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Non-operative management of pancreatic injury
Journal of Pediatric Surgery Case Reports 52 (2020) 101352
Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: http://www.elsevier.com/locate/epsc
Non-operative management of pancreatic injury Elinore J. Kaufman a, Caitlin B. Finn a, Jennifer Minneman a, Michel Kahaleh b, Shaun A. Steigman a, Nitsana A. Spigland a, * a b
NewYork-Presbyterian Hospital-Weill Cornell Medical College, Department of Surgery, 525 East 68th Street, New York, NY, 10065, USA Robert Wood Johnson Hospital, Division of Gastroenterology and Hepatology, 1 RWJ Plaza, New Brunswick, NJ, 08901, USA
A R T I C L E I N F O
A B S T R A C T
Keywords: Pancreatic injury Trauma Non-operative management Endoscopy Type of study: therapeutic Level of evidence: level IV
Background/purpose: Pancreatic injury is a rare complication of blunt abdominal trauma in pediatric populations. Non-operative management is increasingly common in pediatric pancreatic injury, using endoscopic in terventions. We report our institutional experience with non-operative management of pediatric pancreatic trauma, with a focus on the role of endoscopic interventions. Methods: We performed a retrospective review of all cases of blunt pancreatic trauma in children presenting to our urban, academic, level I pediatric trauma center from 1996 to 2016. Results: We identified six cases of blunt pancreatic trauma in children aged 2–15 years. One patient required operative intervention for duodenal perforation, but no patients underwent pancreatic surgery. Endoscopic in terventions were used in four cases to manage complications, such as pancreatic fluid collections and ductal stenosis. Conclusions: Pancreatic trauma can be managed safely and effectively using non-operative interventions in the pediatric population.
1. Introduction Pancreatic injury is rare in children, occurring in just 2% of blunt abdominal injuries, most commonly motor vehicle crashes with inade quate passenger restraints, or handlebar injuries [1,2]. Mortality has been reported as high as 50%, though this is often due to associated injuries [1]. Over the last few decades, management has shifted away from operative intervention toward a trial of non-operative manage ment, even for the most severe injuries. A recent review of that National Trauma Data Bank found that approximately half of pediatric pancreatic injuries in the United States are managed nonoperatively, with equiva lent or superior outcomes to operative intervention [3,4]. Many series in the literature report successful non-operative management of pediatric patients with severe pancreatic injuries with no increase in mortality [1, 4–10]. Non-operative management consists of nasogastric tube (NGT) decompression and total parenteral nutrition (TPN) for an average of 14 days [1], as well as somatostatin analogs [1]. Non-operative manage ment may be associated with increased pancreatic complications, pri marily development of pancreatic fluid collections (PFC) [6]. Of children with grade III-IV injuries, 10–44% of those managed
non-operatively have gone on to develop PFCs, which are generally managed with non-operative drainage [1,8–15]. Although imaging may demonstrate pancreatic atrophy, pancreatic insufficiency has not been reported [1,16]. For patients requiring surgery, intervention within 48 h has been associated with shorter length of stay and fewer complications than delayed surgery. Therefore, a trial of non-operative management might worsen outcomes if unsuccessful [14,17]. Failure of non-operative management and delayed surgery has been associated with ductal injury and increased injury severity score [18]. Holmes et al. found that failure of non-operative management generally occurred within the first 12 h [18]. In this study, pancreatic injury was an independent predictor of failure of nonoperative management in pediatric abdominal injury. Endoscopic drainage of PFCs and stenting of the pancreatic duct has been demonstrated efficacious in the adult population [19], but as this technology continues to evolve, evidence remains limited on its role in pediatric pancreatic trauma. Several series have reported the use of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric pancreatic injury, though many series have used ERCP only as a diag nostic adjuvant with positive results leading to operative intervention, or have not described the intervention [4,6,20]. In this study, we review
* Corresponding author. New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th Street, New York, NY, 10065, USA. E-mail address: [email protected] (N.A. Spigland). https://doi.org/10.1016/j.epsc.2019.101352 Received 25 September 2019; Received in revised form 12 November 2019; Accepted 13 November 2019 Available online 16 November 2019 2213-5766/© 2019 The Authors. Published by Elsevier Inc. This is an open access (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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E.J. Kaufman et al.
