Punt
Pass
Pageantry
Incidence of Pediatric
Pancreatic Trauma
NPTR- 154 injuries in 49540 patients-7
years (only 31- grades III,IV,V)
Canty 18 major ductal injuries-14,245
admissions, 14 years (2.3 million)
Mechanisms of
Pancreatic Trauma
Blunt force traps pancreas against
vertebral column
Lap belt related, falls, bicycle wrecks,
abuse
Angle of force dictates location of injury
Especially true with improperly
restrained children
Diagnosis of Pancreatic
Trauma
Spiral CT +IV contrast; +/- GI contrast
MR Cholangiopancreatography (MRCP)
Mechanism should alert to pancreatic
injury
Amylase>200 and Lipase>1800 + exam
Enzyme levels are not perfectly reliable
Anatomic variant
AAST Pancreas Injury
Scale
I- Minor contusion without duct injury
II-Superficial laceration without duct injury,
major contusion without duct injury or tissue
loss
III- Distal transection or parenchymal injury
with duct injury
IV- Proximal transection or parenchymal
injury involving ampulla (R of SMV)
V- Massive disruption of pancreatic head
Punt!- Nonoperative
Nonoperative treatment correct for
children without major duct/gland
disruption (grades I and II)
Minor injury accounts for 80% of
pediatric pancreas injury
Operative drainage is not useful
Punt- Define the Injury
What to do with ductal transection (III)
Proximal duct vs distal duct
Can the pancreas be treated like the
spleen, liver, and kidney in children?
Rigid adherence to non-operative
management is a mistake
Nonoperative treatmentdistal duct
Toronto- 10 patients with “complete
transection” in 10 years (population?)
9 with complete records
Median Hosp days-24
4 pseudocysts drained
Atrophy distal gland in 6/8
Possibly an incomplete review
Assume you PuntManagement of
Pseudocyst
Many resolve without treatment
Kouchi, et al- Japan- 20 patients
<10 cm, most will resolve
>10 cm, most will need drainage
1 died- TPN related
5% mortality
Pass- Operation for
Distal Transections
Delay in diagnosis is common
Historically, only 50% are diagnosed
upon admission, thus the high incidence
of pseudocyst
Spiral CT may improve this number
Surgical management reasonable,
possibly up to 7 days
Pass- Surgery for Distal
Transections
Spleen sparing distal pancreatectomy
Dallas- 5 patients dx in 12 hours,6
patients dx in 36 hours
9 had surgery within 72 hours
Median hospital stay 11 days
1 late morbidity
Pageantry-Stenting
Proximal Duct Injury
Canty- nonoperative tx of proximal duct
inj (IV or V)
ERCP or MRCP if in doubt
Very few Peds GI people are able to do
this! Think about calling the adult GI
folks
PageantryLaparoscopic repair
Not recommended for proximal injuries
Not recommended if other injuries
suspected (i.e.-bowel)
More than 2 hours of
pneumoperitoneum will start to increase
complications
Summary
No ductal injury- Observe
Midbody Transection- spleen sparing
distal pancreatectomy possibly out to 7
days post injury or observe
Proximal complex injury- observe and
treat the pseudocyst or stent