Traumatic pancreatitis: long-term review of initial non-operative management in children

Paediatric pancreatic trauma in North Queensland: a 10-year retrospective review

PURPOSE

To establish the incidence of pancreatic trauma in North Queensland to the region's only tertiary paediatric referral centre, and to determine the patient's outcomes based on their management.

METHODS

A single centre, retrospective cohort study of patients < 18 years with pancreatic trauma from 2009 to 2020 was performed. There were no exclusion criteria.

RESULTS

Between 2009 and 2020 there were 145 intra-abdominal trauma cases, 37% from motor vehicle accidents (MVA), 18.6% motorbike or quadbike, and 12.4% bicycle or scooter accidents. There were 19 cases of pancreatic trauma (13%), all from blunt trauma and with associated injuries. There were 5 AAST grade I, 3 grade II, 3 grade III, 3 grade IV injuries, and 4 with traumatic pancreatitis. Twelve patients were managed conservatively, 2 were managed operatively for another reason, and 5 were managed operatively for the pancreatic injury. Only 1 patient with a high grade AAST injury was successfully managed non-operatively. Complications included pancreatic pseudocyst (n = 4/19; 3 post-op), pancreatitis (n = 2/19; 1 post op), and post-operative pancreatic fistula (POPF) (n = 1/19).

CONCLUSION

Due to North Queensland's geography, diagnosis and management of traumatic pancreatic injury is often delayed. Pancreatic injuries requiring surgery are at high risk for complications, prolonged length of stay, and further interventions.

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

AIM

Blunt abdominal trauma is the major cause of abdominal injury in children. No clear guidelines exist for the initial management of blunt pancreatic trauma in children. The aim of this study was to perform a systematic review and meta-analysis of initially non-operative versus initially operative treatment in children with blunt pancreatic injury.

METHODS

Studies including children (<18 years) with blunt pancreatic injuries published in any language after year 1990 were included. Total of 849 studies were identified by searching PubMed, Scopus, CINAHL and Cochrane Database. After review, 42 studies met inclusion criteria and were included in this systematic review. There were 1754 patients, of whom 1095 were initially managed non-operatively (NOM), and 659 operatively (OM). Primary outcome was non-operative management success rate, and secondary outcomes were mortality, complications (including specifically pseudocysts and pancreatic fistulas), percent of patients and days on total parenteral nutrition (TPN), length of hospital stay and readmissions.

RESULTS

There was no difference in mortality between NOM and OM groups. The incidence of pseudocysts was significantly higher in NOM group compared to OM (P<0.001), especially for AAST grade III or higher (P<0.00001). Overall incidence of pancreatic fistulas was significantly lower for NOM group (p = 0.02) but no difference was observed for AAST grades III or higher (p = 0.49). There was no difference in the length of hospital stay (P = 0.31). Duration of total parenteral nutrition was not different for all AAST grades (P = 0.35), but was significantly shorter for OM group for AAST grades III and higher (p = 0.0001). There was no overall difference in readmissions (P = 0.94). Overall success rate of initial non-operative treatment was 87%.

CONCLUSIONS

Most patients with pancreatic trauma can initially be treated non-operatively, while early surgical treatment may benefit patients with lesions of the main pancreatic duct. ERCP offers both highly accurate diagnosis and potential treatment of ductal injuries.

What is the role of endoscopic retrograde cholangiopancreatography in assessing traumatic rupture of the pancreatic in children?

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.

A novel thermosensitive in-situ gel of gabexate mesilate for treatment of traumatic pancreatitis: An experimental study

