1 Pediatric Pancreatic Injury Samantha J Quade MD 27 th April 2011

2 Epidemiology – Pediatric Trauma  Injury Leading cause of death in children >1 years old  Unintentional injury 65% in <19 years  MVC’s  Homicides / suicides  Drowning

3  children and teenagers die each year  For every child who dies > 40 more hospitalized and 1120 treated in ER  acquire permanent disability

4  35% of significant injury occurs in the home environment  Blunt Trauma 80-90%  GSW account for majority of penetrating

5 Blunt Trauma  10-22% have intrabdominal injuries  Spleen accounts for 45%  Liver, kidneys, bowel  Pancreatic injury accounts for 3-12%

6 Frequency of Organ Injury BluntPenetratingLiver15%22% Spleen27%9% Pancreas2%6% Kidney27%9% Stomach1%10% Duodenum3%4% Small bowel 6%18% Colon2%16% Other17%6% Frequency of Organ

7 Anatomical Differences  Childs abdomen is square and becomes more rectangular  Thinner muscles to protect the organs  Ribs more flexible  Solid organs larger in child  Lower fat content and more elastic attachements  Intestines not fully attached

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12 FUNCTION  Exocrine and Endocrine Gland  Digestive  Hormonal

13 Mechanisms of Pancreatic Injury  MVC  Bicycle  Falls  NAT

14 Sites of Injury Penetrating  evenly divided between head, body, tail  80% distal - left of superior mesenteric vessels  20% proximal > 10-15% of all pancreatic trauma  90% of all grade IV and V pancreatic injuries Blunt: typically involves junction between Blunt: typically involves junction between head and body 85-90% of all pancreatic trauma 85-90% of all pancreatic trauma

15Grade Injury description IHematoma Minor contusion without ductal injury Laceration Superficial laceration without ductal injury IIHematoma Major contusion without ductal injury or tissue loss Laceration Major laceration without ductal injury or tissue loss IIILaceration Distal transection or pancreatic parenchymal injury with ductal injury IVLaceration Proximal transection or pancreatic parenchymal injury involving the ampulla VLaceration Massive disruption of the pancreatic head AAST Classification of Pancreatic Trauma

16 Assessment  ABC’s  Secondary Survey  Abdominal Exam  Lab evaluation

17 Physical Exam

18 NF  4 Y Female presents to HMC following an ATV rollover 5 hrs before on 8/8/2010  10 MPH in front of father hit rocks and rolled ATV  Found lying prone, - LOC  OSH > CT Abdomen and Pelvis  One episode of vomiting prior to arrival

19 History  Born 10wks premature > 8 wks in NICU  Asthma  Previous L Tib/Fib Fx 2007  L Femur Fx /2 abuse

20 PE  BP 92/73 HR 131 RR 20 Temp 37.2 RA  Lethargic and pale  R occipital contusion  Abdomen rounded > abrasions mid epigastric, no ecchymosis  Tender diffusely > moving when palpated, no crying

21 LABS  OSH 1900hrs > Amylase 164, lipase 248, WBC 13.4  0040hrs > Amylase 434 [pancreatic 372] Lipase 428  WBC 20.57, AST 96, ALT 86, Alk Phos 306

22 Diagnostics  History of abdominal trauma  High suspicion of injury  Hyperamylasemia  CT abdomen  ERCP  Therapeutic stent placement with ERCP

23 CT Scan  Gold standard  IV contrast  +/- PO contrast if concerned for duodenal or pancreatic injury  Recent studies advocate the use of alternatives if possible  1 fatal cancer per 1000 CT scanning performed

24 Ultrasound  FAST exams in the unstable adult > free fluid  Not supportive in children  Presence of free fluid is not enough to guide treatment decisions  Low sensitivity and specificity for the detection of injuries

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LM  5 year old male  Riding bicycle around 1200hrs and lost control falling off over the handlebars  Went home c/o abdominal pain  4hrs later increasing abdominal pain, vomited non bileous  Presented to OSH  WBC 24000, Amylase normal 28

Harborview  Arrived at midnight approximately 12hrs post injury  Vomited x 2 on transfer with increasing abdominal pain  Vitals : Temp 35.4, HR 128, 122/75, 22  PE: listless, uncomfortable, knees to abdomen  Rigid, no bowel sounds  Placed NGT > 300 cc stomach contents 29

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33 What to do?  Non operative management standard of care  Controversy in Pancreatic Injuries

