Demonstration of pancreatic ductal integrity by endoscopic retrograde pancreatography allows conservative surgical management

The management of pancreatic injuries

Pancreatic injuries are relatively uncommon, but considerable morbidity and mortality may result if associated vascular and duodenal injuries are present or if the extent of the injury is underestimated and appropriate intervention is delayed. Optimal management includes the need for early diagnosis and accurate definition of the site and extent of injury. Prognosis is influenced by the cause and complexity of the pancreatic injury, the amount of blood lost, duration of shock, the rapidity of resuscitation and the quality and appropriateness of surgical intervention. Early mortality results from uncontrolled or major bleeding due to associated injuries while late mortality is generally a consequence of infection or multiple organ failure. Initial management of pancreatic trauma is similar to that of any patient with a severe abdominal injury. Stable patients with a suspected pancreatic injury should have non-invasive imaging including a CT scan or MRI. Urgent laparotomy is required in patients with evidence of major intraperitoneal bleeding, associated visceral trauma, or peritonitis. Operative intervention is guided by the integrity of the main pancreatic duct. External drainage is adequate for parenchymal injuries with an intact duct, while duct injuries of the neck, body and tail require a distal pancreatectomy. Pancreatic head injuries are more complex. If the duodenum is reparable and the ampulla is intact, external drainage suffices. Rarely, complex injuries may require a pancreatoduodenectomy after damage control surgery if the patient has multiple injuries and is unstable. Postoperative pancreatic complications including fistula and pseudocysts are common but can usually be treated endoscopically.

Nonoperative management of pancreatic injuries in pediatric patients

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.

Article Commentary: Management of Left Pancreatic Trauma

Left pancreatic traumas (LPTs) are rare but serious lesions occurring in 1 to 6 per cent of abdominal trauma patients and mainly resulting from blunt traumas. LPT severity is primarily dependent on the associated injuries and secondarily related to main pancreatic duct injury responsible for complications: acute pancreatitis, pseudocysts, pancreatic fistulas, or abscesses. The guidelines for blunt LPT management can be presented as follows. In case of emergency laparotomy, pancreas exploration is mandatory to detect pancreatic duct lesions. In the absence of main pancreatic duct lesions, simple drainage is advocated. In case of distal injury to the main pancreatic duct, a left pancreatectomy is mandatory. In the absence of initial laparotomy, the diagnosis is more and more based on CT and magnetic resonance cholangiopancreatography, which tend to replace endoscopic retrograde cholangiopancreatography (ERCP) as a first-intent diagnostic modality. In case of distal injury to the main pancreatic duct, spleen-preserving distal pancreatectomy is recommended. In the absence of main pancreatic duct lesions, nonoperative treatment is advocated. When LPTs are discovered at the time of complications, pancreatic fistulas and/or pseudocysts are associated with main pancreatic lesions, which can be treated by pancreatic duct stenting at ERCP and/or internal endoscopic cystogastrostomy. However, in such cases, spleen-preserving distal pancreatectomy remains the treatment of choice. Pancreatic ductal lesions resulting from LPT have to be diagnosed early to avoid late complications. Distal pancreatectomy remains the treatment of choice in case of severe pancreatic ductal lesions because the role of ERCP stenting and endoscopic techniques needs further evaluation.

Endoscopic retrograde pancreatography in pancreatic trauma: need to break the mental barrier

Pancreatic injury has a high morbidity and mortality. The integrity of the main pancreatic duct is the most important determinant of prognosis. Serum amylase, peritoneal lavage and computed tomography of the abdomen can assist with diagnosis but endoscopic retrograde pancreatography (ERP) is the most accurate investigation for diagnosing the site and extent of ductal disruption. However, it is invasive and can be associated with significant complications. Magnetic resonance cholangiopancreatography (MRCP) and secretin-enhanced MRCP probably parallel ERP in delineating pancreatic ductal injuries. They can also delineate the duct upstream to complete disruption, an area not visualized on ERP. In relation to therapy, endoscopic transpapillary drainage has been successfully used to heal duct disruptions in the early phase of pancreatic trauma and, in the delayed phase, to treat the complications of pancreatic duct injuries such as pseudocysts and pancreatic fistulae. Transpapillary drainage is especially effective in patients who have partial pancreatic duct disruption that can be bridged. Endoscopic transmural drainage has also been successfully used to treat post-traumatic pancreatic pseudocysts. Further large, prospective and randomized studies are required to adjudge the efficacy and long-term safety of pancreatic duct drainage in the treatment of post-traumatic pancreatic duct injuries.