Gabexate mesilate (GM) is a trypsin inhibitor, and mainly used for treatment of various acute pancreatitis, including traumatic pancreatitis (TP), edematous pancreatitis, and acute necrotizing pancreatitis. However, due to the characteristics of pharmacokinetics, the clinical application of GM still needs frequently intravenous administration to keep the blood drug concentration, which is difficult to manage. Specially, when the blood supply of pancreas is directly damaged, intravenous administration is difficult to exert the optimum therapy effect. To address it, a novel thermosensitive in-situ gel of gabexate mesilate (GMTI) was developed, and the optimum formulation of GMTI containing 20.6% (w/w) P-407 and 5.79% (w/w) P188 with different concentrations of GM was used as a gelling solvent. The effective drug concentration on trypsin inhibition was examined after treatment with different concentrations of GMTI in vitro, and GM served as a positive control. The security of GMTI was evaluated by hematoxylin-eosin (HE) staining, and its curative effect on grade II pancreas injury was also evaluated by testing amylase (AMS), C-reactive protein (CRP) and trypsinogen activation peptide (TAP), and pathological analysis of the pancreas. The trypsin activity was slightly inhibited at 1.0 and 5.0 mg/mL in GM group and GMTI group, respectively (P<0.05 vs. P-407), and completely inhibited at 10.0 and 20.0 mg/mL (P<0.01 vs. P-407). After local injection of 10 mg/mL GMTI to rat leg muscular tissue, muscle fiber texture was normal, and there were no obvious red blood cells and infiltration of inflammatory cells. Furthermore, the expression of AMS, CRP and TAP was significantly increased in TP group as compared with control group (P<0.01), and significantly decreased in GM group as compared with TP group (P<0.01), and also slightly inhibited after 1.0 and 5.0 mg/mL GMTI treatment as compared with TP group (P<0.05), and significantly inhibited after 10.0 and 20.0 mg/mL GMTI treatment as compared with TP group (P<0.01). HE staining results demonstrated that pancreas cells were uniformly distributed in control group, and they were loosely arranged, partially dissolved, with deeply stained nuclei in TP group. Expectedly, after gradient GMTI treatment, pancreas cells were gradually restored to tight distribution, with slightly stained nuclei. This preliminary study indicated that GMTI could effectively inhibit pancreatic enzymes, and alleviate the severity of trauma-induced pancreatitis, and had a potential drug developing and clinic application value.

Management of blunt pancreatic trauma: what's new?

Pancreatic injuries are relatively uncommon but present a major challenge to the surgeon in terms of both diagnosis and management. Pancreatic injuries are associated with significant mortality, primarily due to associated injuries, and pancreas-specific morbidity, especially in cases of delayed diagnosis. Early diagnosis of pancreatic trauma is a key for optimal management, but remains a challenge even with more advanced imaging modalities. For both penetrating and blunt pancreatic injuries, the presence of main pancreatic ductal injury is the major determinant of morbidity and the major factor guiding management decisions. For main pancreatic ductal injury, surgery remains the preferred approach with distal pancreatectomy for most injuries and more conservative surgical management for proximal ductal injuries involving the head of the pancreas. More recently, nonoperative management has been utilized, especially in the pediatric population, with the potential for increased rates of pseudocyst and pancreatic fistulae and the potential for the need for further intervention and increased hospital stay. This review presents recent data focusing on the diagnosis, management, and outcomes of blunt pancreatic injury.

Non-operative versus operative treatment for blunt pancreatic trauma in children

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.

Xanthomata and diabetes in an adolescent with familial dysbetalipoproteinemia 9 yr after valproate-induced pancreatitis

A 14-yr-old girl presented with eruptive xanthomata and hypertriglyceridemia. This rare presentation led to diagnoses of diabetes and familial dysbetalipoproteinemia. Type 1 diabetes is a common childhood illness often presenting in adolescence. However, this patient's past medical history revealed valproate-induced severe acute pancreatitis with necrosis at the age of 5 yr. Diabetes, in this case, developed 9 yr later as a result of inadequate pancreatic tissue to support increasing insulin requirements during growth and adolescence. Diabetes was discovered only after the appearance of cutaneous eruptive xanthomata, which appeared due to the previously undiagnosed genetic dyslipidemia. Although the relationship between xanthomata, hypertriglyceridemia, and diabetes may be well known in adults, in children, xanthomata are very rarely the presenting feature of diabetes of any cause. The patient was treated with insulin which induced rapid resolution of hypertriglyceridemia and gradual disappearance of xanthomata. This case acknowledges the rarity of diabetes presenting with xanthomata in adolescence, highlights the importance of searching for an underlying dyslipidemia in such a case, and presents diabetes as a long-term complication of acute pancreatitis in children.

