Traumatic Pancreatic Injury

in paediatric patientsJoint Hospital Surgical Grand

Round Oct 2013Dr WB Wong Tuen Mun Hospital

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/

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

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

ERCP and MRCP

ERCP Diagnose ductal injury Pancreatic stent Difficult procedure in paediatric patients Risk of procedure

MRCP Non-invasive Use of secretin

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/

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

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

Paediatric patients Trivial injury Delayed presentation Isolated injury Low mortality Operative morbidity Incidental splenectomy Bowel obstruction Abscess Fistula

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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/

Open cystogastrostomy

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

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

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

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.

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

End

Thank you for your attention. Questions and discussions welcomed.

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

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

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

Comparing non-operaive vs operative

Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes. Mattix et al. J Pediatr Surg. 2007

Amylase and lipase levels Amylase and lipase measurements in paediatric patients with traumatic

pancreatic injuries. Matsuno et al. Injury. 2009

Amylase Lipase

Adult algorithm (operative) Impact of a defined management algorithm on outcome after traumatic

pancreatic injury. Sharpe et al. J Trauma Acute Care Surg. 2012

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

Surg. 1995

Distal pancreatectomy

Rou-en-Y pancreaticojejunostomy

Pancreaticoduodenectomy