1
|
Kaitouni BI, Achour Y, Ouzzaouit H, El Aoufir O, El Absi M, Sekkat H. Closed traumatism of the distal pancreas (A case series of 6 patients). Int J Surg Case Rep 2024; 124:110415. [PMID: 39423582 DOI: 10.1016/j.ijscr.2024.110415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 10/02/2024] [Accepted: 10/03/2024] [Indexed: 10/21/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE The aim of this retrospective study was to present six cases of trauma to the distal pancreas, highlighting the challenges associated with their diagnosis and management, while underlining their seriousness and the various complications potentially encountered. Our case series highlights individual patient outcomes, demonstrating the diversity of clinical presentations and the importance of customized treatment strategies. CASE SERIES Between January 2015 and December 2020, six cases of distal pancreas trauma were identified. In two cases, the diagnosis was made based on emergency abdominal CT scans, while in the other four patients, the diagnosis was made directly intraoperatively, mainly because of the severity of the associated lesions, which necessitated laparotomy for exploration. CLINICAL DISCUSSION Out of 115 cases of closed abdominal trauma, injury to the distal pancreas was identified in 6 patients, (5.2 %), with a mean age of 21 years. Despite the use of abdominal CT scans for all patients, pancreatic trauma was directly diagnosed intraoperatively in 4 cases (67 %). All patients presented with concomitant abdominal injuries (100 %), and 3 patients (50 %) exhibited multiple severe injuries. Additionally, a significant elevation in pancreatic serum markers was observed in 3 patients (50 %). The pancreatic injuries predominantly involved the tail of the pancreas (67 %), while the body was affected in one patient, and the isthmus was completely transected in another. Three of our patients developed a pancreatic fistula (50 %) and two patients (33 %) passed away; the first had severe associated lesions, and the second, despite undergoing several iterative laparotomies, succumbed to postoperative complications following a left pancreatectomy. CONCLUSION Closed traumatism of the distal pancreas, although rare, is a significant problem. It is often diagnosed during emergency laparotomy but can sometimes be found on preoperative CT scans. When the patient's condition permits, it is highly advisable to undergo a left pancreatectomy. Simple external drainage is reserved for certain specific situations.
Collapse
Affiliation(s)
- Boubker Idrissi Kaitouni
- Digestive Surgical Department, Centre Hospitalier Ibn Sina, Rabat, Morocco; Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco.
| | - Youssef Achour
- Digestive Surgical Department, Centre Hospitalier Ibn Sina, Rabat, Morocco; Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco
| | - Hamza Ouzzaouit
- Digestive Surgical Department, Centre Hospitalier Ibn Sina, Rabat, Morocco; Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco
| | - Omar El Aoufir
- Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco; Central Radiology Department, Centre Hospitalier Ibn Sina, Rabat, Morocco
| | - Mohammed El Absi
- Digestive Surgical Department, Centre Hospitalier Ibn Sina, Rabat, Morocco; Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco
| | - Hamza Sekkat
- Digestive Surgical Department, Centre Hospitalier Ibn Sina, Rabat, Morocco; Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco
| |
Collapse
|
2
|
Molla YD, Mekonnen DC, Beza AD, Alemu HT, Gebrehana DA. Surgical outcome of pediatric abdominal trauma at Tertiary Hospital, Northwest Ethiopia, a 3-year retrospective study. BMC Surg 2024; 24:203. [PMID: 38978029 PMCID: PMC11229280 DOI: 10.1186/s12893-024-02493-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 07/01/2024] [Indexed: 07/10/2024] Open
Abstract
INTRODUCTION Abdominal trauma in children is a significant health concern that often leads to severe complications and even death. Children experience trauma more frequently than adults, with approximately one in four pediatric patients suffering from serious abdominal injuries. Falls are the leading cause of such trauma among children, which is intriguing considering that most hospital admissions for pediatric abdominal injuries result from blunt force impacts. METHOD A retrospective cross-sectional analysis of medical records was conducted to examine all patients under the age of 16 who underwent exploratory laparotomy for abdominal trauma between January 1, 2020, and January 1, 2023. The clinical data were gathered using a data extraction sheet from each patient's medical charts. Information on socio-demographic characteristics, injury mechanisms, clinical conditions at the initial presentation, intraoperative findings and complications, and patient outcomes were collected. RESULTS The study involved a total of 90 patients, consisting of 72 males (80%) and 18 females (20%). The average age of the patients was 10, with a standard deviation of 4.7, ranging from 2 to 16 years. Half of the patients were below the age of 10, accounting for 46 individuals (51%). The causes of the injuries varied among patients below and above the age of 10. However, overall, bullet injuries were the most common cause, accounting for 28 cases (31%), followed by falls in 21 cases (23.3%), horse or donkey kicks in 10 cases (11.1%), stab injuries in 10 cases (11.1%), horn injuries in 7 cases (7.8%), and road traffic accidents in 6 cases (6.7%). Physical assault, blasts, and other types of injuries, such as hen bites and metal rod injuries, were observed in 8 cases (8.9%) of the patients. Fall accidents, horse or donkey kicks, and horn injuries were particularly more common among children below the age of 10, while bullet injuries and stab injuries were most common among those above the age of 10. CONCLUSION Following abdominal trauma in children, a range of complications may arise, including immediate issues such as infections and hemorrhaging, as well as long-term consequences like impaired organ functionality and psychological distress. In our region, young children are particularly vulnerable to accidents involving falls, kicks from horses or donkeys, and injuries caused by horns. Therefore, it is crucial to educate parents about these hazards. Additionally, providing appropriate guidance on firearm safety is essential for individuals who possess such weapons.