Selective nonoperative management of low-grade blunt pancreatic injury: are we there yet?

BACKGROUND

Nonoperative management (NOM) of low-grade blunt pancreatic injuries (LGBPI) diagnosed by computed tomographic (CT) abnormalities of the pancreas in the adult hemodynamically stable (HDS) patient has not been previously defined. We report our experience of patients with LGBPI at a single Level I Trauma Center.

METHODS

Adult HDS patients during a 5-year period with blunt pancreatic injuries with an abbreviated injury score of </=2 were identified through the hospital trauma registry. Management, complications, and outcome were reviewed. Patients who underwent initial emergency laparotomy, died on hospital day one, or had a Glasgow Coma Scale of three were excluded. Failure of NOM was defined by need for subsequent exploratory laparotomy or development of a pancreatic complication. Data are reported as mean +/- SEM.

RESULTS

A total of 120 patients were identified as having blunt pancreatic injury of which 35, with pancreatic abbreviated injury score of </=2, were blunt HDS patients with abdominal CT evidence of pancreatic injury. Amylase elevation was noted in 23 of 35 (68.5%) patients with positive CT scan findings of LGBPI. Study population consisted of 20 male patients and 15 female patients, age 32 +/- 13.22, injury severity score 21 +/- 10.08, systolic pressure 123 +/- 27.06 with mean base deficit -3.78 +/- 2. Of these 12 (34.28%) patients had an associated intra-abdominal solid organ injury. Five patients failed NOM (F-NOM), one had missed small bowel injury, three had pancreatic abscess, of which one developed a pancreatic fistula which resolved with medical management, and one F-NOM for blunt liver injury with missed bowel injury. No death in the F-NOM group and two deaths (5.71%) in the successful NOM (S-NOM) group unrelated to the pancreas. The average length of stay was 11 days +/- 9.71 days.

CONCLUSION

NOM of LGBPI diagnosed by CT was successful in the majority of HDS patients, with low morbidity and mortality. We propose a management algorithm for NOM of LGBPI in which the role for early ductal injury detection with endoscopic retrograde cholangio-pancreatogram or magnetic retrograde cholangio-pancreatogram should be incorporated to better analyze the most appropriate treatment.

Nonoperative treatment of traumatic pancreatic duct disruption in children with an endoscopically placed stent

The presence of ductal injury is the main determinant of consequence and a cause of significant mortality and morbidity in children with blunt pancreatic trauma. Proper treatment must be initiated on the basis of accurate anatomic diagnosis of the type and location of the injury. Computed tomography is an insufficient method for the diagnosis of the type and location of pancreatic ductal injury. Endoscopic retrograde pancreatography (ERP) is a reliable technique for determining the status of the pancreatic duct in children and may allow for definitive treatment of ductal injury by stenting in selected patients. There is only one study of 2 cases reporting therapeutic ERP with ductal stenting in children after blunt trauma. In this report, we present an 11-year-old child with pancreatic ductal injury who was diagnosed and treated endoscopically by stent placement, during ERP. The patient improved steadily and was discharged uneventfully. Endoscopic retrograde pancreatography may be a very useful diagnostic and treatment tool in the management of main ductal disruptions.

The use of MRCP in the detection of pancreatic injuries after blunt trauma

From January 2000 to November 2001, five consecutive, hemodynamically stable trauma patients (age range 8-69 years, mean age 34 years) with parenchymal injuries were evaluated by magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP). One patient also underwent a MRCP-facilitated secretin test. MRI depicted pancreatic laceration in two patients, ductal disruption and a post-traumatic intraparenchymal pseudocyst in one, migrating pancreatic fluid collection in the mediastinal space with disruption in another, and main pancreatic duct rupture and dilatation in the patient evaluated with MRCP following secretin administration. MRI with MRCP is an effective noninvasive test for detecting and managing pancreatic injuries after blunt trauma. Secretin administration improves ductal visualization, particularly of nondilated ducts. Finally, MRI was useful in the follow-up studies of parenchymal damage and minor ductal injuries, providing high-quality images of the pancreatic duct and biliary tract.

Pancreatic trauma in the adult: current knowledge in diagnosis and management

BACKGROUND/AIMS

Although pancreatic trauma, isolated or not, is uncommon, it carries significant morbidity and mortality because of the delay in recognition and consequent treatment.