Blunt pancreatic trauma in children

PURPOSE

To report our experience with blunt pancreatic trauma in pediatric patients and evaluate several various management strategies.

METHODS

Ten children admitted over the last 10 years with pancreatic blunt trauma were included in the present series.

RESULTS

The average time from injury to hospital admission was 2.4 days. All injuries resulted from accidents: bicycle handlebar injuries (5), being kicked by a horse (2), falls from a height (2), and injury sustained during closure of an electric gate (1). Additional systemic and abdominal injuries were recorded in 7 patients. The amylase levels at the time of patient admission were normal in 3 patients, mildly raised in 4 patients, and elevated in 3 patients. Abdominal computed tomography was performed in 10 patients, ultrasonography in 5, and endoscopic retrograde cholangiopancreatography (ERCP) in 4. Pancreatic injuries comprised 4 grade I, 3 grade II, and 3 grade III injuries. Grade I and II injuries were successfully managed by conservative treatment. The 3 children with grade III trauma and pancreatic ductal injury in the neck (1), body (1), and tail (1) of the gland were surgically treated, having an uneventful postoperative stay of 8-14 days and no complications during the 1-year follow-up period.

CONCLUSION

The present study supports early ERCP as an essential part of the initial patient evaluation when pancreatic transection is highly suspected.

The management of pancreatic injuries in children: operate or observe

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.

Operative Intervention for Complete Pancreatic Transection in Children Sustaining Blunt Abdominal Trauma: Revisiting an Organ Salvage Technique

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.

Initial resection of potentially viable tissue is not optimal treatment for grades II-IV pancreatic injuries

PURPOSE

This study was designed to ascertain the optimal therapy and diagnostics for children with pancreatic injury.

METHODS

From January 1, 2001 to January 1, 2007, all children (newborn to 17 years) who presented to this Level I trauma center with demonstrated pancreatic injury were prospectively entered into the TRACS IV system and reviewed for injury type, diagnostics, therapy, demographics, and outcome.

RESULTS

Fourteen children sustained grade II or higher pancreatic injury during this period. CT scan was performed for diagnosis in all cases. There were 11 boys and 3 girls, and mean age was 6.9 (range, 2-16) years. There were five grade II injuries, four grade III injuries, four grade IV injuries, and one grade V injury. All grade II injuries were treated successfully nonoperatively with observation. The nine grade III-IV injuries all underwent operative external drainage without pancreatectomy or stent placement. The single grade V injury died of multiple associated injuries after operative intervention. No pseudocysts developed in these children. All children have normal pancreatic function, and all except one have normal anatomy on follow-up scans. Early exploration and drainage directly reduces length of stay.

CONCLUSION

Grade II pancreatic injuries do not require routine surgical exploration in children. Grade III and IV injuries in this series were treated with expeditious drainage of the pancreatic bed and did not require routine pancreatectomy or endoscopic stent [corrected] placement as some have recommended. Early drainage shortens hospital stay, and outcomes from this therapy are excellent. Pancreatic resection of exocrine defunctionalized segments of pancreas may be performed safely electively after acute injury if necessary, but anecdotal information from this series indicates that too may not be necessary. Grade V injuries often are accompanied by multiple other organ injuries and are associated with a significant mortality rate. A multi-institutional investigation is warranted to reassess optimal therapy for pancreatic injury in children.

Amylase and lipase measurements in paediatric patients with traumatic pancreatic injuries

INTRODUCTION

Pancreatic injuries occur in up to 10% of paediatric patients who suffer blunt trauma. Initial amylase and lipase measurements have not been helpful as a screening tool to detect pancreatic injuries. However, one primarily adult study suggests that a delayed measurement may be useful.

MATERIALS AND METHODS

A retrospective chart review was conducted of patients admitted to a Level I paediatric trauma centre from April 1996 to November 2006 with traumatic pancreatic injuries.

