Pancreatic Trauma in Children Zeljka Jutric MD R2 Swedish Medical Center

Pediatric Trauma Leading cause of morbidity and mortality in children Abdomen 3rd most commonly injured anatomic region Mortality rate up to 8.5% Most common site of initially unrecognized injury

Pediatric Abdominal Trauma Square abdomen Thinner musculature (less protection) More flexible bony structures Increase in compliance, less effective an energy dissipation Solid organs larger More surface area exposed Lower fat content and more elastic attachments Less energy absorption

Handlebar Injuries Direct impact vs. flipping over handle bars Operative intervention, LOS High index of suspicion for visceral injuries Significant morbidity Delay in diagnosis

Pancreatic Trauma 9% of blunt abdominal pediatric trauma with associated pancreatic injury 50% of causes of acute pancreatitis in children Anatomy

Diagnosis of Pancreatic Trauma Often delayed until pancreatitis/fluid collection develops Vague abdominal pain Lipase/amylase CT ERCP MRCP Ultrasound

Grades of Pancreatic Trauma Grade I: minor contusion Grade II: major contusion Grade III: distal transection and duct injury Grade IV: proximal transection (pancreatic duct and CBD) Additional injureis: ruptured spleen, tension ptx, blunt liver and renal trauma, transected common bile duct, mesenteric hematoma

Management of Grade I and II Non operative NPO, IVF, TPN, Octreotide LOS 3-15 days

Management of Grade III and IV Meier et al Retrospective analysis from 1995-1999 Children’s Medical Center Dallas, Tx 3677 trauma admissions, 11 (0.3 % pancreatic transections; 10 in body, 1 in head. 9 dx with CT) Operative and non operative can be successful, difference in LOS, TPN duration, financial burden etc Six had a mean delay of 2.3 days Delay to diagnosis from hospital admission also 10 transections in body, 1 in head Dx with CT, MRI

Meier et al; Dallas, Texas Type of operation Distal pancreatectomy w splenic preservation in 7 Oversewing of proximal stump and Roux-en-Y drainage in 1 Pylorus-sparing Whipple for transection of the head in 1 Non operative in 2 late presentations (1 Duval 4 wks after, 1 cyst gastrostomy 7 wks after) LOS Early operation 11 days Complications in 4 (wound infection, PNE, fistula, ileus), 1 late TPN duration 8.6 days (20 and 45 for non operative) Faster return to good health, less inconvenience, emotional stress and financial burden None with exocrine or endocrine dysfunction

Laparoscopic Operation: Case Reports Laparoscopic distal pancreatectomy with splenic preservation Reynolds & Curnow, Boise, Idaho Discharged within 7 days of injury Tolerating regular diet and resumed full activities 8 days after accident Since then, 2 additional successful operations with similar LOS Nikfarjam et al, Cleveland, OH Boise, Idaho

Non operative management of injuries with duct involvement Wales et al Toronto (1st report) 10 pts complete transection, all CT dx 4 pseudocysts, 3 percutaneously drained LOS 24 days, other complications 47 mo f/u: atrophy of body/tail in 6, NL in 2 5 of 11 (Shilyansky et al) and 5 of 4 (Kouchi et al) developed pseudocysts Average LOS 25-62 days vs 10-16 days after distal pancreatectomy TPN 20-45 days

Complications Pancreatic fistula Pseudocyst Abscess Chronic pancreatitis