METHODS

The current knowledge of pancreatic injury, concerning the incidence, mechanism of induction, diagnosis, treatment, complications and outcome, is herein presented based on a literature review and our limited experience.

RESULTS

The diagnosis of pancreatic trauma entails a high index of suspicion because neither clinical nor laboratory evaluation provide pathognomonic elements. Patients with penetrating injuries are usually evaluated during laparotomy, while those with a blunt trauma can be managed conservatively, provided they are in a stable condition, there is no pancreatic duct involvement and care is intensive. At laparotomy, minor pancreatic injuries are best managed by drainage. Distal pancreatectomy is best suited for distal pancreatic trauma with ductal involvement. For severe trauma, Roux-en-Y pancreaticojejunostomy, pancreaticogastrostomy, duodenal diversion operations and Whipple's procedure are all indicated according to the preoperative evaluation and intraoperative findings. Independent of the procedure to be performed, drainage is mandatory.

CONCLUSION

Because pancreatic injury is rare, most general surgeons lack experience and ability to deal with such injured patients. Therefore, an experienced and skilled surgeon should govern the management of pancreatic trauma in order to minimize the incidence of morbidity and mortality.

Management of major pancreatic duct injuries in children

BACKGROUND

The operative versus nonoperative management of major pancreatic ductal injuries in children remains controversial. The computed tomographic (CT) scan may not be accurate for determination of location and type of injury. We report our experience with ductal injury including the recent use of acute endoscopic retrograde cholangiopancreatography (ERCP) for definitive imaging, and an endoscopically placed stent as definitive treatment. This has not been reported in children.

METHODS

In review of 14,245 admissions to a regional pediatric trauma center over a 14-year period, 18 patients with major ductal injuries from blunt trauma were noted. Records were reviewed for mechanism of injury, method of diagnosis, management, and outcome.

RESULTS

There were 10 girls and 8 boys, ranging in age from 2 months to 13 years. The most common mechanisms of injury were motor vehicle and bicycle crashes. Admission CT scan in 16 children was suggestive of injury in 11, and missed the injury in 5. Distal pancreatectomy was carried out in eight patients with distal duct injuries: one died of central nervous system injury. Nonoperative management in three proximal duct injuries suggested by initial CT scan and in three missed distal duct injuries resulted in pseudocyst formation in five survivors; one patient died of central nervous system injuries. Two children with minimal abdominal pain, normal initial serum amylase, and no initial imaging developed pseudocysts. Two of seven pseudocysts spontaneously resolved and five were treated by delayed cystogastrostomy. Two recent children with suggestive CT scans were definitively diagnosed by acute ERCP and treated by endoscopic stenting. Clinical and chemical improvement was rapid and complete and the stents were removed. Follow-up ERCP, CT scan, and serum amylase levels are normal 1 year after injury.

CONCLUSION

Pancreatic ductal injuries are rare in pediatric blunt trauma. CT scanning is suggestive but not accurate for the diagnosis of type and location of injury. Acute ERCP is safe and accurate in children, and may allow for definitive treatment of ductal injury by stenting in selected patients. If stenting is not possible, or fails, distal injuries are best treated by distal pancreatectomy; proximal injuries may be managed nonoperatively, allowing for the formation and uneventful drainage of a pseudocyst.

Treatment of pancreatic duct disruption in children by an endoscopically placed stent

BACKGROUND

Injuries to the pancreas from blunt abdominal trauma in children are rare. Most are minor and are best treated conservatively. The mainstay for treatment of major ductal injuries has been prompt surgical resection. Diagnostic imaging modalities are the key to the accurate classification of these injuries and planning appropriate treatment. Computed tomography (CT) scan has been the major imaging modality in blunt abdominal trauma for children, but has shortcomings in the diagnosis of pancreatic ductal injury. Endoscopic retrograde cholangiopancreatography (ERCP) has been shown recently to be superior in diagnostic accuracy. The therapeutic placement of stents in the trauma setting has not been described in children.

METHODS

Two children sustained major ductal injuries from blunt abdominal trauma that were suspected, but not conclusively noted, on initial CT scan. Both underwent ERCP within hours of injury. In case 1, a stent was threaded through the disruption into the distal duct. In case 2, a similar injury, the stent could only be placed through the ampulla, thereby reducing ductal pressure. In both cases, clinical improvement was rapid with complete resolution of clinical and chemical pancreatitis, resumption of a normal diet, and discharge from the hospital. The stents were removed at 10 and 12 days postinjury, and both children have remained well. Follow-up ERCP and CT scans show complete healing of the ducts and no evidence of pseudocyst formation 1 year post injury.

