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Zhang T, Luo W, Wang W, Long Q, Ma M. Blunt pancreatic injury in children: Lessons from 11-year experience in a pediatric center. Asian J Surg 2024; 47:269-273. [PMID: 37648540 DOI: 10.1016/j.asjsur.2023.08.111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/23/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVE To study the diagnosis, management strategies, and outcomes of pediatric patients with blunt pancreatic injury. METHODS The clinical data of patients with blunt pancreatic injury at Children's Hospital, Zhejiang University School of Medicine from January 2011 to September 2022 were collected and analyzed retrospectively. RESULTS A total of 51 patients were enrolled. According to the American Association for the Surgery of Trauma (AAST) classification of pancreatic injury, 41 patients were categorized in the low-grade and nine in the high-grade groups. On admission, serum amylase and lipase levels in the high-grade group were significantly higher than in the low-grade group (P = 0.025 and P = 0.021, respectively). The peak levels of serum amylase and lipase in the high-grade group were considerably higher than in the low-grade group (P = 0.017 and P = 0.038, respectively). Two patients received surgical treatment, but none experienced pancreatectomy. The remaining 49 patients were successfully treated with conservative methods. The incidence of pancreatic pseudocysts in patients was 47.1% (24/51), and half required external drainage. CONCLUSION Conservative management is safe for most children with blunt pancreatic injury, surgical intervention should be adopted in patients with hemodynamic instability or multiple organ failure.
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Affiliation(s)
- Ting Zhang
- Department of Clinical Nutrition, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Wenjuan Luo
- Department of General Surgery, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Wenqiao Wang
- Department of Clinical Nutrition, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Qi Long
- Department of Clinical Nutrition, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Ming Ma
- Department of Clinical Nutrition, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China.
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Schunn MC, Schäfer J, Neunhoeffer F, Lieber J, Fuchs J. [Blunt abdominal trauma in children and adolescents: treatment concepts in the acute phase]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:651-663. [PMID: 37338573 DOI: 10.1007/s00104-022-01798-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 06/21/2023]
Abstract
Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5].
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Affiliation(s)
- M C Schunn
- Klinik für Kinder- und Jugendmedizin, Abteilung für Kinderchirurgie und Kinderurologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland.
| | - J Schäfer
- Diagnostische und Interventionelle Radiologie, Abteilung für Kinderradiologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - F Neunhoeffer
- Klinik für Kinderheilkunde, Abteilung für Kinderkardiologie, Intensivmedizin und Pulmonologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - J Lieber
- Klinik für Kinder- und Jugendmedizin, Abteilung für Kinderchirurgie und Kinderurologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - J Fuchs
- Klinik für Kinder- und Jugendmedizin, Abteilung für Kinderchirurgie und Kinderurologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
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3
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Gong SC, An S, Shin IS, Jung PY. Usefulness of Endoscopic Retrograde Cholangiopancreatography in the Diagnosis and Treatment of Traumatic Pancreatic Injury in Children. Diagnostics (Basel) 2023; 13:2044. [PMID: 37370939 DOI: 10.3390/diagnostics13122044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Pediatric trauma patients are increasing, and trauma is the leading cause of death in children. Pancreatic injury is known as the fourth most common solid organ injury, but the diagnosis of pancreatic injury is often delayed due to the retroperitoneal location of the pancreas and the low sensitivity and specificity of diagnostic tests. Endoscopic retrograde cholangiopancreatography (ERCP) is an important test for the diagnosis and treatment of various biliary tract and pancreatic diseases. However, cases of performing ERCP in traumatic pancreatic injury in children have been rarely reported. Thus, we aimed to evaluate the usefulness of ERCP in traumatic pancreatic injury in children. Between January 1983 and December 2022, pediatric patients under the age of 18 who were treated for traumatic pancreatic injury at a single institution were recruited and retrospectively analyzed. Patient characteristics and clinical outcomes were assessed. Thirty-one patients were enrolled in this study. Among them, 15 (48.4%) patients underwent ERCP. The time to diet was significantly longer in the ERCP group. There were no statistically significant differences in other characteristics between the ERCP and the non-ERCP group. In nine (60%) patients of the ERCP group, ERCP was used for therapeutic intervention or as a decision-making tool for surgery, and was used to resolve pancreas-related complications. ERCP may be useful for the diagnosis and treatment of traumatic pancreatic injury in children. In addition, ERCP can be safely applied in children, and complications related to ERCP also may not increase. When obscure pancreatic injury is suspected, it is necessary to consider performing ERCP.