Collapse
Affiliation(s)
- Yohannis Derbew Molla
- Department of Surgery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | | | - Andinet Desalegn Beza
- Department of Surgery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | | | - Deresse Abebe Gebrehana
- Department of Internal Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| |
Collapse
|
3
|
Wu AA, Thompson ED, Cameron JL, He J, Burkhart RA, Burns WR, Lafaro KJ, Shubert CR, Canto MI, Fishman EK, Hruban RH. Distinctive Pathology Associated With Focal Stenosis of the Main Pancreatic Duct Secondary to Remote Trauma: A Long-term Complication of Seat Belt Pancreatitis. Am J Surg Pathol 2024; 48:726-732. [PMID: 38482693 DOI: 10.1097/pas.0000000000002207] [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: 05/16/2024]
Abstract
The radiologic finding of focal stenosis of the main pancreatic duct is highly suggestive of pancreatic cancer. Even in the absence of a mass lesion, focal duct stenosis can lead to surgical resection of the affected portion of the pancreas. We present four patients with distinctive pathology associated with non-neoplastic focal stenosis of the main pancreatic duct. The pathology included stenosis of the pancreatic duct accompanied by wavy, acellular, serpentine-like fibrosis, chronic inflammation with foreign body-type giant cell reaction, and calcifications. In all cases, the pancreas toward the tail of the gland had obstructive changes including acinar drop-out and interlobular and intralobular fibrosis. Three of the four patients had a remote history of major motor vehicle accidents associated with severe abdominal trauma. These results emphasize that blunt trauma can injure the pancreas and that this injury can result in long-term complications, including focal stenosis of the main pancreatic duct. Pathologists should be aware of the distinct pathology associated with remote trauma and, when the pathology is present, should elicit the appropriate clinical history.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Elliot K Fishman
- Radiology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | |
Collapse
|
4
|
Alnagar A, Khamag O, Sharif K, Mirza DF, Ong EGP. The Broad Spectrum of Paediatric Pancreatic Disease: A Single-center 26-years Retrospective Review. J Pediatr Surg 2024; 59:261-267. [PMID: 37957099 DOI: 10.1016/j.jpedsurg.2023.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/11/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Paediatric pancreatic pathology and its management is rarely described. We present our experience. METHODS A retrospective case-note review of all patients with pancreatic disease from 1995 to 2021 was completed. Data are quoted as median (range). RESULTS Two hundred and twelve patients were identified with 75.9% presenting with pancreatitis. Referrals for pancreatitis increased during the study period and affected a wide age range (2 months-15.6 years). Acute pancreatitis (n = 118) (age 10.6 (0.18-16.3) years). The most common causes were idiopathic (n = 60, 50.8%) and biliary (n = 28, 23.8%). About 10% required treatment for complications or underlying biliary causes. Recurrent pancreatitis (n = 14) (11.6 (0.3-14.3) years). The most common cause was hereditary pancreatitis (n = 6, 42.9%). One patient required endoscopic drainage of pseudocyst. Chronic pancreatitis (n = 29) (16 (0.38-15.5) years). The underlying diagnosis was idiopathic (n = 14, 48.4%) or hereditary pancreatitis (n = 10, 34.5%). 13 patients required active management, including pancreaticojejunostomies (n = 5). Blunt Trauma (n = 34) was managed conservatively in 24 (70.5%). 6 patients required open surgery, but 4 were managed by either endoscopy or interventional radiology. Pancreatic tumours (n = 13) presented at 11.2 (2.3-16) years. Pathology included pancreaticoblastomas (n = 3), solid pseudopapillary tumours (n = 3), neuroendocrine tumours (n = 2), acinar cell cystadenoma (n = 1), intraductal papillary mucinous neoplasm (n = 1), pancreatic insulinoma (n = 1), pancreatic ductal adenocarcinoma (n = 1), and embryonal rhabdomyosarcoma (n = 1). OTHERS (N = 4): Pancreatic cyst (n = 3) and annular pancreas (n = 1). CONCLUSION Paediatric pancreatic disease spans a wide spectrum of both benign and malignant disease and benefits from access to specialist medical, surgical, endoscopic, and interventional radiology expertise. Referrals for paediatric pancreatitis are increasing, but aetiology is different to that seen in adults. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Amr Alnagar
- The Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham UK
| | - Omer Khamag
- The Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham UK
| | - Khalid Sharif
- The Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham UK
| | - Darius F Mirza
- The Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham UK
| | - Evelyn G P Ong
- The Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham UK.
| |
Collapse
|
5
|
Youn JK, Yang HB, Ko D, Kim HY. Pediatric blunt pancreatic trauma at a single center in Korea: a retrospective review from 2007 to 2022. JOURNAL OF TRAUMA AND INJURY 2023; 36:242-248. [PMID: 39381697 PMCID: PMC11309271 DOI: 10.20408/jti.2023.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/24/2023] [Accepted: 06/28/2023] [Indexed: 10/10/2024] Open
Abstract
Purpose Blunt pancreatic trauma in pediatric patients is relatively rare, yet it is associated with high risks of morbidity and mortality This study aimed to review pediatric patients with blunt pancreatic trauma treated at a single center and provide treatment guidelines. Methods This study included patients under the age of 18 years who visited our center's pediatric emergency department and were diagnosed with pancreatic injury due to abdominal trauma via radiological examination between January 2007 and December 2022. Patients' medical records were retrospectively reviewed and analyzed. Results Among 107 patients with abdominal trauma, 14 had pancreatic injury, with a median age of 8.2 years (interquartile range, 3.1-12.3 years). Eight patients were male and six were female. The most common mechanism of injury was falls from a height and bicycle handlebars (four cases each). Six patients had associated injuries. Two patients had American Association for the Surgery of Trauma grade I or II, eight had grade III, and four had grade IV or V injuries. Eight patients underwent surgical resection, and four were discharged with only an intervention for duct injuries. Conclusions Patients with blunt pancreatic trauma at our center have been successfully treated with surgical modalities, and more recently through nonsurgical approaches involving active endoscopic and radiologic interventions.
Collapse
Affiliation(s)
- Joong Kee Youn
- Department of Pediatric Surgery, Seoul National University Hospital, Seoul, Korea
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hee-Beom Yang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dayoung Ko
- Department of Pediatric Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University Hospital, Seoul, Korea
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Tamrat G, Kejela S. Delayed distal pancreatectomy for isolated complete pancreatic disruption secondary to "trivial" blunt abdominal injury: A case report and literature review. Clin Case Rep 2022; 10:e6295. [PMID: 36093448 PMCID: PMC9446079 DOI: 10.1002/ccr3.6295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 08/08/2022] [Accepted: 08/17/2022] [Indexed: 11/12/2022] Open
Abstract
Pancreatic injury is a formidable diagnostic and therapeutic challenge owing to its relative rarity. Most injuries are from motor vehicle related injuries in blunt trauma patients. We present a 22-year-old male patient presented after sustaining a kick to the abdomen. He developed progressive abdominal pain with vomiting with delayed generalization of the pain and involuntary guarding. On initial exploratory laparotomy, suction drainage was inserted, and patient underwent delayed spleen sparing distal pancreatectomy on the 25th post-admission day. Patient had smooth postoperative course and was discharged on the 7th postoperative day.
Collapse
Affiliation(s)
- Girmaye Tamrat
- Department of SurgeryCollege of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
| | - Segni Kejela
- Department of SurgeryCollege of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
| |
Collapse
|
8
|
Minimally Invasive Approaches for Traumatic Rupture of the Pancreas in Children—A Case Series. CHILDREN 2022; 9:children9081102. [PMID: 35892605 PMCID: PMC9329767 DOI: 10.3390/children9081102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 11/18/2022]
Abstract
Pancreatic trauma in children is rare; therefore, both scientific knowledge and clinical experience regarding its management are limited. Abdominal sonography and subsequent computed tomography (CT) imaging are the diagnostic mainstay after severe abdominal trauma in many pediatric trauma centers. However, the diagnosis of pancreatic injury is missed on the initial imaging in approximately one third of cases, with even higher numbers in young children. While conservative treatment is preferred in low-grade injuries, surgical interventions may be indicated in more severe injuries. We present a case series including four patients with high-grade pancreatic injury. Two patients were treated surgically with open laparotomy and primary suture of the head of the pancreas and pancreatico-enterostomy, one patient underwent endoscopic stenting of the pancreatic duct and one received conservative management including observation and secondary endoscopic treatment. We want to emphasize the fact that using a minimally invasive approach can be a feasible option in high-grade pancreatic injury in selected cases. Therefore, we advocate the necessity of fully staffed and equipped high-level pediatric trauma centers.