CONCLUSIONS

Acute ERCP should be the imaging modality of choice in suspected major pancreatic ductal injury. Successful treatment by placement of an intrapancreatic ductal stent may be possible at the same time. Surgical resection or reconstruction can then be reserved for cases in which stenting is impossible or fails.

Pancreatographic classification of pancreatic ductal injuries caused by blunt injury to the pancreas

BACKGROUND

In the treatment of patients with pancreatic injury, the focus of attention is usually on main ductal injuries.

METHODS

To develop a classification system for pancreatic ductal injuries, we retrospectively analyzed blunt pancreatic injuries in 40 patients. We assessed the relationships between findings on pancreatography (36 endoscopic retrograde procedures and 4 transduodenal procedures), the treatment modality, and the clinical course.

RESULTS

Patients with class 1 injuries (radiographically normal ducts, n = 13) could be treated nonsurgically without major complications. Patients with class 2 injuries (branch injuries, n = 7), in whom contrast medium from ductal branches did not leak from the pancreatic parenchyma (class 2a, n = 3), could be treated nonsurgically. Patients with leaks into the retroperitoneal space (class 2b, n = 4) required at least a drainage laparotomy. Patients with class 3 injuries (main duct injuries, n = 20), including two patients in whom conservative treatment resulted in severe complications, required laparotomy.

CONCLUSION

This classification system for pancreatic ductal injuries may facilitate the selection of appropriate therapeutic modalities for patients with blunt pancreatic injury.

Nonoperative management of blunt pancreatic injury in childhood

PURPOSE

Nonoperative management for blunt pancreatic injury in children was performed between 1977 and 1998. The efficiency and safety of nonoperative management was examined.

METHODS

Pancreatic injury was diagnosed in 20 children. The surgical indication was determined by hemodynamic instability and the management of associated injuries. Children without surgical indications were treated initially by nonoperative management.

RESULTS

Nineteen of 20 children were treated initially nonoperatively, and 18 of the 19 survived. Surgical exploration was performed in only 1 child with perforation of the duodenum and bile duct. One child died of complications of total parenteral nutrition. Ultrasound scan and computed tomography scan showed pancreatic contusion in 9, laceration in 6, and injury of the main pancreatic duct (MPD) in 5. Pseudocysts were detected in 10 (5 laceration and 5 MPD injury). Pseudocysts smaller than 10 cm disappeared after nonoperative management, and those larger than 10 cm required operative management. Rupture of pseudocysts occurred in 2 children by rotating the upper torso.

CONCLUSIONS

Nonoperative management of pancreatic injuries is effective in children, although careful management is required to avoid complications. Pseudocysts smaller than 10 cm were treated successfully by nonoperative management, and those larger than 10 cm required surgical management.

Management of pancreatic injury in pediatric blunt abdominal trauma

BACKGROUND/PURPOSE

Nonoperative management of low-grade pancreatic injury is widely accepted. Management of major pancreatic parenchymal or ductal injury in children remains controversial. This study will review management strategies as they relate to site and type of pancreatic injury and their outcomes.

METHODS

A total of 11,794 consecutive admissions to a regional pediatric trauma center from 1984 to 1997 were reviewed to identify children with pancreatic injury as documented by serum amylase; imaging by computed tomographic (CT) scan, ultrasonography (US), and endoscopic retrograde cholangiopancreatography (ERCP); and surgical or postmortem reports.

RESULTS

Pancreatic injury was documented in 56 children, age 2 months to 14 years, with blunt mechanisms of injury. Serum amylase level was elevated on admission in 40 (71%), and no correlation was found between admission amylase values and severity of pancreas injury. An admission CT scan was obtained in 44 (79%) patients and was positive for pancreatic injury in 25 (57%). Twelve children, who had diagnoses of other intraabdominal injury by CT scan, had pancreatic injuries discovered on exploratory laparotomy. Seven children with normal admission CT scans, and the 12 children who did not undergo imaging on admission, had pancreatic injuries that were later documented by imaging, exploration, or autopsy. Thirty children were treated with immediate exploration, 17 for nonpancreatic indications and 13 with pancreatic injuries on admission CT scan. Of 19 minor injuries noted in the operating room, only three were treated with external drainage. Seven patients with distal duct injuries underwent distal pancreatectomy with splenic preservation. Twenty-six children were treated nonoperatively, including 19 with minor pancreas injuries, three with proximal pancreatic duct injuries, and four with duct injuries that were missed at admission. There were no advantages or complications of external drainage versus nondrainage of minor pancreatic injuries. There were seven deaths (overall mortality rate, 12.5%), none related to pancreatic injury. Of the seven patients in whom pseudocysts developed (two not imaged at admission, two from known proximal duct injuries treated nonoperatively, and three from injuries missed by initial studies), five were treated by delayed internal drainage and recovered promptly, and two resolved spontaneously. Pancreas-related complications included one persistent fistula and one prolonged hyperamylasemia, both of which resolved.