Journal of Pediatric Surgery Case Reports 52 (2020) 101352
our institutional experience with pediatric pancreatic transection, with emphasis on the role of endoscopic intervention.
Table 2 Patient characteristics and outcomes.
2. Methods In this single-institution case series we reviewed the charts of all pediatric patients with blunt pancreatic trauma presenting to our urban, academic, level I pediatric trauma center from 1996 to 2016. Patients were included if they had an International Classification of Diseases, version 9 or 10, code indicating pancreatic injury (Table 1) confirmed by evidence of pancreatic injury on abdominal imaging (see Table 2). Data extracted from the medical record included patient histories, exam findings, and clinical course, procedure reports, laboratory values, and imaging findings at admission and follow-up. Injuries were graded according to the American Association for the Surgery of Trauma Organ Injury Scaling guidelines [21]. Case histories were summarized.
3 Deep venous thrombosis (2), malfunction (3), infection (1) Pancreatic duct stricture and recurrent pancreatitis (1) None (1), ERCP with no intervention (1), Cystgastrostomy (2), Pancreatic duct stenting (3)
3.2. Case 2 Case 2 was a healthy 2-year-old boy who ran into an open, metal cellar door, hitting his abdomen on the edge. Initial evaluation by his pediatrician was negative, but he developed worsening abdominal pain over the next day and was referred to the emergency department (ED). He presented to an outside hospital, where computed tomography (CT) scan of the abdomen showed moderate free fluid in the pelvis and a linear hypodensity in the distal pancreatic body. He was transferred to our institution for a higher level of care. On presentation, he was he modynamically stable, with epigastric tenderness and a large ecchy mosis of the left abdomen. His labs showed elevated amylase and lipase to 605 U/L and 714 U/L, respectively. Repeat imaging confirmed tran section of the pancreatic body (Fig. 1D). A nasogastric (NG) tube and PICC line were placed and TPN was initiated. He gradually improved, and after 6 weeks he was discharged to a rehabilitation facility for continuation of TPN with normal exam and labs. He was readmitted twice for PICC malfunction, but recovered well. At 3 months, he un derwent magnetic resonance cholangiopancreatography (MRCP), which showed decreased signal in the pancreatic tail consistent with distal ductal stricture and a small pseudocyst (Fig. 1E), but no other abnor malities. Oral feeding was commenced, and he recovered well thereafter with CT showing a healed pancreatic duct. (Fig. 1F).
Case 1 was a previously healthy 7-year-old boy who was transferred from an outside hospital after a bicycle accident. He was diagnosed with duodenal perforation and contusion to the head of the pancreas. At operative exploration, the duodenum was repaired with primary duo denoduodenostomy. No pancreatic resection was performed, and drains were placed in the area. He was kept nil per os (NPO) and given octreotide and total parenteral nutrition (TPN) via a peripherallyinserted central venous catheter (PICC). He had persistently high output from his peripancreatic drain, and repeat imaging demonstrated an additional undrained collection for which he underwent percuta neous drainage by interventional radiology (IR). At the time of the procedure, this collection was found to communicate with the main pancreatic duct to the right of the superior mesenteric vessels. At the time, pediatric ERCP was not available at our institution, and the patient was transferred to another hospital, where ERCP demonstrated com plete transection of the pancreatic duct (Fig. 1A and B). He developed a pseudocyst at two months post-injury, which was 3.1 � 7.0 � 5.6 cm, and ultimately resorbed without additional drainage (Fig. 1C). He