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Ayoob AR, Lee JT, Herr K, LeBedis CA, Jain A, Soto JA, Lim J, Joshi G, Graves J, Hoff C, Hanna TN. Pancreatic Trauma: Imaging Review and Management Update. Radiographics 2020; 41:58-74. [PMID: 33245670 DOI: 10.1148/rg.2021200077] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Traumatic injuries of the pancreas are uncommon and often difficult to diagnose owing to subtle imaging findings, confounding multiorgan injuries, and nonspecific clinical signs. Nonetheless, early diagnosis and treatment are critical, as delays increase morbidity and mortality. Imaging has a vital role in diagnosis and management. A high index of suspicion, as well as knowledge of the anatomy, mechanism of injury, injury grade, and role of available imaging modalities, is required for prompt accurate diagnosis. CT is the initial imaging modality of choice, although the severity of injury can be underestimated and assessment of the pancreatic duct is limited with this modality. The time from injury to definitive diagnosis and the treatment of potential pancreatic duct injury are the primary factors that determine outcome following pancreatic trauma. Disruption of the main pancreatic duct (MPD) is associated with higher rates of complications, such as abscess, fistula, and pseudoaneurysm, and is the primary cause of pancreatic injury-related mortality. Although CT findings can suggest pancreatic duct disruption according to the depth of parenchymal injury, MR cholangiopancreatography and endoscopic retrograde cholangiopancreatography facilitate direct assessment of the MPD. Management of traumatic pancreatic injury depends on multiple factors, including mechanism of injury, injury grade, presence (or absence) of vascular injury, hemodynamic status of the patient, and associated organ damage. ©RSNA, 2020 See discussion on this article by Patlas.
Collapse
Affiliation(s)
- Andres R Ayoob
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - James T Lee
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Keith Herr
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Christina A LeBedis
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Ashwin Jain
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Jorge A Soto
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Jihoon Lim
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Gayatri Joshi
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Joseph Graves
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Carrie Hoff
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Tarek N Hanna
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| |
Collapse
|
11
|
Hadjizacharias T, Kaliviotis I, Kottakis G, Pavlides O, Papalouka D, Polydorou A. Distal pancreatectomy after pancreatic injury, in two pediatric patients. Int J Surg Case Rep 2020; 76:293-296. [PMID: 33065489 PMCID: PMC7567176 DOI: 10.1016/j.ijscr.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 02/07/2023] Open
Abstract
Blunt trauma to the abdomen, accounts for the majority of abdominal injuries in children. Pancreas injury from blunt abdominal trauma in children is very rare. The emergent use of ERCP in children has not been implement widely. Operative vs non-operative management of blunt pancreatic trauma in children. A key is the status of pancreatic duct.
Introduction Although serious trauma is rare in pediatric patients, the management of blunt force trauma to the abdomen remains a challenge for Child Surgery Departments. Pancreatic injury comprises the fourth most common injury among the solid organs and cases accompanied by rupture of the main pancreatic duct (MPD) present a further challenge for physicians (Fayza Haider et al.; Wood et al., 2010; Jobst et al., 1999; Grosfeld et al., 2006). Case presentation Two adolescents, both 13 years old, where referred to our Pediatric Hospital, due to blunt force abdominal trauma. During admission, both patients were hemodynamically stable, in good general condition but suffering from abdominal pain and vomiting. After a full diagnostic check-up, grade IV pancreatic injury was diagnosed in both patients and they were taken to the operation room 3 and 6 days post-injury. Intra-operatively a distal pancreatectomy along with splenectomy was performed in both cases, with catheterization and ligation of the main pancreatic duct. Both patients were admitted to the pediatric ICU for 2 and 4 days. Both made an uneventful recovery and remain well 6 months postoperatively. Conclusion While hemodynamically stable, patients with Grade IV pancreatic injury, benefit from sub-acute management, allowing for planning of the surgical intervention. Distal pancreatectomy with splenectomy, along with catheterization and ligation of the main pancreatic duct, has excellent post-operative results. The chief of the Pediatric Hospital, said that in 35 years at pediatric surgery, is the first time with the need of operative management, in pancreatic injury. The hepatobiliary surgical expert in adults, who was consulted in both cases, said that without the surgeries, both children were going to die.
Collapse
Affiliation(s)
- Theodoros Hadjizacharias
- 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Greece.
| | - Ioannis Kaliviotis
- 1st Department of Pediatric Surgery, Panagioti kai Aglaia Kyriakou Pediatric Hospital, Athens, Greece.
| | - George Kottakis
- 1st Department of Pediatric Surgery, Panagioti kai Aglaia Kyriakou Pediatric Hospital, Athens, Greece.
| | - Orestis Pavlides
- 1st Department of Pediatric Surgery, Panagioti kai Aglaia Kyriakou Pediatric Hospital, Athens, Greece.
| | - Dimitra Papalouka
- 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Greece.
| | - Andreas Polydorou
- 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Greece.
