Punt Pass

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Incidence of Pediatric Pancreatic Trauma

NPTR- 154 injuries in 49540 patients-7 years (only 31- grades III,IV,V)

Canty 18 major ductal injuries-14,245 admissions, 14 years (2.3 million)

Mechanisms of Pancreatic Trauma

Blunt force traps pancreas against vertebral column

Lap belt related, falls, bicycle wrecks, abuse

Angle of force dictates location of injury

Especially true with improperly restrained children

Diagnosis of Pancreatic Trauma

Spiral CT +IV contrast; +/- GI contrast

MR Cholangiopancreatography (MRCP)

Mechanism should alert to pancreatic injury

Amylase>200 and Lipase>1800 + exam

Enzyme levels are not perfectly reliable

Anatomic variant

AAST Pancreas Injury Scale

I- Minor contusion without duct injuryII-Superficial laceration without duct injury, major contusion without duct injury or tissue lossIII- Distal transection or parenchymal injury with duct injuryIV- Proximal transection or parenchymal injury involving ampulla (R of SMV)V- Massive disruption of pancreatic head

Punt!- Nonoperative

Nonoperative treatment correct for children without major duct/gland disruption (grades I and II)

Minor injury accounts for 80% of pediatric pancreas injury

Operative drainage is not useful

Punt- Define the Injury

What to do with ductal transection (III)

Proximal duct vs distal duct

Can the pancreas be treated like the spleen, liver, and kidney in children?

Rigid adherence to non-operative management is a mistake

Nonoperative treatment- distal duct

Toronto- 10 patients with “complete transection” in 10 years (population?)

9 with complete records

Median Hosp days-24

4 pseudocysts drained

Atrophy distal gland in 6/8

Possibly an incomplete review

Assume you Punt-Management of

PseudocystMany resolve without treatment

Kouchi, et al- Japan- 20 patients

<10 cm, most will resolve

>10 cm, most will need drainage

1 died- TPN related

5% mortality

Pass- Operation for Distal Transections

Delay in diagnosis is common

Historically, only 50% are diagnosed upon admission, thus the high incidence of pseudocyst

Spiral CT may improve this number

Surgical management reasonable, possibly up to 7 days

Pass- Surgery for Distal Transections

Spleen sparing distal pancreatectomy

Dallas- 5 patients dx in 12 hours,6 patients dx in 36 hours

9 had surgery within 72 hours

Median hospital stay 11 days

1 late morbidity

Pageantry-Stenting

Proximal Duct Injury

Canty- nonoperative tx of proximal duct inj (IV or V)

ERCP or MRCP if in doubt

Very few Peds GI people are able to do this! Think about calling the adult GI folks

Pageantry- Laparoscopic repair

Not recommended for proximal injuries

Not recommended if other injuries suspected (i.e.-bowel)

More than 2 hours of pneumoperitoneum will start to increase complications

Summary

No ductal injury- Observe

Midbody Transection- spleen sparing distal pancreatectomy possibly out to 7 days post injury or observe

Proximal complex injury- observe and treat the pseudocyst or stent