Computed tomography for pancreatic injuries in pediatric blunt abdominal trauma

Blunt pancreatic injury in children: Lessons from 11-year experience in a pediatric center

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.

Minimally Invasive Approaches for Traumatic Rupture of the Pancreas in Children—A Case Series

Pancreatic trauma in children is rare; therefore, both scientific knowledge and clinical experience regarding its management are limited. Abdominal sonography and subsequent computed tomography (CT) imaging are the diagnostic mainstay after severe abdominal trauma in many pediatric trauma centers. However, the diagnosis of pancreatic injury is missed on the initial imaging in approximately one third of cases, with even higher numbers in young children. While conservative treatment is preferred in low-grade injuries, surgical interventions may be indicated in more severe injuries. We present a case series including four patients with high-grade pancreatic injury. Two patients were treated surgically with open laparotomy and primary suture of the head of the pancreas and pancreatico-enterostomy, one patient underwent endoscopic stenting of the pancreatic duct and one received conservative management including observation and secondary endoscopic treatment. We want to emphasize the fact that using a minimally invasive approach can be a feasible option in high-grade pancreatic injury in selected cases. Therefore, we advocate the necessity of fully staffed and equipped high-level pediatric trauma centers.

Learning from Mistakes: Pancreatic Laceration: Devastating Complication During Spine Surgery

BACKGROUND

Posterior decompression and fusion surgery is one of the most commonly performed surgeries for thoracolumbar tuberculosis with destruction of vertebral bodies. Tuberculosis causes gross destruction of the vertebral bodies and surrounding tissue, making them friable.

CASE DESCRIPTION

We present an unusual but dreaded complication which we encountered during posterior decompression and instrumentation surgery in a 65-year-old woman with T10-11 tuberculosis of the spine. During surgical exposure, while reflecting posterior paraspinal muscles on the left side, there was an accidental slip of the Cobb elevator around the transverse process to the extent of two-thirds of its length on the left side anteriorly. The instrument was immediately withdrawn. There was no active bleeding in the field. The rest of the surgery was uneventful. In the postoperative period, however, the patient developed severe abdominal pain with abdominal distention. General surgery opinion was immediately taken and the patient was immediately investigated in the form of a computed tomography scan. It was found that there was a traumatic laceration of the pancreas. The patient underwent emergency exploratory laparotomy and repair of the pancreatic laceration. The patient required intensive monitoring and critical care unit stay and ultimately went on to recover fully over the next few weeks.

CONCLUSIONS

This case illustrates the possibility of pancreatic injury should always be kept in mind if the patient develops acute abdominal discomfort in the postoperative period. Also, a multidisciplinary approach along with intensive care backup and vigilant postoperative monitoring is of utmost importance, especially when an unusual event has occurred during the surgery.

CT and MRI findings in pancreatic trauma in children and correlation with outcome

BACKGROUND

There are limited published data on pancreatic trauma imaging in children.

OBJECTIVE

To present our experience using computed tomography (CT) and magnetic resonance (MR) imaging of pancreatic trauma in children and to correlate the imaging grade of pancreatic injury with management and outcome.

MATERIALS AND METHODS

A retrospective cohort study of children with pancreatic injury presenting between Jan. 1, 2000, and Dec. 31, 2016, was performed. Patient charts were reviewed to note demographics, the mechanism of injury, associated abdominal injuries, management and outcome. All imaging was rereviewed by two radiologists blinded to clinical and laboratory information, and pancreatic injuries were graded according to the American Association for the Surgery of Trauma (AAST).

