PANCREATIC INJURY IN CHILDREN Controversy and Current Management Accidental Trauma in Children ● 9.2 million medical visits for accidental trauma ● 151,000 hospitalizations for accidental trauma ● >16% of accidental trauma results in permanent injury ● Accidental trauma is the leading cause of death in people <18 yrs of age ● 30 deaths per day Epidemiology ABDOMINAL TRAUMA—10% of all injuries in children. #1 Spleen #2 Liver #3 Kidney #4 Pancreas—3% to 12% of blunt abdominal trauma Scenario 1-Isolated injury from blunt blow. Scenario 2-Multisystem trauma ie MVA, ATV associated injury as high as 60% Relevant Anatomy • Proximity of vascular structures to the head of the pancreas has a marked effect on the morbidity and mortality. – Subhepatic IVC and the aorta sit just posterior to the pancreatic head to the patient's right side – Superior mesenteric vein coalesces into the portal vein immediately behind the pancreas – Splenic artery (off the celiac trunk) and vein (draining into the portal vein) run superior and posterior to the body and tail of the pancreas and are relatively easier to expose and control compared to the IVC and portal vein PHYSIOLOGIC PADDING ADULT ABDOMEN: -posteriorly protected by thick musculature -anteriorly protected by rectus and abdominal musculature and energy absorbing liver,colon, stomach, duodenum, and small bowel “physiologic padding” CHILD ABDOMEN: -Rib cage higher, muscles less developed, organ more mobile, less fat. No “physiologic padding” Duodenal Hematoma • Duodenal Hematoma Duodenal Hematoma The Chance Fx Hyperflexion injury during Chance Fracture sudden deceleration. Anterior vertebral compression-ligament rupture. Associated intrabdominal injuries. Presentation • A high degree of clinical suspicion is necessary to ensure that pancreatic injuries are not overlooked or missed • The type of injury (ie, blunt vs penetrating) and information about the injuring agent (eg, GSW, knife) help focus the clinician on the possibility of pancreatic injury. • Physical examination. • Seat belt marks • flank ecchymoses, or penetrating injuries. • Dull epigastric pain or back pain • severe peritoneal irritation (transection) • Nausea and bilious vomiting (often a delayed symptom) Seat belt Bike handle WorkUp Laboratory studies • Elevation in amylase levels is suggestive of pancreatic injury or inflammation but is not diagnostic • Elevated amylase levels in trauma may be from – salivary glands, – small bowel injury, – ovarian injury – Perforated ulcer – Ruptured Tubal pregnancy . Imaging • Plain Film-foreign body, free air, loss of psoas • Ultrasound-edema and pseudocyst followup • CT scan: simplest and least invasive • --Sensitivity 40 -60% time dependent • Contraindicated in penetrating trauma and hemodynamically unstable. Workup • Magnetic resonance cholangiopancreatography(MRCP) – is being used to assess injury to the ductal components but not frequently used as yet – DSS MRCP (dynamic secretin-stimulated) – Controversy. Image quality and no therapeutic ability as in ERCP Workup • ERCP is Gold standard for detection of pancreatic ductal injuries. • However Controversial (risk vs benefit) • Some authors suggest early ERCP – i.e. within 6-12 h of injury – to minimize delayed complications – Real value is in the head of the pancreas injury – Stenting Diagnosis: Does Time Matter? • Main pancreatic ductal injury increases morbidity and mortality: • ---Increased abscess rate • ---Increased splenectomy rate • ---Increased LOS • ---Increased Pseudocyst rate Workup summary • A child who presents with a history of blunt trauma to the abdomen who has physical findings of pain and guarding who may have bruising or erythema of the abdominal wall who may have elevated amylase. ----Get CT 28 A CT scan performed after abdominal trauma showing diffuse pancreatic enlargement and was interpreted as suspicious for pancreatic injury. (Grade 1 injury) Grade II pancreatic injury: Superficial pancreatic laceration without duct Injury. Contrast CT scan showing transection of distal pancreas Grade III injury Intra-operative photograph of transected distal body of pancreas (arrow). THE CONTROVERSY • What to do with the grade 3 pancreatic injury (the transected pancreas) • Operative vs Non Operative. • Factors-When was the injury? -Is the imaging diagnostic? -Is the patient stable? -Will I cause pancreatic dysfunction? 33 Spleen preserving distal pancreatectomy Treatment • Indication of conservative management – Blunt trauma with Hemodynamically stable patient. – CT scans showing no transection and /or ERCP confirming. • Patients having suspicion of pancreatic injury should be observed for at least 72 hours . Operative • Indications for exploratory laparotomy include: – Penetrating injury in region of pancreas – Peritonitis based on physical examination – Hypotension in combination with a positive focussed assessment with sonography (ultrasound) for trauma (FAST); – Pancreatic duct disruption based on the results of CT scan or ERCP. • Optimal management of pancreatic trauma is determined by – where the parenchymal damage is located – Whether the intrapancreatic common bile duct and main pancreatic duct remains intact. • If operating=To determine the integrity of the pancreatic duct, several options exist – Direct exploration of the parenchymal laceration – Operative pancreatography can be performed through a duodenotomy by cannulating the duct using a 5F pediatric feeding tube • Options for treating injuries of the pancreatic body and tail when the pancreatic duct is transected include – In stable patients, spleen-preserving distal pancreatectomy should be performed. – An alternative, which preserves both the spleen and distal transected end of the pancreas, is either a Roux- en-Y pancreaticojejunostomy or pancreaticogastrostomy • For injuries to the head of the pancreas that involve the main pancreatic duct but not the intrapancreatic bile duct, – Distal pancreatectomy alone is rarely indicated due to the extended resection of normal gland and the resultant risk of pancreatic insufficiency • Central pancreatectomy preserves the common bile duct, and mobilization of the pancreatic body permits drainage into a Roux-en-Y pancreaticojejunostomy. Central pancreatectomy • Injuries to the pancreatic head add an additional element of complication because the intrapancreatic portion of the common bile duct traverses this area and often converges with the pancreatic duct. • Identification of intrapancreatic common bile duct disruption – First method is to squeeze the gallbladder and look for bile leaking from the pancreatic wound. – Cholangiography, optimally via the cystic duct, is diagnostic Pancreatoduedenectomy Complications • Pancreatic Fistula • Peripancreatic abscess • Pancreatic pseudocyst • Delayed complications include – recurrent pancreatitis, – splenic artery aneurysm, – and endocrine or exocrine insufficiency. Pancreatic pseudocyst • If the patient is symptomatic or the size of the pseudocyst is enlarging, MRCP or ERCP should be done to identify any ductal injury. • If no communication of the main pancreatic duct to the pseudocyst, percutaneous drainage should be performed under CT or ultrasound guidance. • If the pseudocyst is in communication with the main proximal pancreatic duct, endoscopic drainage should be attempted. • If the pseudocyst is adherent to the stomach or duodenum and a bulge is identified during endoscopy, drainage can be attempted via endoscopic ultrasound guidance. • If endoscopic drainage is not possible, operative drainage is required PANCREATIC LACERATION PH PH MD .