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Affiliation(s)
- Seong Chan Gong
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Sanghyun An
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - In Sik Shin
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Pil Young Jung
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
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Resection versus drainage in the management of patients with AAST-OIS grade IV blunt pancreatic injury: A single trauma centre experience. Injury 2022; 53:129-136. [PMID: 34364681 DOI: 10.1016/j.injury.2021.07.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/07/2021] [Accepted: 07/24/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We aimed to compare outcomes of pancreatic resection with that of peripancreatic drainage for American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) grade IV blunt pancreatic injury in order to determine the optimal treatment method. MATERIALS AND METHODS Nineteen surgical patients with AAST-OIS grade IV blunt pancreatic injury between 1994 and 2016 were retrospectively studied. RESULTS Among the 19 patients, 14 were men and 5 were women (median age: 33 years). Twelve patients underwent pancreatic resection (spleen-sacrificing distal pancreatectomy, n = 6; spleen-preserving distal pancreatectomy, n = 3; and central pancreatectomy with Roux-en-Y anastomosis, n = 3), and seven underwent peripancreatic drainage. After comparing these two groups, no significant differences were found in terms of gender, shock at triage, laboratory data, injury severity score, associated injury, length of hospital stay, and complication. The only significant difference was that in the drainage group, the duration from injury to surgery was longer than that from injury to resection (median, 48 hours vs. 24 hours; P = 0.036). In the drainage group, three patients required reoperation, and another three required further pancreatic duct stent therapy. CONCLUSIONS In the surgery of the grade IV blunt pancreatic injury, pancreatic resection is warranted in early, conclusive MPD injury; if surgery is delayed or MPD injury has not been clearly assessed, peripancreatic drainage is an alternative method. However, peripancreatic drainage alone is not adequate and further pancreatic duct stent or reoperation is required. Further studies should be conducted to confirm our conclusions.
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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.
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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
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Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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8
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Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019; 14:56. [PMID: 31867050 PMCID: PMC6907251 DOI: 10.1186/s13017-019-0278-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.
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Keil R, Drábek J, Lochmannová J, Šťovíček J, Koptová P, Wasserbauer M, Frýbová B, Šnajdauf J, Matouš J, Kotalová R, Rygl M, Hlava Š. ERCP in infants, children, and adolescents-Different roles of the methods in different age groups. PLoS One 2019; 14:e0210805. [PMID: 30653580 PMCID: PMC6336232 DOI: 10.1371/journal.pone.0210805] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/02/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is seldom used in children, and published series have limited numbers of pediatric patients. The aim of this retrospective observational study was to assess the efficacy and safety of pediatric ERCP in a large group of children. METHODS Data were evaluated from 626 children with biliopancreatic disorders admitted to University Hospital Motol, Prague, between January 1999 and January 2018. Clinical data were obtained by retrospective evaluation of our database of pediatric ERCP procedures and from clinical records. RESULTS We performed 856 ERCPs on 626 pediatric patients; of these procedures, 59% were therapeutic and 41% were diagnostic. We achieved 96% technical success. Indications for ERCP and pathological findings differed in different age groups. The main role of ERCP was in excluding biliary atresia in those aged less than one year. In children aged 1 to 6 years, the most frequent diagnoses were choledochal cyst followed by choledocholithiasis. In children aged 7 to 12 years and 13 to 19 years, the most frequent diagnoses were choledocholithiasis followed by pancreatic pathology. The overall complication rate found in this study was similar to rates observed in adult populations. CONCLUSIONS Our study shows the efficacy and safety of diagnostic and therapeutic ERCP in a large series of infants and children with technical success and complication rates comparable to those in adults. Our data show that ERCP had different roles in different age groups of children.
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Affiliation(s)
- Radan Keil
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Jiří Drábek
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Jindra Lochmannová
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Jan Šťovíček
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Petra Koptová
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Martin Wasserbauer
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Barbora Frýbová
- Department of Pediatric Surgery, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Jiří Šnajdauf
- Department of Pediatric Surgery, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Jan Matouš
- 2 Department of Internal Medicine Charles University, 3 Faculty of Medicine, FNKV, Prague, Czech Republic
| | - Radana Kotalová
- Department of Pediatry, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Michal Rygl
- Department of Pediatric Surgery, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Štěpán Hlava
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
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Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2018; 66:159-176. [PMID: 29280782 PMCID: PMC5755713 DOI: 10.1097/mpg.0000000000001715] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed. METHODS The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation. RESULTS The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP. CONCLUSIONS This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.