RESULTS

The trauma database identified 51 patients with traumatic pancreatic injuries. Inclusion and exclusion criteria were met by 26 patients. Patients with initial amylase and lipase levels measured greater than 2h post-injury were more consistently elevated compared to those patients who had levels measured at 2h or less post-injury. There was a significant association between time of measurement and an increased amylase level (p=0.012). No significant association was found for lipase measurements (p=0.178).

DISCUSSION AND CONCLUSIONS

In children with blunt pancreatic injury, elevated serum amylase levels were seen in a significantly higher percentage of patients with initial measurements at greater than 2h post-injury compared to those measured at 2h or less. Lipase measurements demonstrated a similar trend. Delayed amylase and lipase measurements may be helpful to detect pancreatic injuries, but further study is needed.

Pancreatic injuries in under-age Australian rules footballers

Blunt injury to the pancreas is rare in children. It has significant physiological effects and can result in death. The most common injury mechanism is a high-velocity motor vehicle accident. Bicycle accidents, non-accidental injuries and falls can also cause pancreatic injury.(1) Given the protected retroperitoneal location of the pancreas, it is not surprising that low-velocity injuries are an uncommon cause of pancreatic injury. Over a 12-month period we have observed three cases of blunt pancreatic injury, occurring during under-age Australian rules football (AFL) matches. These represented a spectrum of injuries from 'traumatic pancreatitis' to a devascularized distal pancreas requiring initial percutaneous drainage complicated by pseudocyst development requiring cyst gastrostomy. AFL is a free flowing game that combines certain attributes of soccer and rugby. There is an emphasis on physical contact and high-velocity interpersonal collisions are frequent.

Traumatic pancreatic duct injury in children: minimally invasive approach to management

BACKGROUND

The management of children with main pancreatic duct injuries is controversial. We report a series of patients with pancreatic trauma who were treated using minimally invasive techniques.

METHODS

Retrospective review of children with pancreatic trauma treated at a UK tertiary referral institution between 1999 and 2004.

RESULTS

Fifteen children (11 boys) were admitted with pancreatic trauma. Twelve (80%) were less than 50th centile for body weight. Contrast-enhanced computed tomography (CT) scans were used to define organ injury, supplemented by magnetic resonance cholangiopancreatography (MRCP) in 7. Twelve (80%) underwent diagnostic endoscopic retrograde cholangiopancreatography (ERCP) with a median time after injury of 11 (range, 6-29) days. The degree of pancreatic injury was defined by ERCP and CT/MRCP as grade II (n = 2), grade III (n = 4), grade IV (n = 9) (American Association for the Surgery of Trauma grades). Nine children had a transductal pancreatic stent inserted endoscopically. Computed tomography/ultrasound-guided drainage was performed in 4 children for acute fluid collections. Two children later underwent endoscopic cyst-gastrostomy, one of whom later required conversion to an open cyst-gastrostomy.

CONCLUSION

Body habitus may predispose to pancreatic duct trauma. Contrast-enhanced CT scan (and MRCP) should dictate the need for ERCP. Transductal pancreatic stenting allows internal drainage of peripancreatic collections and may reestablish duct continuity, although a proportion still requires percutaneous or endoscopic cyst-gastrostomy drainage. Open surgery for pancreatic trauma should now be an exception.

The role of imaging studies in pancreatic injury due to blunt abdominal trauma in children

BACKGROUND

The role imaging studies play in the choice of treatment in traumatic pancreas damage remains unclear. This study was performed to gain insight into the role of radiological studies in children 16 years of age or younger admitted to our hospital with pancreatic damage due to a blunt abdominal trauma.

METHOD

Retrospectively, the radiological as well as patient clinical records were reviewed of all children admitted to our hospital between 1975 and 2003 with a pancreatic lesion due to blunt abdominal trauma.

