Pancreatic Trauma in Children: Controversies in Care Annie Pugel, MD Seattle Children’s Hospital Department of Surgery

Case 4yo boy booster seated backseat passenger in low mechanism MVC – Immediate epigastric pain – Transient erythematous seatbelt sign – Lipase 125 (normal <120) – Ultrasound showed no evidence of abdominal injury – Normal vital signs, slightly ttp in epigastrium

Epidemiology Low incidence (0.5-12%) – 4 th most common solid organ injury Mechanism – MVC – Bicycle collision or handlebar – Equestrian – Falls

Diagnosis Physical Exam – Ecchymoses – Abdominal distention/tenderness – Direct examination during laparotomy Labs – Transaminases – Amylase, lipase Imaging – CT scan – Ultrasound – ERCP

Classification of Injury f

Controversy Non-operative management well established for grade I/II injuries More controversial for high grade injuries, especially involving ductal injury

Controversy Adults: operative management is standard of care for ductal injury – Drainage is acceptable for Grade I/II Children: standard of care is less well established – Goal is to preserve as much functional organ as possible while minimizing morbidity and mortality

Non-Op Management Late 1990s: retrospective analysis showed non-op management to be safe – Keller, et al, 1997: warranted in the absence of clinical deterioration or known major ductal injury – Shilyansky, et al, 1998: safe for both contusion and transection – Kouchi, et al, 1999: effective in children for most injuries, including main pancreatic duct

Complications Pseudocyst Abscess Fistula Leakage Outcome data – Increased hospital LOS – Longer time on TPN – Need for later intervention (drain, operation)

Operative Management Mattix, et al, 2007: advantage to early operation in patients with ductal injury – Decreased morbidity – Fewer complications Beres, et al, 2013: improved outcome with early intervention for high grade injury – 8x complications – 13d extra of TPN – Likely restricted to patients resectable injury

ERCP with Stenting Canty, et al, 2001: ERCP is safe, may allow for definitive treatment Mattix, et al, 2007: useful for diagnosis – May become useful for definitive treatment

Challenges Rare injury Multiple confounders – Often do not distinguish grade of injury Many studies report single-center experiences – Retrospective

Conclusions Pancreatic injuries in children are rare Diagnosis can be difficult Injuries are graded based on degree of hematoma/laceration and presence of ductal injury Management of ductal injuries in children is controversial

Sources Beres AL, et al. Non-operative management of high-grade pancreatic trauma: Is it worth the wait? J Ped Trauma 2013;48: Canty TG Sr. Management of major pancreatic duct injuries in children. J Trauma 2001; 50: Keller MS, Stafford PW, Vane DW. Conservative management of pancreatic trauma in children. J Trauma 1997;42: Kouchi K, Tanabe M, Yoshida H, et al. Nonoperative management of blunt pancreatic injury in childhood. J Pediatr Surg 1999;34: Mattix KD, et al. Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes. J Pediatr Surg 2007;42: Mendez DR. Management of blunt abdominal trauma in children. UpToDate. Updated February Shilyansky J, Sena LM, Kreller M, et al. Nonoperative management of pancreatic injuries in children. J Pediatr Surg 1998;33:343-9.