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Traumatic Pancreatic Injury
in paediatric patientsJoint Hospital Surgical Grand
Round Oct 2013Dr WB Wong Tuen Mun Hospital
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Epidemiology
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
http://www.cobywootenlaw.com/bicycle-accidents/
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Diagnosis History, physical examination, X-ray Serum markers Contrast CT scan ERCP and MRCP Exploratory laparotomy Suspected associated injuries Hypotension Peritonitis
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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
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ERCP and MRCP
ERCP Diagnose ductal injury Pancreatic stent Difficult procedure in paediatric patients Risk of procedure
MRCP Non-invasive Use of secretin
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Surgical exploration
Indicator of ductal injuries: Direct visualizaion of injury Complete transection of
gland Laceration of greater than
½ of gland Central perforation Severe maceration http://www.trauma.org/index.php/main/image/
1028/
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American Assoication for the Surgery of Trauma Classification
Pancreas Injury ScaleGrade 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
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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
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Paediatric patients Trivial injury Delayed presentation Isolated injury Low mortality Operative morbidity Incidental splenectomy Bowel obstruction Abscess Fistula
http://www.templates.com/blog/come-up-smiling-amazing-3d-characters/
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A case for illustration
14 year old boy Fell on a bicycle Attended AED D6 Epigastric pain and
vomiting Amylase 178
http://www.tinha.org/blog/200910/bicycle/strida-bike/strida-at-namsangwai-and-atv-interview/
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Open cystogastrostomy
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Management in paediatrics
Controversy over management of patients with ductal injuriesShiyansky Toronto 1998Non-operative Management of Pancreatic Injuries in Children. Journal of Pediatric Surgery
Series of 35 patients28 patient treated conservativelyOperated only for associated injuries40% developed pseudocystNo ERCP involved
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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
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Proposed algorithmBlunt abdominal
injuryAbdominal pain
Hyperamylaseamia
Management of Major Pancreatic Duct Injuries in Children. Journal of Trauma-Injury Infection & Critical Care. 50(6):1001-1007, June 2001.
CT scan to look for ductal injury
Yes No
ERCP to look for ductal injuries
No
Follow-up imaging and amylase
Stenting
Observe symptoms
Yes
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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.
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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
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End
Thank you for your attention. Questions and discussions welcomed.
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ReferencesManagement of pancreatic trauma Injury. Degiannis et al. Int. J. Care Injured 2008Pancreatic injury in children: good outcome of nonoperative treatment. Blaauw et al. J Pediatr Surg. 2008Impact of a defined management algorithm on outcome after traumatic pancreatic injury. Sharpe et al. J Trauma Acute Care Surg. 2012Non-operative Management of Pancreatic Injuries in Children. Shiyansky et al. Journal of Pediatric Surgery. 1998Is octreotide beneficial following pancreatic injury? Nwariaku et al. Am J Surg. 1995Amylase 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. 2011Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes. Mattix et al. J Pediatr Surg. 2007Management of major pancreatic duct injuries in children. Canty et al. J Trauma. 2001Imaging of blunt pancreatic trauma. Rekhi et al. Emerg Radiol. 2010
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Modifed LUCAS Classification
Class I Simple superficial contusion or peripheral laceration with minimal parenchymal damage, any portion of the pancreas can be affected, but intact main pancreatic duct
Class II Deep laceration, perforation or transection of the neck, body or tail of the pancreas, with or without pancreatic duct injury
Class III Severe crush, perforation or transection of the head of the pancreas, with or without pancreatic duct injury
Class IV Combined pancreaticoduodenal injuries
(a) Minor pancreatic injury
(b) Severe pancreatic and also duct injury
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Classification by Smego
Grade I Contusion/ haematoma, intact capsule, no parenchymal injury
Grade II Parenchymal injury without major duct injury
Grade III Parenchymal disruption, presumed major ductal injury
Grade IV Massive parenchymal disruption
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Comparing non-operaive vs operative
Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes. Mattix et al. J Pediatr Surg. 2007
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Amylase and lipase levels Amylase and lipase measurements in paediatric patients with traumatic
pancreatic injuries. Matsuno et al. Injury. 2009
Amylase Lipase
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Adult algorithm (operative) Impact of a defined management algorithm on outcome after traumatic
pancreatic injury. Sharpe et al. J Trauma Acute Care Surg. 2012
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Role of octreotide Is octreotide beneficial following pancreatic injury? Nwariaku et al. Am J
Surg. 1995
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Distal pancreatectomy
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Rou-en-Y pancreaticojejunostomy
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Pancreaticoduodenectomy
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