RESULTS

Thirty-four children with ages ranging from 3 to 14 years old were admitted with traumatic pancreas damage. Initially 33 children were treated conservatively for the pancreatic damage and only one had immediate surgery of the pancreas with a Roux-y pancreaticojejunostomy. Five other children had immediate surgery for other reasons. Overall, five children proved to have a pancreas transection on CT scans or during laparotomy. One child had a pancreas hematoma and 28 a pancreas contusion. In total 15 children developed a pseudocyst (44%), nine of which resolved spontaneously while six were treated by intervention. None of the children had residual morbidity, and there were no deaths. Considering the pancreas, the 11 available CT's were re-evaluated by two radiologists independently. Grade 3 pancreas damage (distal transection of the pancreatic duct) was diagnosed in five patients by radiologist A and four patients by radiologist B (80% match); Grade 1 was diagnosed in, respectively six and one patients (15% match). An US was performed on 19 children with 82 follow-up examinations, mostly for follow-up of the pseudocysts.

CONCLUSION

Traumatic pancreas damage is a rare and difficult diagnosis. There is no straightforward answer for diagnostic imaging in blunt abdominal trauma in children. The diagnostic relevance of CT is limited. CT in combination with MRCP may be a better option for exclusion of pancreatic duct lesions.

Pancreatic Injury in the Athlete

Pancreatic injuries in the athlete are seldom reported in the literature. These injuries can result from atraumatic etiologies and blunt abdominal trauma. Atraumatic pancreatic injuries in the athlete are diagnosed and treated in a similar manner to the nonathletic patient. Fluid replacement, analgesic support, metabolic stabilization, and minimization of gastric stimulation are the primary management methods for this type of pancreatic injury. Athletically related traumatic pancreatic injury is associated with a high morbidity and mortality. The consequences of a delayed diagnosis make this type of injury an important diagnostic consideration in an athlete with abdominal pain. Initial clinical, radiologic, and laboratory findings of direct injury to the pancreas are often equivocal, and require clinical suspicion and further investigation. Current evidence suggests that pancreatic duct injury is the primary cause of the morbidity and mortality associated with the direct trauma. A conservative or surgical management plan should be based on a combination of serial clinical examinations, pancreatic enzyme levels, and either magnetic resonance retrograde choleopancreatogram or endoscopic retrograde chloangiopancreatography investigations to rule out ductal injury. The prevention of pancreatic and other intra-abdominal injuries is an evolving area of sports medicine research. Sports specific epidemiologic data collection and analysis are important elements in the development of evidence-based interventions.

Management of childhood pancreatic disorders: a multidisciplinary approach

INTRODUCTION

Data on therapeutic endoscopy and radiologic interventions for the management of childhood pancreatic disorders are relatively limited. This study focuses on the multidisciplinary approach to the management of pancreatitis in children.

PATIENTS AND METHODS

Children with pancreatic disorders were studied from January 1992 to May 2001. Acute pancreatitis (AP) was diagnosed by clinical evaluation, serum amylase more than three times normal, and morphologic abnormalities of the pancreas on imaging. Children with recurrent abdominal pain, pancreatic calcification or ductal stones on imaging, and pancreatic ductal changes on endoscopic retrograde cholangiopancreatography (ERCP) were diagnosed with chronic pancreatitis (CP). Patients were treated by gastroenterologists, surgeons, and interventional radiologists. Pancreatic exocrine insufficiency was diagnosed in appropriate settings.

RESULTS

Fifteen children--6 with AP (posttrauma, 3; gallstone disease, 1; and viral, 1), 7 with CP, and 2 with pancreatic exocrine insufficiency--were diagnosed. Local complications observed in children with AP included pseudocyst in three, and infected acute fluid collection, right-sided pleural effusion, and ascites in one patient each. Complications of AP were managed with percutaneous catheter drainage (n = 3; pseudocyst, 2; infected fluid collection, 1), additional pancreatic duct stenting (n = 2), surgical drainage (n = 1), and octreotide for pleural effusion (n = 1). Signs of CP included abdominal pain (n = 7), obstructive jaundice resulting from lower common bile duct stricture (n = 2), and bleeding from gastroduodenal artery pseudoaneurysm (n = 1). Pancreatic duct stenting relieved pain in one patient, and steel coil embolization arrested bleeding from the pseudoaneurysm. Common bile duct strictures were managed by surgical bypass (n = 2), one of which required preoperative endoscopic bile duct stenting for management of cholangitis. Two other patients with CP required no intervention.

