1. Punt Pass Pageantry

2. 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)

3. 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

4. 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

5. Anatomic variant

6. 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

7. 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

8. 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

9. Nonoperative treatment- distal 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

10. Assume you Punt- Management 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

11. 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

12. 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

13. 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

14. Pageantry- Laparoscopic 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

18. 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