3.3. Case 3 Case 3 was a 9-year-old boy with a history of asthma and attention deficit hyperactivity disorder who was admitted after falling from the monkey bars while playing, striking his abdomen on an iron bar. On presentation, he had normal vital signs and complained only of abdominal pain and vomiting. His abdomen was soft with moderate epigastric tenderness without distension or rebound. Admission amylase was 558 U/L and lipase was 201 U/L. CT showed laceration at the junction of pancreatic body and tail and moderate peripancreatic and left upper quadrant fluid (Image 1G). Upper GI endoscopy was per formed with no evidence of duodenal injury. NG tube and PICC line were placed and TPN was initiated. Pancreatic enzymes doubled on hospital day (HD) 3, and MRCP demonstrated a fluid collection at the transection site with a normal pancreatic duct. However, his bowel function resumed and the NGT was removed on post-injury day 9. Follow up ultrasound showed two <5 cm peripancreatic collections. He was asymptomatic, and his activity was gradually advanced and he was discharged to a facility for continuation of TPN on day 14. He was readmitted one month post-injury with dehydration due to
Table 1 International classification of diseases codes for pancreatic injury. ICD-9 Injury to pancreas, head, without mention of open wound into cavity Injury to pancreas, body, without mention of open wound into cavity Injury to pancreas, tail, without mention of open wound into cavity Injury to pancreas, multiple and unspecified sites, without mention of open wound into cavity Injury to pancreas, head, with open wound into cavity Injury to pancreas, body, with open wound into cavity Injury to pancreas, tail, with open wound into cavity Injury to pancreas, multiple and unspecified sites, with open wound into cavity
ICD-10 Unspecified injury of Unspecified injury of Unspecified injury of Unspecified injury of
11 (2–15) 5 1 Sports collision (2), fall while playing (2) fall from horse, bicycle accident II (2), III (4) 2.5 months (4 days–5 months)
remained NPO on TPN for a total of 5 months, at which point follow up imaging demonstrated complete healing of the pancreatic duct. He was followed for five years post-injury with a normal pancreas on ultra sound, normal growth and development and no symptoms.
3.1. Case 1
S36.200A S36.201A S36.202A S36.209A
Age (median, range) Male (n) Female (n) Mechanism (n)
Chronic complications (n) Interventions (n)
We identified 6 patients with blunt pancreatic injuries at our center over this time period, 5 males and 1 female. Ages ranged from 2 to 15 at presentation. Mechanisms of injury were all blunt, including fall from horse, sports, bicycle accident, and fall. Patient characteristics are dis played in Table 1. One patient underwent abdominal exploration for duodenal perforation; no patients underwent operative intervention for pancreatic injury. There were no deaths.
863.91 863.92 863.93 863.94
Sample Description (N ¼ 6)
Injury grade (n) NPO/TPN duration (median, range) Pseudocyst PICC complications (n)
3. Results
863.81 863.82 863.83 863.84
Patient Characteristics
head of pancreas, initial encounter body of pancreas, initial encounter tail of pancreas, initial encounter unspecified part of pancreas
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E.J. Kaufman et al.
Journal of Pediatric Surgery Case Reports 52 (2020) 101352
Fig. 1. Images from cases 1-4. Case 1: A. ERCP image showing contrast extravasation from main pancreatic duct to fill collection. B. Endoscopic ultrasound images re-demonstrating pseudocyst. C. CT showing pseudocyst formation following injury. Case 2: D. CT showing hypodensity of the pancreas consistent with laceration. E. Follow up MRCP demonstrating stricture and small pseudocyst. F. Subsequent CT showing healing of the pancreatic duct. Case 3: G. CT demonstrating pancreatic laceration at the time of injury. H. Pseudocyst six weeks following injury. I. Ultrasound showing resolution of fluid collection following endoscopic drainage. Case 4: J. CT demonstrating laceration of the distal pancreas. K. MRI showing transection of the pancreatic tail with injury to the distal pancreatic duct.
PICC dysfunction, and on repeat imaging, the two small collections had coalesced into a pseudocyst measuring 5.1 cm (Image 1H). Six weeks post-injury, this pseudocyst increased in size to 7.2 cm, abutting the patent splenic vein. He was transferred to our sister institution for endoscopic drainage with cystgastrostomy and pancreatic duct stenting. On return transfer, his diet was advanced, TPN was stopped, and PICC was removed. He was discharged home on a low-fat diet 2 months postinjury. Follow-up ultrasound showed a normal pancreas, with mild ductal dilation up to 2 mm and no fluid collection (Image 1I). The pancreatic duct stent was subsequently removed. He was followed for 5 years post injury with no evidence of pancreatic issues.