CONCLUSION

A multidisciplinary approach of radiologic and endoscopic interventions and surgery are complimentary to each other in achieving successful outcomes of complicated childhood pancreatitis.

Reversible pancreatic duct stricture after a blunt abdominal trauma

A 32-year-old man developed acute pancreatitis with a main duct stricture resulting from blunt abdominal trauma sustained during a car accident 11 weeks before admission. No interventions were performed and unusually, after 3 months' follow-up, the pancreatic main duct stricture resolved and the patient remained asymptomatic. There are no other reports in the literature demonstrating resolution of pancreatic main duct stricture without any endoscopic or surgical treatment subsequent to a blunt abdominal trauma.

Long-term outcome after nonoperative management of complete traumatic pancreatic transection in children

PURPOSE

The treatment of complete pancreatic transection (CPT) from blunt trauma remains controversial. To determine the natural history and long-term outcome of nonoperative management of CPT, we analyzed all such patients over the last 10 years at a level I trauma center.

METHODS

Retrospective analysis between 1990 and 1999 was performed on 10 consecutive patients. Complete records were available for 9 patients. Data pertaining to their trauma admission, plus long-term radiologic and clinical outcome were analyzed.

RESULTS

There were 6 boys and 3 girls with a median age of 8 years (range, 4 to 16 years) and a median injury severity score (ISS) of 25. All patients displayed CPT on admission computed tomography (CT) scan. Four patients (44%) had associated intraabdominal injuries, but only 2 were significant. All patients were treated nonoperatively. Four patients (44%) had pseudocysts, and 3 required percutaneous drainage. Other complications included a single drainage of subphrenic collection, 1 inadvertent removal of drainage catheter, and 2 cases of line sepsis. The duration of percutaneous drainage was 14 to 60 days. The median length of hospitalization was 24 days (range, 6 to 52 days). After median follow up of 47 months, no patients showed exocrine or endocrine insufficiency. One patient had abdominal pain not related to the pancreatic injury. Follow-up abdominal CT scans in 8 of 9 patients showed complete atrophy of the body and tail in 6 patients and 2 completely normal glands.

CONCLUSIONS

Pancreatic transection is rare and commonly is found in isolation of other major abdominal injuries. No patients required surgery for their pancreatic transection. Pseudocysts can be managed effectively with percutaneous drainage. After a median follow-up of 47 months, no patients had endocrine or exocrine dysfunction. Anatomically, the distal body and tail usually atrophies; however, occasionally, the gland can heal and appear to recanalize. To the authors' knowledge, this is the first report to show the effectiveness of nonoperative management after complete pancreatic transection.

Early operation in children with pancreas transection

BACKGROUND/PURPOSE

The preferred treatment for children with major pancreatic ductal injury remains controversial. This report compares our results using early operation with previously reported series using both operative and nonoperative management.

METHODS

This is a retrospective analysis of all children with pancreatic transection identified at Children's Medical Center of Dallas, Texas, from 1995 through 1999.

RESULTS

There were 11 children with pancreatic transection. There was a delay of 2.3 days before presentation to a hospital in 6. Transection was diagnosed within 12 hours of presentation in 5 children. In the other 6 there was a mean delay of 36 hours. Nine children underwent operation within 72 hours of injury. Two late presenters initially were treated nonoperatively, and both developed a pseudocyst. The length of hospital stay in patients undergoing early operation averaged 11 days. Early postoperative morbidity occurred in 4 children and late morbidity in 1.

CONCLUSIONS

Major pancreatic injuries are uncommon in children, and the diagnosis often is delayed. A high index of suspicion and repeated computed tomography scans should lead to earlier diagnosis. When compared with nonoperative management, early pancreatic resection more expeditiously returns the child to good health and lessens the inconvenience and emotional stress associated with prolonged hospitalization.