CONCLUSIONS

Pancreatic injuries are uncommon in children. Initial serum amylase level does not correlate with the severity of pancreatic injury. The majority of pancreatic injuries can be managed nonoperatively. Initial nonoperative management of injuries of the proximal pancreatic duct allows for the formation and uneventful delayed drainage of a pseudocyst, rather than the risks of early radical interventions. Distal duct injuries are best managed by prompt spleen-sparing distal pancreatectomy. There is no benefit of closed drainage for management of minor pancreatic injuries discovered at laparotomy.

Pancreatectomia distal no trauma: estudo multicêntrico

No período de cinco anos, 87 doentes com trauma pancreático foram tratados por pancreatectomia corpo-caudal em cinco serviços de emergência. A idade variou de 7 a 64 anos (média de 28), sendo que 73 (84%) eram do sexo masculino. O principal mecanismo de trauma foi o ferimento penetrante em 72,5%, com ferimentos por projéteis de arma de fogo em 3/4 dos casos. Lesões associadas ocorreram em 96% dos doentes. A extensão da ressecção pancreática correspondeu de 30% a 70%, em 62% dos casos. O baço foi preservado em 45,6% dos 57 doentes que se apresentaram sem lesão esplênica. A taxa de complicações foi de 40,2%, sendo a fístula pancreática e a pancreatite pós-operatória as mais freqüentes. A mortalidade total foi de 12 doentes (13,7%). As conclusões deste estudo foram as seguintes: a) há relação nas taxas de morbidade com o mecanismo de lesão; b) a morbidade é mais freqüente em doentes com trauma fechado; c) não há diferença na incidência de complicações com o método de fechamento do pâncreas remanescente nem com a extensão da ressecção; d) não há relação da mortalidade com o mecanismo de trauma; e) há uma tendência no aumento da taxa de mortalidade no trauma fechado com presença de lesões associadas.

Nonoperative management of pancreatic injuries in children

PURPOSE

The safety and efficacy of nonoperative management of pancreatic contusions and transections was examined by reviewing the case histories of 35 consecutive children with pancreatic injuries treated over the past 10 years.

METHODS/RESULTS

Surgical exploration was performed for the management of associated injuries only. The diagnosis of pancreatic trauma was suspected in children with abdominal pain, tenderness, elevated serum amylase levels and findings consistent with pancreatic injury on abdominal ultrasound scan or computerized tomography (CT) examination. After children were diagnosed with pancreatic injury, enteral feedings were withheld and total parenteral nutrition administered until abdominal pain resolved and serum amylase levels and radiographic findings improved. Twenty-three children received diagnosis within 24 hours of injury, and in 12, the diagnosis was delayed 2 to 14 days. Hyperamylasemia was found in 27 of 35 children. Twenty-eight children sustaining pancreatic injuries were treated nonoperatively. Abdominal imaging in these children demonstrated pancreatic contusion in 14, transection in 11, and pseudocyst in three. Enteral feeding resumed an average of 15 days after injury. The average hospital stay was 21 days. Pseudocysts formed in 10 children (2 of 14 with contusion; 5 of 11 with transection; three children presented late, and the type of pancreatic injury could not be determined), whose average hospital stay was 25 days. All pseudocysts were successfully managed nonoperatively, although percutaneous aspiration or drainage was required in six children. Children underwent follow-up for an average of 10 months after injury (range, 1 to 144 months). Abdominal pain and radiological abnormalities resolved in all children before discharge from the clinic.

CONCLUSIONS

Nonoperative management of pancreatic contusion and transection diagnosed radiologically is effective and safe. Pseudocysts may form after pancreatic injury, and if large or symptomatic, can be managed successfully by percutaneous drainage.