| |
Collapse
|
12
|
Hosseininejad SM, Bozorgi F, Assadi T, Montazar SH, Jahanian F, Hoseini V, Shamsaee M, Tabarestani M. The predictive role of amylase and lipase levels on pancreas injury diagnosis in patients with blunt abdominal trauma. Horm Mol Biol Clin Investig 2020; 41:hmbci-2019-0066. [PMID: 32374282 DOI: 10.1515/hmbci-2019-0066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 04/04/2020] [Indexed: 12/26/2022]
Abstract
Objectives Despite the low incidence of pancreatic injury in the abdominal blunt trauma (BTA), its early diagnosis is very important; since pancreatic injury is associated with high rates of morbidity and mortality. However, due to the high association of pancreatic injury with injury of other abdominal organs, its diagnosis may be delayed and complicated. The use of imaging modalities is also subject to limitations for reasons such as cost, unavailability, and harmfulness. Consequently, the present study aimed to investigate the predictive role of amylase and lipase enzyme levels in the final diagnosis of pancreatic injury in patients with BTA. Methods In a prospective diagnostic study, 384 patients with BTA referring to Imam Khomeini hospital of Sari (north of Iran) were enrolled according to the inclusion and exclusion criteria. Initial patient data including age and sex were recorded. Blood samples were analyzed in the laboratory to measure complete blood count (CBC), amylase and lipase enzyme levels. Patients were followed up during hospitalization and focal ultrasound for abdominal trauma (FAST), CT-Scan and laparotomy results were recorded. Finally, the data was analyzed using SPSS version 22. Results The level of amylase enzyme was significantly higher in males (p = 0.04), but the level of lipase enzyme was not significantly different between two genders (p > 0.05). The most common symptoms and signs in patients were pain, tenderness, and hematoma, respectively. The frequency of pancreatic injury in all patients with blunt abdominal trauma was 7.5% based of FAST, 7% based on CT-Scan and 12.4% based on laparotomy. Comparison of laboratory findings based on FAST, CT-Scan and laparotomy results showed that the level of amylase and lipase enzymes in patients with internal organ and pancreatic damage were higher than in patients without internal organ injury (p < 0.05). But based on FAST results; patients with pancreatic injury and injury of other organs had no significant difference (p > 0.05). However, comparison of laboratory findings based on CT-Scan and laparotomy results showed a significant increase in the level of amylase and lipase enzymes in patients with pancreatic trauma compared to patients with injury of other organs (p < 0.001). Conclusions The results of this study showed that pancreatic injury in blunt trauma is associated with a significant increase in levels of amylase and lipase enzymes. In addition, an increase in levels of amylase and lipase enzymes is associated with internal organ damage. Serum amylase and lipase levels can be used as useful biomarkers to decide whether to perform CT-Scan or laparotomy.
Collapse
Affiliation(s)
- Seyed Mohammad Hosseininejad
- Department of Emergency Medicine, Diabetes Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Farzad Bozorgi
- Department of Emergency Medicine, Gut And Liver Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Touraj Assadi
- Department of Emergency Medicine, Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Seyyed Hosein Montazar
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Fatemeh Jahanian
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Vahid Hoseini
- Department of Emergency Medicine, Gut And Liver Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Mahboobeh Shamsaee
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Mohammad Tabarestani
- Student Research Committee, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| |
Collapse
|
13
|
Odedra D, Mellnick VM, Patlas MN. Imaging of Blunt Pancreatic Trauma: A Systematic Review. Can Assoc Radiol J 2020; 71:344-351. [PMID: 32063010 DOI: 10.1177/0846537119888383] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Devang Odedra
- Department of Radiology, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Vincent M Mellnick
- Abdominal Imaging Division, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Michael N Patlas
- Division of Emergency/Trauma Radiology, Department of Radiology, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
| |
Collapse
|
14
|
|
15
|
Ravindranath A, Srivastava A, Yachha SK, Poddar U, Sarma MS, Saraswat VA, Mohindra S, Yadav RR, Kumar S. Childhood pancreatic trauma: Clinical presentation, natural history and outcome. Pancreatology 2020; 20:68-73. [PMID: 31706820 DOI: 10.1016/j.pan.2019.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/06/2019] [Accepted: 10/27/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To study the presentation, management strategies and long-term natural history of children with pancreatic trauma. METHODS Children admitted with pancreatic trauma were analyzed for their presentation, management and outcome. Management included nasojejunal feeds, total parenteral nutrition (TPN), octreotide, drainage (radiological and endoscopic), endoscopic retrograde cholangiopancreatography (ERCP) and surgery. Patients were assessed in follow-up for development of chronic pancreatitis (CP). RESULTS 36 children [29 boys, age 144 (13-194) months] presented at 30 (3-210) days after trauma. Most common cause of trauma was bicycle handle bar injury [n = 18,50%]. Presenting features were abdominal pain [n = 26,72%], lump [n = 16, 44.4%], ascites [n = 13,36%], pleural effusion [n = 9,25%] and anasarca [n = 3,8.3%]. All presented with sequelae of ductal disruption with pseudocyst, ascites or pleural effusion. Fifteen (41.6%) patients each had Grade III and IV injury, 4 (11%) had grade V, and grading was unavailable in 2. Other organs were injured in 4 (11%) cases. Management consisted of various combinations of nasojejunal feeds [n = 17,47.2%], TPN [n = 5,13.8%], octreotide [n = 13,36%], pseudocyst drainage [radiological (n = 18,50%), endoscopic (n = 3,8.3%)] and ERCP [n = 12,33.3%]. Surgical intervention was done in 2 (5.5%) cases [cystojejunostomy and peritoneal lavage in 1 each]. Two (5.5%) patients died due to sepsis. Of the 32 cases in follow-up, 19 (59.3%) recovered and 13 (40.6%) developed CP, with half (6/13) of them being symptomatic with recurrent pain. CONCLUSION Multi-disciplinary non-operative management is effective for managing pancreatic trauma in 94.4% of children, with 75% requiring radiological or endoscopic intervention. 40% developed structural changes later but only half were symptomatic.
Collapse
Affiliation(s)
- Aathira Ravindranath
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vivek A Saraswat
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Samir Mohindra
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajanikant R Yadav
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sheo Kumar
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
16
|
Sue T, Matcovici M, Paran S. A non-operative strategy for grade IV blunt pancreatic trauma. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2019.101287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
|
17
|
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.
Collapse
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.
| |
Collapse
|
18
|
Garside G, Khan O, Mukhtar Z, Sinha C. Paediatric duodenal injury complicated by common bile duct rupture due to blunt trauma: a multispecialist approach. BMJ Case Rep 2018; 2018:bcr-2018-225221. [PMID: 30158263 DOI: 10.1136/bcr-2018-225221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of late presenting duodenal perforation with common bile duct rupture secondary to blunt handlebar trauma in an 11-year-old boy. The patient presented with upper abdominal wall ecchymosis, pain and vomiting. He was discharged after 24 hours with resolving symptoms. However, the boy presented 2 days later febrile with signs of peritonitis. CT indicated duodenal perforation, which was confirmed during laparotomy where common bile duct rupture was also demonstrated. Primary repair of the duodenum was undertaken. Here, decompression was achieved with a nasogastric tube proximal to the injury and T-tube duodenostomy distally. Common bile duct repair was achieved over a biliary stent. This case represents a rare subset of duodenal injury for which there is a paucity of evidence for optimal surgical management, particularly in the paediatric setting. This operative plan will guide surgeons and junior doctors in managing complicated cases like this in future.