3.4. Case 4 Case 4 was an otherwise healthy 15-year-old boy who was hit in the abdomen while playing basketball. Later that day, he developed severe abdominal pain and was brought to an outside ED. Labs showed a lipase of 2600 U/L, and CT showed a laceration to the tail of the pancreas (Image 1J). He was transferred to our institution for further manage ment. He had no other symptoms and no evidence of additional injuries. He was hemodynamically stable, and his exam was notable for a soft abdomen with tenderness to palpation in the epigastrium without rebound or guarding. Admission labs showed a lipase of 565 U/L. MRCP demonstrated transection of the pancreatic tail with injury to the distal 3
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Journal of Pediatric Surgery Case Reports 52 (2020) 101352
knee to the abdomen. He initially presented to an outside hospital, where an ultrasound was positive for free fluid. On transfer to our institution, he was hemodynamically stable and his abdomen was tender to palpation in the epigastrium. Admission white blood cell count was 12.0, hemoglobin was 11.2, and amylase was 274 U/L. CT of the abdomen and pelvis showed moderate hemoperitoneum with a contu sion of the right lobe of the liver and complete transection of the pancreas distal to the superior mesenteric vessels (Fig. 2D). He was kept NPO and his abdominal pain and tenderness improved, though amylase and lipase tripled over the first 2 hospital days. A PICC was placed and TPN and octreotide were begun, though this was complicated by a PICCassociated DVT. Given his slow improvement, on HD 10, he was taken for ERCP with sphincterotomy. The endoscopist was not able to cross the transected duct with a wire. A stent was placed in the proximal duct to augment drainage. Repeat ultrasound on HD 12 showed a pseudocyst with in ternal debris that was displacing the stomach medially. MRI confirmed a 7 cm pseudocyst (Fig. 2E). On HD 14, he developed new fever and abdominal pain. Given concern for infected pseudocyst, endoscopic ultrasound-guided cystgastrostomy was performed with placement of a lumen apposing metal stent (Axios, Boston Scientific, Natick, MA). Pseudocyst fluid cultures grew streptococcus viridans and streptococcus sanguinis, for which he received a 3-week course of meropenem. Fevers and pain improved, and repeat endoscopy showed a clean pseudocyst cavity with granulation and no necrosis. On HD 20, he had a repeat MRI that showed resolution of the pseudocyst. However, he subsequently developed recurrent epigastric pain and vomiting. Ultrasound showed minimal change, but he under went repeat ERCP. At this point, the endoscopy team was able to cross the ductal transection with a wire and 5 French plastic stent was placed to seal the disruption. His pain and nausea resolved and he was dis charged on TPN on HD 32. Ultrasound performed one week postdischarge showed a partially healed pancreatic laceration, and MRCP two weeks later showed further healing with no collection (Fig. 2F). His diet was advanced, and a repeat ERCP 3 months post injury showed normal filling of the pancreatic duct with atrophy of the pancreatic tail. The pancreatic stent was removed and the patient has continued to thrive.
pancreatic duct and retroperitoneal fluid, but no organized collection (Image 1K). He was made NPO, and his diet was advanced to a low-fat diet over 4 days. He was discharged home in good condition on HD 7. Follow up ultrasound again demonstrated transection of the pancreatic tail with no fluid collection or free fluid. He recovered well, resumed a regular diet, and returned to basketball 5 weeks post-injury. 3.5. Case 5 Case 5 was a 13-year-old otherwise healthy girl who presented to the ED with abdominal pain five days after falling twice from a horse, landing on her back and stomach. She was hemodynamically stable. At presentation, her abdomen was soft and diffusely tender to palpation with no rebound or guarding. Admission amylase was 373 U/L. CT of the abdomen and showed peripancreatic fluid tracking into the bilateral paracolic gutters. Given high suspicion for pancreatic injury, MRCP was performed which showed a laceration and contusion of the pancreatic body, and possible laceration of the tail, but was not able to clearly assess the integrity of the pancreatic duct (Fig. 2A). A PICC line was placed and TPN was initiated. Her abdominal pain improved gradually over the next four days and bowel function resumed. She was discharged home with TPN. Repeat imaging 3 months post-injury showed resolu tion of her pancreatic lacerations with no residual peripancreatic fluid and no pseudocyst development, and she tolerated a regular diet and activity. Six months after her initial injury, she returned to the ED with abdominal pain after colliding with another player during a volleyball game the previous day. She was found to have recurrent, traumatic pancreatitis (Fig. 2B). She was initially maintained on TPN, which was complicated by PICC-associated deep vein thrombosis (DVT) requiring enoxaparin and PICC removal. However, when she was unable to advance her diet after 2 months of TPN, re-imaging with MRCP demonstrated chronic pancreatitis with an ultrashort stricture of the main pancreatic duct (Fig. 2C). This was treated successfully by ERCP with sphincterotomy and stenting of the stricture. She was then able to advance her diet, but had several recurrent episodes of pancreatitis requiring ERCP with dilations and stent revisions. She is currently stent free for the last 18 months.