34 Operative vs. Non Operative Management

35 Grade I (n = 18) Grade II (n = 6) Grade III (n = 17) Grade IV (n = 2) P Age (y) 7 ± ± ± ± Male67%67%61%100%.71 ISS 14 (6-22) 16 (10-22) 10 (10-10) 26 (10-42).34 LOS (d) 5.5 (3-9) 8.5 (6-9) 17 (11-22) 26 (10-42).0008 ICU (d) 0.5 (0-3) 1 (0-2) 0 (0-2) 10.5 (0-21).84 Nonop0%50%41%50%.0002 Patient Data by Pancreatic Injury Grade

36 Operative (n = 14) Nonop (n = 11) P LOS (d) 13 (8-24) 17 (9-25).82 Readmission11%40%.5 Non-PC57%20%.07 PC21%73%.02 Operative vs Non Outcomes

37 Conclusions  Decision to operate is case dependant  No demonstrable association of either injury grade or ISS  ERCP limitations in this study  Operative management results in sig decreased rates of PCs but doesn’t decrease LOS

38 Predictors of non operative management failure and associated outcomes  Failure of non operative management > intrabdominal intervention  1823 patients > 173 (9.2%)  43 (26%) operation

39 All pancreatic injuries Ductal injuries NOM (n = 128) Failure (n = 45) P NOM (n = 30) Failure (n = 23) P Age (y) 7.7 ± ± ± ± 3.7 Sex (% male) 63.3%63.2% ISS 15 ± ± ± ± GCS 13 ± 4 10 ± ± 3 11 ± Bicycle21.8%32.6%40%30% MVC26.6%20.9%16.7%17.4% LOS (d) 9.6 ± ± ± ± ICU LOS (d) 4.17 ± ± ± ±

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41 Conclusions  Non operative management successful in 74%  Overall no difference in NOM vs surgery  However there maybe an advantage in pts with ductal injuries > decreased pseudocysts

42 Treatment  Basic surgical principles: unstable patients  diagnosed and treated in the OR; control hemorrhage / contamination.  Diagnose major ductal injury Conservative operative management: Conservative operative management:  external drainage - imperative  internal drainage / defunctioning procedures rarely  indicated and increase morbidity

43 NF Treatment Strategy  Grade IV: proximal injury with ductal injury / high suspicion ductal injury. < 1% pancreatic injuries stable patient: “pancreatography” stable patient: “pancreatography” No ductal injury: drainage No ductal injury: drainage Ductal injury: subtotal pancreatectomy Ductal injury: subtotal pancreatectomy injury distal to confluence of CBD and pancreatic injury distal to confluence of CBD and pancreatic duct duct +/- roux-en Y pancreaticojejunostomy / controversial +/- roux-en Y pancreaticojejunostomy / controversial unstable patient: external drainage used almost exclusively unstable patient: external drainage used almost exclusively

44 Operation  Retroperitoneal Hematoma at base of the of transverse colon  Areas of bleeding close to pancreatic body  Injury at the neck of the pancreas  Contusion with small laceration  No transection  2 JP drains > one at neck and one at the head  NGT, unable to place feeding tube

45 Course  8/11 > JP amylase 283,000  8/12 > VM for ERCP > main pancreatic duct intact, injury to side duct  No stent  8/13 > JT tube, started on clears  8/19 JP amylase 85000

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48 External Drainage  Vital in most all pancreatic injuries Minimum of 4 drains for major injuries Minimum of 4 drains for major injuries  Closed-suction drains: in several randomized studies have proven more effective less incidence of septic complication less incidence of septic complication provides a controlled and effective drainage of fluid provides a controlled and effective drainage of fluid

LM  Labs: WBC 24000, Amylase T: 506 [P:409]  No free air on abdomen films  Taken emergently to OR for exploration  Duodenal Perforation - bile staining in retropertioneum - bile staining in retropertioneum - Dissection near head of pancreas > full thickness laceration 50% : primary repair - Placement NJ FT 49

Hospital Course  NJ feeds  Amylase continued to decrease  UGI on post op day 5  No leak  Advanced diet  DC home post op day 6  Follow up in clinic 2wks later normal activities 50

51 Pancreatic Fistula  Most common complication arising from pancreatic trauma  invariably seen with proximal injuries  > 100 cc/day for greater than 10 days with elevated amylase  vast majority close in 2-12 weeks with conservative treatment  octreotide has not been proven beneficial  5-7% will require reoperation, usually with a Roux limb to injured pancreatic segment to injured pancreatic segment

52 Conclusions  No long term data to support non operative vs operative management  Difficult to study due to the small population with these injuries  No long term outcome data on the children who underwent operations and level of function of their pancreas  ERCP both for diagnostics and therapeutics may provide an alternative