Collapse
Affiliation(s)
| | - Omar Khan
- Department of Upper GI and Bariatric Surgery, St George's Hospital, London, UK
| | - Zahid Mukhtar
- Department of Paediatric Surgery, St George's Hospital, London, UK
| | - Chandrasen Sinha
- Department of Paediatric Surgery, St George's Hospital, London, UK
| |
Collapse
|
19
|
Malik A, Faerber EN. Pediatric abdominal and pelvic imaging in non-accidental trauma. APPLIED RADIOLOGY 2018. [DOI: 10.37549/ar2473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
|
20
|
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
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Haider F, Al Awadhi MA, Abrar E, Al Dossari M, Isa H, Nasser H, Al Hashimi H, Al Arayedh S. Pancreatic injury in children: a case report and review of the literature. J Med Case Rep 2017; 11:217. [PMID: 28886723 PMCID: PMC5591494 DOI: 10.1186/s13256-017-1383-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 07/07/2017] [Indexed: 12/26/2022] Open
Abstract
Background Trauma is the main cause of morbidity and mortality in the pediatric population. Blunt trauma to the abdomen accounts for the majority of abdominal injuries in children. Pancreatic injury, although uncommon (2 to 9%), is the fourth most common solid organ injury. Unlike other solid organ injuries, pancreatic trauma may be subtle and difficult to diagnose. Computed tomography currently is the imaging modality of choice. As the incidence of pancreatic injury in children sustaining blunt abdominal trauma is low, management remains a challenge. Case presentation We present a 7-year-old Bahraini boy who sustained blunt trauma to his abdomen. He presented with abdominal pain and vomiting. His examination revealed abdominal distension and an epigastric bruise. Contrast-enhanced computed tomography reported grade III liver injury, grade I bilateral renal injury, a suspicion of splenic injury, and a grade III to IV pancreatic injury. He was admitted to Pediatric Intensive Care Unit and was treated conservatively. Because he was stable, he was discharged to the surgical ward at day 3. At day 18 he developed a pancreatic pseudocyst that was aspirated and recurred at day 25 when a pigtail catheter was inserted. He was kept on total parenteral nutrition through a peripherally inserted central catheter. The pigtail catheter was removed on day 36 and a low fat diet was started by day 44. He was discharged home at day 55 in good health. Out-patient follow-up and serial abdominal ultrasound showed resolution of the cyst and normalization of blood tests. Conclusion Non-operative management of pancreatic injury is effective and safe in hemodynamically stable patients with no other indication for surgery.
Collapse
Affiliation(s)
- Fayza Haider
- Pediatric Surgery Unit-Department of Surgery, Salmaniya Medical Complex, P.O. Box 12, Manama, Kingdom of Bahrain.
| | - Mohammed Amin Al Awadhi
- Pediatric Surgery Unit-Department of Surgery, Salmaniya Medical Complex, P.O. Box 12, Manama, Kingdom of Bahrain
| | - Eizat Abrar
- Pediatric Surgery Unit-Department of Surgery, Salmaniya Medical Complex, P.O. Box 12, Manama, Kingdom of Bahrain
| | - Mooza Al Dossari
- Pediatric Surgery Unit-Department of Surgery, Salmaniya Medical Complex, P.O. Box 12, Manama, Kingdom of Bahrain
| | - Hasan Isa
- Department of Pediatrics, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Husain Nasser
- Department of Radiology, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Hakima Al Hashimi
- Department of Radiology, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Sharif Al Arayedh
- Department of Radiology, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| |
Collapse
|
23
|
Addison P, Iurcotta T, Amodu LI, Crandall G, Akerman M, Galvin D, Glazer A, Christopherson N, Prince J, Bank M, Sorrentino C, Cagliani J, Nicastro J, Coppa G, Molmenti EP, Rilo HLR. Outcomes following operative vs. non-operative management of blunt traumatic pancreatic injuries: a retrospective multi-institutional study. BURNS & TRAUMA 2016; 4:39. [PMID: 27981056 PMCID: PMC5148879 DOI: 10.1186/s41038-016-0065-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 11/26/2016] [Indexed: 01/28/2023]
Abstract
Background Traumatic pancreatic injuries are rare, and guidelines specifying management are controversial and difficult to apply in the acute clinical setting. Due to sparse data on these injuries, we carried out a retrospective review to determine outcomes following surgical or non-surgical management of traumatic pancreatic injuries. We hypothesize a higher morbidity and mortality rate in patients treated surgically when compared to patients treated non-surgically. Methods We performed a retrospective review of data from four trauma centers in New York from 1990–2014, comparing patients who had blunt traumatic pancreatic injuries who were managed operatively to those managed non-operatively. We compared continuous variables using the Mann-Whitney U test and categorical variables using the chi-square and Fisher’s exact tests. Univariate analysis was performed to determine the possible confounding factors associated with mortality in both treatment groups. Results Twenty nine patients were managed operatively and 32 non-operatively. There was a significant difference between the operative and non-operative groups in median age (37.0 vs. 16.2 years, P = 0.016), grade of pancreatic injury (grade I; 30.8 vs. 85.2%, P value for all comparisons <0.0001), median injury severity score (ISS) (16.0 vs. 4.0, P = 0.002), blood transfusion (55.2 vs. 15.6%, P = 0.0012), other abdominal injuries (79.3 vs. 38.7%, P = 0.0014), pelvic fractures (17.2 vs. 0.00%, P = 0.020), intensive care unit (ICU) admission (86.2 vs. 50.0%, P = 0.003), median length of stay (LOS) (16.0 vs. 4.0 days, P <0.0001), and mortality (27.6 vs. 3.1%, P = 0.010). Conclusions Patients with traumatic pancreatic injuries treated operatively were more severely injured and suffered greater complications than those treated non-operatively. The greater morbidity and mortality associated with these patients warrants further study to determine optimal triage strategies and which subset of patients is likely to benefit from surgery.
Collapse
Affiliation(s)
- Poppy Addison
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA.,Pancreas Disease Center, Northwell Health, Manhasset, NY USA
| | - Toni Iurcotta
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA.,Pancreas Disease Center, Northwell Health, Manhasset, NY USA
| | - Leo I Amodu
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA.,Pancreas Disease Center, Northwell Health, Manhasset, NY USA
| | - Geoffrey Crandall
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA
| | - Meredith Akerman
- Department of Biostatistics, Feinstein Institute for Medical Research, Manhasset, NY USA
| | - Daniel Galvin
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA
| | - Annemarie Glazer
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA
| | | | - Jose Prince
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA
| | - Matthew Bank
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA
| | | | | | - Jeffrey Nicastro
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA.,Pancreas Disease Center, Northwell Health, Manhasset, NY USA
| | - Gene Coppa
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA.,Pancreas Disease Center, Northwell Health, Manhasset, NY USA
| | - Ernesto P Molmenti
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA.,Pancreas Disease Center, Northwell Health, Manhasset, NY USA
| | - Horacio L Rodriguez Rilo
- Department of Surgery, Hofstra-Northwell School of Medicine, Hempstead, NY USA.,Pancreas Disease Center, Northwell Health, Manhasset, NY USA.,Northwell Health, 900 Northern Boulevard, Suite 150, Great Neck, NY 11020 USA
| |
Collapse
|
24
|
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: 40] [Impact Index Per Article: 5.0] [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.