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Rosenfeld EH, Vogel AM, Klinkner DB, Escobar M, Gaines B, Russell R, Campbell B, Wills H, Stallion A, Juang D, Thakkar RK, Upperman J, Jafri M, Burd R, Naik-Mathuria BJ. The utility of ERCP in pediatric pancreatic trauma. J Pediatr Surg 2017; 53:S0022-3468(17)30660-7. [PMID: 29150368 DOI: 10.1016/j.jpedsurg.2017.10.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 10/05/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND/PURPOSE Endoscopic retrograde cholangiopancreatography (ERCP) is an adjunct for pediatric pancreatic injury management, but its use and utility in pediatric patients are unclear. We set out to evaluate the use of ERCP and its effects on outcomes. METHODS A retrospective review was performed for children who had pancreatic injuries at 22 pediatric trauma centers between 2010 and 2015. ERCP details and outcomes were collected. Analysis was performed using descriptive statistics and Wilcoxon rank-sum tests. RESULTS ERCP was used at 14/22 centers for 26 patients. Indications were duct evaluation, duct leak control, pseudocyst, fistula, and stricture. ERCP altered management or improved outcomes in 13/26 (50%), most commonly in patients with ERCP for duct evaluation, stricture, and fistula. In patients managed nonoperatively, those with early endoscopic intervention (within one week of injury) with stent or sphincterotomy (n=9) had similar time to regular diet [median (IQR)]: [10 (7-211) vs 7 (4-12) days; p=0.55], similar hospital days: [12 (8-20) vs 11 (6-19) days, p=0.63], and similar time on parenteral nutrition: [17 (10-40) vs 10 (6-18) days; p=0.19] compared to patients who were only observed. CONCLUSIONS In children with blunt pancreatic injury, ERCP can be useful to diagnose duct injury and for management of late complications such as stricture and fistula. However, early endoscopic intervention for pancreatic duct disruption may not improve outcome or expedite recovery. Further study is needed. STUDY TYPE Retrospective Study; Treatment Study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Eric H Rosenfeld
- Texas Children's Hospital and the Michael E DeBakey, Department of Surgery, Houston, TX.
| | | | | | - Mauricio Escobar
- MultiCare Mary Bridge Children's Hospital & Health Center, Tacoma, WA
| | - Barbara Gaines
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | | | | | - Hale Wills
- Hasbro Children's Hospital, Providence, RI
| | | | | | | | | | - Mubeen Jafri
- Randall Children's Hospital at Oregon Health & Science University, Portland, OR; Doernbecher Children's Hospital Oregon Health and Science University, Portland, OR
| | - Randall Burd
- Children's National Medical Center, Washington, DC
| | - Bindi J Naik-Mathuria
- Texas Children's Hospital and the Michael E DeBakey, Department of Surgery, Houston, TX.
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Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative. J Trauma Acute Care Surg 2017; 83:589-596. [PMID: 28930953 DOI: 10.1097/ta.0000000000001576] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Guidelines for nonoperative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers to develop a consensus-based standard clinical pathway. METHODS A multicenter, retrospective review was conducted of children with high-grade (American Association of Surgeons for Trauma grade III-V) pancreatic injuries treated with NOM between 2010 and 2015. Data were collected on demographics, clinical management, and outcomes. RESULTS Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range, 1-18 years). The majority (73%) of injuries were American Association of Surgeons for Trauma grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range, 4-66). All patients had computed tomography scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. 3Endoscopic retrograde cholangiopancreatogram was obtained in 25%. An organized peripancreatic fluid collection present for at least 7 days after injury was identified in 59% (42 of 71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at a median of 6 days (IQR, 3-13 days) and regular diet at a median of 8 days (IQR 4-20 days). Median hospitalization length was 13 days (IQR, 7-24 days). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. CONCLUSION High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. LEVEL OF EVIDENCE Therapeutic/care management, level V (case series).
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Abstract
PURPOSE OF REVIEW Pediatric acute pancreatitis has been on the rise in the last decades, with an incidence close to adult pancreatitis. In the majority of cases acute pancreatitis resolves spontaneously, but in a subset of children the disease progresses to severe acute pancreatitis with attendant morbidity and mortality. RECENT FINDINGS Pediatric acute pancreatitis in this era is recognized as a separate entity from adult acute pancreatitis given that the causes and disease outcomes are different. There are slow but important advances made in understanding the best management for acute pancreatitis in children from medical, interventional, and surgical aspects. SUMMARY Supportive care with fluids, pain medications, and nutrition remain the mainstay for acute pancreatitis management. For complicated or severe pancreatitis, specialized interventions may be required with endoscopic or drainage procedures. Surgery has an important but limited role in pediatric acute pancreatitis.
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Belyaev O, Tcholakov O, Uhl W. A traumatic pancreatic transection despite a child safety seat. Acta Chir Belg 2017; 117:196-199. [PMID: 27735226 DOI: 10.1080/00015458.2016.1242216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A 5-year-old boy sustained blunt abdominal trauma in a car crash. The buckle mechanism of the five-point harness of his child safety seat compressed his upper abdomen causing an isolated complete pancreatic rupture. Diagnosis was delayed due to subtle symptoms and normal initial findings. A CT scan confirmed diagnosis. An emergency limited central pancreatic resection was performed. The outcome was excellent.
