1. Pancreatic Trauma in Children
Zeljka Jutric MD R2
Swedish Medical Center

2. 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

3. 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

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

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

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

8. 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

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

12. Management of Grade III and IV
Meier et al Retrospective analysis from 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

13. 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

14. 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

15. 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 days vs days after distal pancreatectomy
TPN days

16. Complications Pancreatic fistula Pseudocyst Abscess
Chronic pancreatitis