Collapse
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
| |
Collapse
|
25
|
Keil R, Drabek J, Lochmannova J, Stovicek J, Rygl M, Snajdauf J, Hlava S. What is the role of endoscopic retrograde cholangiopancreatography in assessing traumatic rupture of the pancreatic in children? Scand J Gastroenterol 2016. [PMID: 26200695 DOI: 10.3109/00365521.2015.1070899] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND STUDY AIMS Trauma is one of the most common causes of morbidity and mortality in the pediatric population. The diagnosis of pancreatic injury is based on clinical presentation, laboratory and imaging findings, and endoscopic methods. CT scanning is considered the gold standard for diagnosing pancreatic trauma in children. PATIENTS AND METHODS This retrospective study evaluates data from 25 pediatric patients admitted to the University Hospital Motol, Prague, with blunt pancreatic trauma between January 1999 and June 2013. RESULTS The exact grade of injury was determined by CT scans in 11 patients (47.8%). All 25 children underwent endoscopic retrograde cholangiopancreatography (ERCP). Distal pancreatic duct injury (grade III) was found in 13 patients (52%). Proximal pancreatic duct injury (grade IV) was found in four patients (16 %). Major contusion without duct injury (grade IIB) was found in six patients (24%). One patient experienced duodeno-gastric abruption not diagnosed on the CT scan. The diagnosis was made endoscopically during ERCP. Grade IIB pancreatic injury was found in this patient. One patient (4%) with pancreatic pseudocyst had a major contusion of pancreas without duct injury (grade IIA). Four patients (16%) with grade IIB, III and IV pancreatic injury were treated exclusively and nonoperatively with a pancreatic stent insertion and somatostatine. Two patients (8%) with a grade IIB injury were treated conservatively only with somatostatine without drainage. Eighteen (72 %) children underwent surgical intervention within 24 h after ERCP. CONCLUSION ERCP is helpful when there is suspicion of pancreatic duct injury in order to exclude ductal leakage and the possibility of therapeutic intervention. ERCP can speed up diagnosis of higher grade of pancreatic injuries.
Collapse
Affiliation(s)
- Radan Keil
- a 1 Departement of Internal Medicine, Motol University Hospital , Prague, Czech Republic
| | - Jiri Drabek
- a 1 Departement of Internal Medicine, Motol University Hospital , Prague, Czech Republic
| | - Jindra Lochmannova
- a 1 Departement of Internal Medicine, Motol University Hospital , Prague, Czech Republic
| | - Jan Stovicek
- a 1 Departement of Internal Medicine, Motol University Hospital , Prague, Czech Republic
| | - Michal Rygl
- b 2 Departement of Pediatric Surgery, Motol University Hospital , Prague, Czech Republic
| | - Jiri Snajdauf
- b 2 Departement of Pediatric Surgery, Motol University Hospital , Prague, Czech Republic
| | - Stepan Hlava
- a 1 Departement of Internal Medicine, Motol University Hospital , Prague, Czech Republic
| |
Collapse
|
26
|
|
27
|
Fuchs JR. Blunt Pediatric Pancreatic Trauma: An Update. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-016-0139-0] [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]
|
28
|
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]
|
29
|
Nejabatian A, Rahmani F, Rajaei Ghafori R, Shams Vahdati S, Varghayi P, Ebrahimi Bakhtavar H. Predictive value of serum amylase level in outcome of multiple trauma patients. JOURNAL OF ANALYTICAL RESEARCH IN CLINICAL MEDICINE 2016. [DOI: 10.15171/jarcm.2016.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
|
30
|
Kamath SU, Dharap SB. Non Operative Approach to Isolated Traumatic Pancreatic Duct Disruption. J Clin Diagn Res 2016; 10:PD08-10. [PMID: 27134933 DOI: 10.7860/jcdr/2016/16605.7451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/11/2015] [Indexed: 11/24/2022]
Abstract
Management of isolated traumatic pancreatic duct disruption remains challenging due to associated morbidity and mortality. Two children with isolated pancreatic ductal disruption were treated conservatively. Both developed a pseudocyst which resolved spontaneously due to the atrophy of the distal pancreas in a five-year-old girl while remained persistent and was treated by endoscopic cystogastrostomy in an eight-year-old boy. Non-operative management may be pursued in patients with pancreatic ductal injury in the hope of a pseudocyst formation which may spontaneously resolve or may be treated later with a minimally invasive procedure. However, the literature review precludes its practice as a standard due to high incidence of associated complications of non-operative management.
Collapse
Affiliation(s)
- Sheshang U Kamath
- Post Graduate Student, Lokmanya Tilak Municipal Medical College and General Hospital , Mumbai, Maharashtra India
| | - Satish B Dharap
- Professor, Department of General Surgery, Lokmanya Tilak Municipal Medical College and General Hospital , Mumbai, Maharashtra India
| |
Collapse
|
31
|
Girard E, Abba J, Arvieux C, Trilling B, Sage PY, Mougin N, Perou S, Lavagne P, Létoublon C. Management of pancreatic trauma. J Visc Surg 2016; 153:259-68. [PMID: 26995532 DOI: 10.1016/j.jviscsurg.2016.02.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Pancreatic trauma (PT) is associated with high morbidity and mortality; the therapeutic options remain debated. MATERIAL AND METHODS Retrospective study of PT treated in the University Hospital of Grenoble over a 22-year span. The decision for initial laparotomy depended on hemodynamic status as well as on associated lesions. Main pancreatic duct lesions were always searched for. PT lesions were graded according to the AAST classification. RESULTS Of a total of 46 PT, 34 were grades II or I. Hemodynamic instability led to immediate laparotomy in 18 patients, for whom treatment was always drainage of the pancreatic bed; morbidity was 30%. Eight patients had grade III injuries, six of whom underwent immediate operation: three underwent splenopancreatectomy without any major complications while the other three who had simple drainage required re-operation for peritonitis, with one death related to pancreatic complications. Four patients had grades IV or V PT: two pancreatoduodenectomies were performed, with no major complication, while one patient underwent duodenal reconstruction with pancreatic drainage, complicated by pancreatic and duodenal fistula requiring a hospital stay of two months. The post-trauma course was complicated for all patients with main pancreatic duct involvement. Our outcomes were similar to those found in the literature. CONCLUSION In patients with distal PT and main pancreatic duct involvement, simple drainage is associated with high morbidity and mortality. For proximal PT, the therapeutic options of drainage versus pancreatoduodenectomy must be weighed; pancreatoduodenectomy may be unavoidable when the duodenum is injured as well. Two-stage (resection first, reconstruction later) could be an effective alternative in the emergency setting when there are other associated traumatic lesions.