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Affiliation(s)
- Orlin Belyaev
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Oleg Tcholakov
- Department of Surgery, Pirogov Institute, Sofia, Bulgaria
| | - Waldemar Uhl
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Bochum, Germany
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Lin BC, Wong YC, Chen RJ, Liu NJ, Wu CH, Hwang TL, Hsu YP. Major pancreatic duct continuity is the crucial determinant in the management of blunt pancreatic injury: a pancreatographic classification. Surg Endosc 2017; 31:4201-4210. [PMID: 28281124 DOI: 10.1007/s00464-017-5478-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 02/15/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND To evaluate the management and outcomes of blunt pancreatic injuries based on the integrity of the major pancreatic duct (MPD). METHODS Between August 1996 and August 2015, 35 patients with blunt pancreatic injuries underwent endoscopic retrograde pancreatography (ERP). Medical charts were retrospectively reviewed for demography, ERP timing, imaging findings, management, and outcome. RESULTS Of the 35 patients, 21 were men and 14 were women, with ages ranging from 11 to 70 years. On the basis of the ERP findings, we propose a MPD injury classification as follows: class 1 indicates normal MPD; class 2, partial injury with intact MPD continuity; and class 3, complete injury with disrupted MPD continuity. Both classes 2 and 3 are subdivided into classes a, b, and c, which represent the pancreatic tail, body, and head, respectively. In this report, 14 cases belonged to class 1, 10 belonged to class 2, and 11 belonged to class 3. Of the 14 patients with class 1 injuries, 10 underwent nonsurgical treatment and 4 underwent pancreatic duct stenting. Of the 10 patients with class 2 injuries, 4 underwent nonsurgical treatment and 6 underwent pancreatic duct stenting. Two of the 11 patients with class 3 injuries underwent pancreatic duct stenting; one in the acute stage developed sepsis that led to death even after converting to distal pancreatectomy plus splenectomy. Of the 11 patients with class 3 injuries, spleen-preserving distal pancreatectomy was performed in 6, distal pancreatectomy plus splenectomy in 2, and Roux-en-Y pancreaticojejunostomy after central pancreatectomy in 2. The overall pancreatic-related morbidity rate was 60% and the mortality rate was 2.8%. CONCLUSION Based on our experience, class 1 and 2 injuries could be treated by nonsurgical means and pancreatic duct stenting could be an adjunctive therapy in class 2b and 2c injuries. Operation is warranted in class 3 injuries.
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Affiliation(s)
- Being-Chuan Lin
- Division of Trauma & Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei-Shan, Tao-Yuan City, 333, Taiwan, ROC.
| | - Yon-Cheong Wong
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan City, Taiwan, ROC
| | - Ray-Jade Chen
- Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan, ROC
| | - Nai-Jen Liu
- Department of Gastroenterology, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan City, Taiwan, ROC
| | - Cheng-Hsien Wu
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan City, Taiwan, ROC
| | - Tsann-Long Hwang
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan City, Taiwan, ROC
| | - Yu-Pao Hsu
- Division of Trauma & Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei-Shan, Tao-Yuan City, 333, Taiwan, ROC
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Specialized Imaging and Procedures in Pediatric Pancreatology: A North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Clinical Report. J Pediatr Gastroenterol Nutr 2017; 64:472-484. [PMID: 28230608 DOI: 10.1097/mpg.0000000000001371] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES An increasing number of children are being diagnosed with pancreatitis and other pancreatic abnormalities. Dissemination of the information regarding existing imaging techniques and endoscopic modalities to diagnose and manage pancreatic disorders in children is sorely needed. METHODS We conducted a review of the medical literature on the use of the following imaging and procedural modalities in pediatric pancreatology: transabdominal ultrasonography (TUS), computed tomography (CT), magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP). Recommendations for current use and future research were identified. RESULTS TUS offers noninvasive images of the pancreas but has limitations to details of parenchyma and ductal structures. CT offers improved detail of pancreatic parenchyma, solid masses, and traumatic injuries, but requires relatively high levels of ionizing radiation and does not adequately assess ductal anatomy. MRI/MRCP offers detailed intrinsic tissue assessment and pancreatic ductal characterization, but requires longer image acquisition time and is relatively poor at imaging calcifications. EUS provides excellent evaluation of pancreatic parenchyma and ductal anatomy, but can be subjective and operator dependent and requires sedation or anesthesia. EUS offers the capacity to obtain tissue samples and drain fluid collections and ERCP offers the ability to improve drainage by performing sphincterotomy or placing pancreatic stents across duct injuries and strictures. CONCLUSIONS Various imaging modalities may be used in pediatric pancreatology, but TUS and MRI/MRCP are favored. Interventional therapeutic maneuvers primarily involve use of ERCP and EUS. Future research is necessary to optimize equipment, expertise, and appropriate indications.
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