitalization duration, blood transfusion requirement, and mortality rate were recorded.

RESULTS

Twenty-four patients were male, and 7 were female. The mean age was 9 years. The leading cause was bicycle accidents, with 12 cases, followed by traffic accidents/bumps, with 7 cases each. Comorbid organ injuries accompanied 18 cases. Duodenal trauma was most commonly accompanied by liver injuries (4/8), whereas pancreatic injury by pulmonary injuries (7/23). Serum amylase at initial hospital presentation was elevated in 83.9% of the patients. Thirty patients underwent abdominal CT, and FAST was performed in 20. While 54.8% of the patients were conservatively managed, 45.2% underwent surgery.

CONCLUSION

Because of the anatomical proximity of the pancreas and the duodenum, both organs should be considered being co-affected by a localized trauma. Radiologic confirmation of perforation in duodenal trauma and an intra-abdominal pancreatic pseudocyst in pancreatic trauma are the most critical surgical indications of pancreaticoduodenal trauma. Conservative management's success is increased in the absence of duodenal perforation and cases of non-symptomatic pancreatic pseudocyst.

Usefulness of Endoscopic Retrograde Cholangiopancreatography in the Diagnosis and Treatment of Traumatic Pancreatic Injury in Children

Pediatric trauma patients are increasing, and trauma is the leading cause of death in children. Pancreatic injury is known as the fourth most common solid organ injury, but the diagnosis of pancreatic injury is often delayed due to the retroperitoneal location of the pancreas and the low sensitivity and specificity of diagnostic tests. Endoscopic retrograde cholangiopancreatography (ERCP) is an important test for the diagnosis and treatment of various biliary tract and pancreatic diseases. However, cases of performing ERCP in traumatic pancreatic injury in children have been rarely reported. Thus, we aimed to evaluate the usefulness of ERCP in traumatic pancreatic injury in children. Between January 1983 and December 2022, pediatric patients under the age of 18 who were treated for traumatic pancreatic injury at a single institution were recruited and retrospectively analyzed. Patient characteristics and clinical outcomes were assessed. Thirty-one patients were enrolled in this study. Among them, 15 (48.4%) patients underwent ERCP. The time to diet was significantly longer in the ERCP group. There were no statistically significant differences in other characteristics between the ERCP and the non-ERCP group. In nine (60%) patients of the ERCP group, ERCP was used for therapeutic intervention or as a decision-making tool for surgery, and was used to resolve pancreas-related complications. ERCP may be useful for the diagnosis and treatment of traumatic pancreatic injury in children. In addition, ERCP can be safely applied in children, and complications related to ERCP also may not increase. When obscure pancreatic injury is suspected, it is necessary to consider performing ERCP.

Operative versus non-operative management of blunt pancreatic trauma in children: Systematic review and meta-analysis

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.

CT and MRI findings in pancreatic trauma in children and correlation with outcome

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.

Imaging of Blunt Pancreatic Trauma: A Systematic Review

PURPOSE

Despite several published reports on the value of imaging in acute blunt pancreatic trauma, there remains a large variability in the reported performance of ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). The purpose of this study is to present a systematic review on the utility of these imaging modalities in the acute assessment of blunt pancreatic trauma. In addition, a brief overview of the various signs of pancreatic trauma will be presented.

METHODS

Keyword search was performed in MEDLINE, EMBASE, and Web of Science databases for relevant studies in the last 20 years (1999 onward). Titles and abstracts were screened, followed by full-text screening. Inclusion criteria were defined as studies reporting on the effectiveness of imaging modality (US, CT, or MRI) in detecting blunt pancreatic trauma.

RESULTS

After initial search of 743 studies, a total of 37 studies were included in the final summary. Thirty-six studies were retrospective in nature. Pancreatic injury was the primary study objective in 21 studies. Relevant study population varied from 5 to 299. Seventeen studies compared the imaging findings against intraoperative findings. Seven studies performed separate analysis for pancreatic ductal injuries and 9 studies only investigated ductal injuries. The reported sensitivities for the detection of pancreatic injuries at CT ranged from 33% to 100% and specificity ranged from 62% to 100%. Sensitivity at US ranged from 27% to 96%. The sensitivity at MRI was only reported in 1 study and was 92%.

CONCLUSION

There remains a large heterogeneity among reported studies in the accuracy of initial imaging modalities for blunt pancreatic injury. Although technological advances in imaging equipment would be expected to improve accuracy, the current body of literature remains largely divided. There is a need for future studies utilizing the most advanced imaging equipment with appropriately defined gold standards and outcome measures.

Pediatric ultrasonography of the pancreas: normal and abnormal findings

The pancreas is easily investigated in children thanks to the relative lack of fat tissue and the large left hepatic lobe with an optimal acoustic window. The use of high frequency, even linear transducers, usually results in detailed images of all pancreatic areas. A wide spectrum of pancreatic pathologic conditions can be identified and monitored at ultrasound although they are relatively uncommon during childhood compared to the adult. In this paper we briefly review the anatomy, technique, and sonographic aspects of normal and pathological pediatric pancreas.