Collapse
Affiliation(s)
- E Girard
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - J Abba
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - C Arvieux
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - B Trilling
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - P Y Sage
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - N Mougin
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - S Perou
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - P Lavagne
- Réanimation post-chirurgicale, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France
| | - C Létoublon
- Service de chirurgie digestive et de l'urgence, hôpital Michallon, CHU, boulevard de la Chantourne, 38700 La Tronche, France.
| |
Collapse
|
32
|
Chandrasekaran A. Pancreatico duodenectomy for pediatric combined duodenal, pancreatic and biliary trauma. TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408615580203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pancreaticoduodenal trauma in children is uncommon but carries high morbidity and mortality rates, especially when the diagnosis is delayed. A case of combined pancreatico duodenal and bile duct injury following blunt abdominal trauma is described which presented two days after injury. It highlights the extremes of surgical procedures that may be needed in massive blunt trauma.
Collapse
|
33
|
Abstract
Trauma is the leading cause of death in children of all ages. The most common site of injury in pediatric patients is the head followed by the extremities and the abdomen. Though less than 10% of admissions to the hospital are secondary to intra-abdominal injuries, mortality related to these injuries is not insignificant. Pancreatic and duodenal trauma occurs in 3 to 12% of the patients with abdominal injuries and can be associated with significant morbidity. The management of pancreatic and duodenal trauma in children is based mostly on adult data, but there is an increasing volume of research on the subject.
Collapse
Affiliation(s)
- Aaron Lesher
- Division of Pediatric Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Regan Williams
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| |
Collapse
|
34
|
Garvey EM, Haakinson DJ, McOmber M, Notrica DM. Role of ERCP in pediatric blunt abdominal trauma: a case series at a level one pediatric trauma center. J Pediatr Surg 2015; 50:335-8. [PMID: 25638632 DOI: 10.1016/j.jpedsurg.2014.08.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/22/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is no consensus regarding the appropriate use of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric trauma. We report our experience with ERCP for management of pediatric pancreatic and biliary injury following blunt abdominal trauma. METHODS A retrospective chart review was performed for pediatric patients with blunt abdominal trauma from July 2008 through December 2012 at our pediatric trauma center. For patients who underwent ERCP, demographics, injury characteristics, diagnostic details, procedures performed, length of stay, total parenteral nutrition use, and complications were reviewed. RESULTS There were 532 patients identified: 115 hepatic injuries, 25 pancreatic injuries and one gall bladder injury. Nine patients (mean age 7.8 years) underwent ERCP. Seven (78%) had pancreatic injuries, while two (22%) had bilateral hepatic duct injuries. The median time to diagnosis was one day (range, 0-12). Diagnostic ERCP only was performed in three patients, two of which proceeded to distal pancreatectomy. Five patients had stents placed (two biliary and three pancreatic) and four sphincterotomies were performed. Despite pancreatic stenting, one patient required distal pancreatectomy for persistent leak. Median length of stay was 11 days. CONCLUSIONS Pediatric pancreatic and biliary ductal injuries following blunt abdominal trauma are uncommon. ERCP can safely provide definitive treatment for some patients.
Collapse
Affiliation(s)
- Erin M Garvey
- Division of General Surgery, The Mayo Clinic, 5777 E Mayo Blvd. Phoenix, AZ 85255 USA
| | - Danielle J Haakinson
- Division of General Surgery, The Mayo Clinic, 5777 E Mayo Blvd. Phoenix, AZ 85255 USA
| | - Mark McOmber
- Pediatric Gastroenterology, Phoenix Children's Hospital, 1920 E Cambridge Ave. Phoenix, AZ 85006 USA
| | - David M Notrica
- Division of General Surgery, The Mayo Clinic, 5777 E Mayo Blvd. Phoenix, AZ 85255 USA; Pediatric Surgery, Phoenix Children's Hospital, 1920 E Cambridge Ave. Phoenix, AZ 85006 USA.
| |
Collapse
|
35
|
Dahiya D, Singh Rana S, Kaman L, Behera A. Conservative surgery for pancreatic neck transection. POLISH JOURNAL OF SURGERY 2015; 87:315-9. [DOI: 10.1515/pjs-2015-0061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Indexed: 11/15/2022]
Abstract
AbstractPancreas is the fourth solid organ injured in blunt abdominal trauma. Isolated pancreatic injury is present in less than 1% of patients. As it is associated with high morbidity and mortality, management is controversial.Isolated pancreatic trauma cases with pancreatic neck transection following blunt abdominal trauma were analyzed. All these patients were treated with immediate surgery involving lesser sac drainage and feeding jejunostomy only.Authors conclude that lesser sac drainage can be used as an alternative to distal pancreatectomy or pancreaticojejunostomy or pancreaticogastrostomy.
Collapse
|
36
|
Kawahara I, Maeda K, Ono S, Kawashima H, Deie R, Yanagisawa S, Baba K, Usui Y, Tsuji Y, Fukuta A, Sekine S. Surgical reconstruction and endoscopic pancreatic stent for traumatic pancreatic duct disruption. Pediatr Surg Int 2014; 30:951-6. [PMID: 25070690 DOI: 10.1007/s00383-014-3570-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2014] [Indexed: 12/26/2022]
Abstract
Nonoperative management is acceptable treatment for minor pancreatic injuries. However, management of major pancreatic duct injury in children remains controversial. We present our experience in treating isolated pancreatic duct injury. We describe the cases of three male patients treated for complete pancreatic duct disruption in the past 5 years at our institution. We performed pancreatic duct repair to avoid distal pancreatectomy and to maintain normal pancreatic function. All patients underwent enhanced computed tomography and endoscopic retrograde cholangiopancreatography in the early period. The injuries were classified as grade III according to the American Association for the Surgery of Trauma classification. In two cases, we performed end-to-end anastomosis of the pancreatic duct during the delayed period. In the third case, we placed a stent across the disruption to the distal pancreatic duct. The patients' postoperative courses were uneventful, and the average hospitalization was 25.6 days after the procedure. At a median follow-up of 36 months (range 14-54 months), all patients remain asymptomatic, with normal pancreatic function, but with persistent distal pancreatic duct dilatation. We suggest that distal pancreatectomy should not be routinely performed in patients with isolated pancreatic duct injury.