RESULTS

Of 3,265 patients presented as trauma team activations during the study period, only 28 (0.86%) children (19 boys, 9 girls; mean age: 7.14 years; age range: 1-15 years) had pancreatic injury. Of the available 27 CTs of the abdomen, 26 were performed on the day of trauma. Associated injuries were seen in 25/27 children, most frequently in the liver and lung, 16 (59.2%) each. There were 5 (19%) Grade I, 9 (33%) Grade II, 8 (30%) Grade III and 3 (11%) Grade IV. No patients had Grade V injury. No pancreatic parenchymal injury was identified in 2 (7%) patients with isolated fluid around the pancreas and mesentery. The pancreatic duct was visible in all 10 children (days: 0-330, median days: 41 post-trauma) who had MRI. Eight of these children, who had Grade III/IV injuries on CT and confirmed pancreatic duct injury on endoscopic retrograde cholangiopancreatography (ERCP) or surgery, showed either signal intensity difference in pancreatic parenchyma and/or caliber difference in the pancreatic duct proximal and distal to the injury site. Two patients died because of multiorgan injuries, 9 patients (mainly with Grade III and IV injuries) underwent surgery and/or ERCP, and 16 patients were managed conservatively. AAST grading of pancreatic injury on CT correlated with type of management (P=0.0001) with most of the Grade III and IV injuries treated with intervention and/or surgery while all of the Grade I and II injuries were treated conservatively.

CONCLUSION

Pancreatic injury is rare in children but often associated with other organ injuries most frequently involving the liver and lung. CT grading of injury correlates with management and guides intervention and/or surgery versus conservative treatment. MRI is useful for assessing pancreatic duct injury by demonstrating the pancreatic duct directly and/or secondary changes like signal intensity difference in pancreatic parenchyma and caliber difference in the pancreatic duct.

The Pancreas in Child Abuse

The pancreas can be a critical indicator of inflicted injury in young children. Due to its retroperitoneal location and the amount of incursion of the abdomen required to cause injury, the pancreas is unlikely to be significantly injured in minor trauma incidents. Typical blunt force injury mechanisms for the pancreas include motor vehicle collisions, inflicted injury from blows or kicks, and bicycle handlebar injuries with deep incursion of the abdomen. The death of a toddler is described in which a pancreatic injury was a critical indicator of abusive injury rather than the claimed accidental fall or cardiopulmonary resuscitation-related trauma. Review of the medical literature regarding the epidemiology, etiology, and pathology of childhood pancreatic injuries is discussed. Pancreatic injury is a marker of severe blunt force trauma and should rouse a suspicion of nonaccidental trauma in young children. In the absence of a severe, high velocity or deep abdominal incursion traumatic mechanism, such as motor vehicle collision or bicycle handlebar injury, pancreatic laceration specifically is a marker of inflicted injury in children under the age of five. Acad Forensic Pathol. 2018 8(2): 219-238.

Pancreatic Laceration in a Pediatric Patient: An Unexpected Diagnosis

Pediatric pancreatic injuries are rare. We present an atypical case that occurred in a 4-year-old male. The child presented with a twenty-four-hour history of vomiting that had progressed to right lower quadrant abdominal pain on examination in the emergency department. The initial differential was gastroenteritis versus appendicitis. An abnormality on the ultrasonography and an elevated lipase level eventually led to an MRI showing a complete transection through the posterior margin of the pancreas. The patient was admitted to pediatric surgery and underwent a successful distal pancreatectomy with preservation of the spleen. On further inquiry specific to trauma, the child disclosed that his older brother had punched him in his abdomen the night before. The child's parents were separated due to intimate partner violence, and this older sibling recently had been very stressed. The sibling was referred for mental health evaluation and counseling, and the case reported to the county children and youth investigative services system. A low threshold for considering trauma and child abuse in the pediatric population is recommended when significant intra-abdominal injury is diagnosed.

Pancreatic Injury Caused By A Fall From Height: Transection at the Tail

Isolated pancreatic injury due to blunt abdominal trauma is rare and may be clinically difficult to diagnose. Parenchymal injuries may not be recognized during initial evaluation. We report the case of a 30-year-old male presented to the Emergency Department (ED) with the complaint of persistent abdominal pain, nausea, and vomiting. His medical history revealed that he fell from a height of approximately 1.5 meters 1 day ago and hit an iron block. He was presented and discharged from another hospital ED. Contrast enhanced computerized tomography (CECT) of the abdomen was ordered during his second presentation and revealed pancreatic parenchymal contusion, laceration, and transection at the tail of pancreas. Our findings suggest that, when there is high index of suspicion for pancreatic injury, a CECT should always be ordered.