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Traumatic Pancreatic Injury in paediatric patients

Traumatic Pancreatic Injury in paediatric patients. Joint Hospital Surgical Grand Round Oct 2013. Dr WB Wong Tuen Mun Hospital. Epidemiology. http://www.cobywootenlaw.com/bicycle-accidents/. 4th most common solid organ injury following spleen, liver and kidneys

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Traumatic Pancreatic Injury in paediatric patients

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  1. Traumatic Pancreatic Injuryin paediatric patients Joint Hospital Surgical Grand Round Oct 2013 Dr WB Wong Tuen Mun Hospital

  2. Epidemiology http://www.cobywootenlaw.com/bicycle-accidents/ • 4th most common solid organ injury following spleen, liver and kidneys • 3 to 12% of all trauma admissions • Causes: • Bicycle handlebar • Motor vehicle accident • Horse kicking • Penetrating injuries

  3. Diagnosis • History, physical examination, X-ray • Serum markers • Contrast CT scan • ERCP and MRCP • Exploratory laparotomy • Suspected associated injuries • Hypotension • Peritonitis

  4. Use of CT • Associated injuries • Uncertain sensitivity for ductal injuries • Features of ductal injury: • 50% laceration through the gland • Complete gland transection • Presence of early peripancreatic fluid collection

  5. ERCP and MRCP • ERCP • Diagnose ductal injury • Pancreatic stent • Difficult procedure in paediatric patients • Risk of procedure • MRCP • Non-invasive • Use of secretin

  6. Surgical exploration http://www.trauma.org/index.php/main/image/1028/ Indicator of ductal injuries: Direct visualizaion of injury Complete transection of gland Laceration of greater than ½ of gland Central perforation Severe maceration

  7. American Assoication for the Surgery of Trauma Classification Pancreas Injury Scale Grade Type of Injury Description of Injury   I Hematoma Minor contusion without duct injury   Laceration Superficial laceration without duct injury             II Hematoma Major contusion without duct injury or tissue loss Laceration Major laceration without duct injury or tissue loss III Laceration Distal transection or parenchymal injury with duct involvement IV Laceration Proximal transection or parenchymal injury involving ampulla V Laceration Massive disruption of pancreatic head *Advance one grade for multiple injuries up to grade III

  8. Management • Conservative management for Grade I and II • Operative management for ductal injuries • Grade III: Distal pancreatectomy +/- spleen preservation • Grade IV: Pancreaticojejunostomy • Grade V: Pancreaticoduodenectomy

  9. Paediatric patients http://www.templates.com/blog/come-up-smiling-amazing-3d-characters/ • Trivial injury • Delayed presentation • Isolated injury • Low mortality • Operative morbidity • Incidental splenectomy • Bowel obstruction • Abscess • Fistula

  10. A case for illustration http://www.tinha.org/blog/200910/bicycle/strida-bike/strida-at-namsangwai-and-atv-interview/ 14 year old boy Fell on a bicycle Attended AED D6 Epigastric pain and vomiting Amylase 178

  11. Open cystogastrostomy

  12. Management in paediatrics Controversy over management of patients with ductal injuries Shiyansky Toronto 1998 Non-operative Management of Pancreatic Injuries in Children. Journal of Pediatric Surgery Series of 35 patients 28 patient treated conservatively Operated only for associated injuries 40% developed pseudocyst No ERCP involved

  13. Evidence in literature Management of pancreatic injury in pediatric blunt abdominal trauma. Jobst et al. J Pediatr Surg. 1999 Management of major pancreatic duct injuries in children. Canty et al. J Trauma. 2001 Traumatic pancreatic duct injury in children: minimally invasive approach to management. Houben et al. J Pediatr Surg. 2007 Pancreatic injury in children: good outcome of nonoperative treatment. Blaauw et al.J Pediatr Surg. 2008

  14. Proposed algorithm Blunt abdominal injury Abdominal pain Hyperamylaseamia CT scan to look for ductal injury No Yes Observe symptoms ERCP to look for ductal injuries Yes No Follow-up imaging and amylase Stenting Management of Major Pancreatic Duct Injuries in Children. Journal of Trauma-Injury Infection & Critical Care. 50(6):1001-1007, June 2001.

  15. Proposed algorithm Stenting Fail Success Proximal Distal Drainage ?Spleen preserving distal pancreatectomy Management of Major Pancreatic Duct Injuries in Children. Journal of Trauma-Injury Infection & Critical Care. 50(6):1001-1007, June 2001.

  16. Special features in paediatric injury Delayed presentation in isolated injury Role of ERCP and stenting Controversy over non-operative management in ductal injury Management of pseudocyst for non-operative management

  17. End Thank you for your attention. Questions and discussions welcomed.

  18. References Management of pancreatic trauma Injury. Degiannis et al. Int. J. Care Injured 2008 Pancreatic injury in children: good outcome of nonoperative treatment. Blaauw et al.J Pediatr Surg. 2008 Impact of a defined management algorithm on outcome after traumatic pancreatic injury. Sharpe et al. J Trauma Acute Care Surg. 2012 Non-operative Management of Pancreatic Injuries in Children. Shiyansky et al. Journal of Pediatric Surgery. 1998 Is octreotide beneficial following pancreatic injury? Nwariaku et al. Am J Surg. 1995 Amylase and lipase measurements in paediatric patients with traumatic pancreatic injuries. Matsuno Injury. 2009 Utility of amylase and lipase as predictors of grade of injury or outcomes in pediatric patients with pancreatic trauma. Herman. J Pediatr Surg. 2011 Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes. Mattix et al. J Pediatr Surg. 2007 Management of major pancreatic duct injuries in children. Canty et al. J Trauma. 2001 Imaging of blunt pancreatic trauma. Rekhi et al. Emerg Radiol. 2010

  19. Modifed LUCAS Classification

  20. Classification by Smego

  21. Comparing non-operaive vs operative Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes. Mattix et al. J Pediatr Surg. 2007

  22. Amylase and lipase levels Amylase Lipase Amylase and lipase measurements in paediatric patients with traumatic pancreatic injuries. Matsuno et al. Injury. 2009

  23. Adult algorithm (operative) Impact of a defined management algorithm on outcome after traumatic pancreatic injury. Sharpe et al. J Trauma Acute Care Surg. 2012

  24. Role of octreotide Is octreotide beneficial following pancreatic injury? Nwariaku et al. Am J Surg. 1995

  25. Distal pancreatectomy

  26. Rou-en-Y pancreaticojejunostomy

  27. Pancreaticoduodenectomy

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