Collapse
Affiliation(s)
- Insu Kawahara
- Division of Pediatric Surgery, Department of Surgery, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review. Injury 2014; 45:1384-93. [PMID: 24702828 DOI: 10.1016/j.injury.2014.02.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 01/28/2014] [Accepted: 02/06/2014] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Reliability of serum pancreatic enzyme levels in predicting pancreatic injuries has been a parameter of interest and the present recommendations on its utility are based primarily on anecdotal observations. The aim of this study was to evaluate the utility of serum pancreatic enzyme assessment in predicting blunt pancreatic injury with imaging and surgical correlation and compare our results with a systematic review of literature till date. METHODS A prospective cohort study conducted over 4 years in a tertiary care referral centre with 164 consecutive patients who presented to the emergency department with a history of blunt abdominal trauma and had serum pancreatic enzyme assessment, USG and subsequent diagnostic CECT were analyzed. The CT findings and AAST grade of pancreatic injury, various intra-abdominal injuries and time elapsed since injury and other associated factors were correlated with serum pancreatic enzyme levels. For systematic review of literature MEDLINE database was searched between 1940 and 2012, also the related citations and bibliographies of relevant articles were analyzed and 40 articles were included for review. We compared our results with the systematic critique of literature till date to formulate recommendations. RESULTS 33(21%) patients had pancreatic injury documented on CT and were graded according to AAST. Statistically significant elevated serum amylase levels were observed in patients with pancreatic and bowel injuries. However, elevated serum lipase was observed specifically in patients with pancreatic injury with or without bowel injury. Combined serum amylase and lipase showed 100% specificity, 85% sensitivity in predicting pancreatic injury. Elevated (n=28, 85%) vs. normal (n=5, 15%) serum amylase and lipase levels showed sole statistically significant association with time elapse since injury to admission, with a cutoff of 3h. CONCLUSIONS Based on our results and the systematic review of the literature till date we conclude, persistently elevated or rising combined estimation of serum amylase and lipase levels are reliable indicators of pancreatic injury and is time dependent, nondiagnostic within 6h or less after trauma. In resource constrained countries where CT is not available everywhere it may support a clinical suspicion of pancreatic injury and can be reliable and cost-effective as a screening tool.
Collapse
|
38
|
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.
Collapse
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
| | | |
Collapse
|
39
|
Abstract
Blunt trauma to the abdomen accounts for the majority of abdominal injuries in children. Pancreatic injury is the fourth most common solid organ injury, following injuries to the spleen, liver and kidneys. The most common complications are the formation of pancreatic fistulae, pancreatitis and the development of pancreatic pseudocysts, which usually present several weeks after injury. The nonoperative management of minor pancreatic injury is well accepted; however, the treatment of more serious pancreatic injuries with capsular, ductal or parenchymal disruption in pediatric patients remains controversial. Based on the data presented in this literature review, although children with pancreatic injuries (without ductal disruption) do not appear to suffer increased morbidity following conservative management, patients with ductal disruption may benefit from operative intervention.
Collapse
Affiliation(s)
- Kosaku Maeda
- Division of Pediatric Surgery, Department of Surgery, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan,
| | | | | | | |
Collapse
|
40
|
Kerrey BT, Rogers AJ, Lee LK, Adelgais K, Tunik M, Blumberg SM, Quayle KS, Sokolove PE, Wisner DH, Miskin ML, Kuppermann N, Holmes JF. A Multicenter Study of the Risk of Intra-Abdominal Injury in Children After Normal Abdominal Computed Tomography Scan Results in the Emergency Department. Ann Emerg Med 2013; 62:319-26. [PMID: 23622949 DOI: 10.1016/j.annemergmed.2013.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 04/01/2013] [Accepted: 04/08/2013] [Indexed: 12/26/2022]
|
41
|
Abu-Zidan FM, Hefny AF, Mousa H, Torab FC, Hassan I. Camel-related pancreatico-duodenal injuries: a report of three cases and review of literature. Afr Health Sci 2013; 13:762-7. [PMID: 24250319 DOI: 10.4314/ahs.v13i3.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Human pancreatico-duodenal injuries caused by camels are extremely rare. OBJECTIVE We report three patients who sustained camel-related pancreatico-duodenal injuries and review the literature on this topic. RESULTS A 32-year camel caregiver was kicked by a camel which then stepped on his abdomen trying to kill him. The patient's abdomen was soft and lax. CT scan of the abdomen showed free retroperitoneal air. Laparotomy revealed a complete tear of the anterior wall of the second part of duodenum which was primarily repaired. A 40-year camel caregiver was directly kicked into his abdomen by a camel. He developed traumatic pancreatitis which was treated conservatively. A 31-year-old male fell down on his abdomen while riding a camel. Abdominal examination revealed tenderness and guarding. Abdominal CT Scan showed complete transection of the neck of the pancreas which was confirmed by laparotomy. The patient had distal pancreatectomy with preservation of the spleen. All patients were discharged home in good condition. CONCLUSION These cases demonstrate the misleading presentation of the camel-related pancreatico-duodenal injuries and their unique mechanism of injury.
Collapse
Affiliation(s)
- F M Abu-Zidan
- Trauma Group, Faculty of Medicine and Health Sciences, UAE University, UAE ; Department of Surgery, Al-Ain Hospital, Al-Ain, UAE
| | | | | | | | | |
Collapse
|
42
|
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.
Collapse
Affiliation(s)
- Alana L Beres
- The Hospital for Sick Children, Division of General and Thoracic Surgery, University of Toronto, Toronto ON, Canada
| | | | | | | | | | | |
Collapse
|
43
|
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.
Collapse
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
| |
Collapse
|
44
|
Holowaychuk MK, Monteith G. Ionized hypocalcemia as a prognostic indicator in dogs following trauma. J Vet Emerg Crit Care (San Antonio) 2011; 21:521-30. [DOI: 10.1111/j.1476-4431.2011.00675.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
45
|
Ankouz A, Elbouhadouti H, Lamrani J, Taleb KA, Louchi A. Pancreatic transection due to blunt trauma. J Emerg Trauma Shock 2011; 3:76-8. [PMID: 20165727 PMCID: PMC2823149 DOI: 10.4103/0974-2700.58657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 12/04/2009] [Indexed: 12/26/2022] Open
Abstract
Blunt fractures of the pancreas are rare and serious lesions. An isolated injury to the pancreas is uncommon. Physical signs and laboratory parameters are often inaccurate, and missing the diagnosis can cause serious clinical problems. We report a case of a 28-year-old woman with blunt pancreatic trauma in whom computed tomography revealed a fracture through the tail of the pancreas. It was complicated by pseudocyst formation. She was treated surgically with good outcome. This case is a reminder that pancreatic injuries should be considered in the differential diagnosis in cases of blunt abdominal trauma. Also, the clinician should be aware that when pancreatic injuries are managed conservatively, the clinical, radiological, and laboratory parameters need to be monitored till resolution.
Collapse
Affiliation(s)
- Amal Ankouz
- Department of General Surgery, UH Hassan II of Fez, Morocco
| | | | | | | | | |
Collapse
|
46
|
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.
Collapse
Affiliation(s)
- Michael D Paul
- Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | | |
Collapse
|
47
|
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.
Collapse
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
| |
Collapse
|
48
|
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.
Collapse
Affiliation(s)
- Murat Kemal Cigdem
- Department of Pediatric Surgery, Dicle University Medical School, 21280, Diyarbakir, Turkey
| | | | | | | | | | | |
Collapse
|
49
|
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: 25] [Impact Index Per Article: 1.9] [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.
Collapse
Affiliation(s)
- Richard Herman
- University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | | | | | | | | |
Collapse
|
50
|
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.
Collapse
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
| | | | | |
Collapse
|