4. Discussion
3.6. Case 6
In this series, we report our institutional experience with pancreatic injury in children, a rare consequence of blunt abdominal trauma. We
Case 6 was a 14-year-old boy who sustained blunt abdominal trauma after colliding with another player during a baseball game and taking a
Fig. 2. Images from cases 4-5. Case 5: A. MRI showing pancreatic lacera tion and peripancreatic fluid. B. MRCPs demonstrating pancreatic laceration small pseudocyst after a second trauma. C. MRCP showing pancreatic duct stricture. Case 6: D. Initial CT showing laceration through body of pancreas. E. MRIs showing development of 7 cm pancreatic pseudocyst two weeks following initial injury. F. MRCP showing resolution following ERCP.
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Journal of Pediatric Surgery Case Reports 52 (2020) 101352
identified six cases, all managed non-operatively despite the presence of complex injuries. Our results are consistent with several previous studies that found low rates of failure of non-operative management in this population. In 1996, Huckfeldt et al. published the first case report of a patient with a traumatic pancreatic transection successfully treated with endoscopic stenting [22]. Canty et al. published two more cases in 2001, with endoscopic stenting of major pancreatic duct injuries. In both cases, ERCP was performed for acute worsening abdominal pain on initial presentation and both patients avoided resection without subsequent complication [23]. In 2005, Cay et al. reported a similar case in an 11-year-old child [24], and Wood reported one additional case [6]. Houben et al. reported on 14 cases of pediatric pancreatic injury with initial non-operative management [2]. Twelve underwent ERCP, and 9 stents were placed, 3 across a ductal injury and 6 to drain a pseudocyst. Management was successful, with no delayed operations or mortalities, though median length of TPN and hospital stay were long (28 and 41 days, respectively) [2]. Other multi-center studies have shown that peri-pancreatic and psudocyst formation is common following blunt trauma [15], requiring drainage in 1/3 of cases with fluid collections [10]. However, there was no difference between those who underwent drainage procedures compared with observation in TPN use, time to tolerate a regular diet, hospital length of stay, or failure of non-operative management [10]. As endoscopic management of the pancreas continues to advance, we believe that the indications for operation in these patients will continue to narrow; even severe injuries can be managed without laparotomy in the absence of concomitant abdominal injuries that mandate surgery. Concern about nonoperative management has centered on peripancreatic collection and pseudocyst formation. Half of our patients developed pseudocysts, consistent with published rates. These too, however, can be managed nonoperatively with acceptable risk profiles. While the disincentive to operate may be reduced as distal ductal disruption has been managed with laparoscopic, spleen-preserving distal pancreatectomy [25,26], short- and long-term complications of operative management must be considered. Avoiding operation in these patients likely limits risk not only of short-term perioperative morbidity but also of long-term sequela of exocrine or endocrine insufficiency. Acute complications are common after blunt pancreatic injury, and are similar among management strategies. A recent review of NTDB data found adjusted complication rates of 21.5% in non-operative and 17.5% in early operative management, with no significant difference [3]. Pseudocysts were more common in non-operative management, while infections were more common in operative patients, and length of stay was similar [3]. To our knowledge, long-term follow-up data are not available on children after blunt pancreatic injury. However, in children undergoing elective pancreatic resection for other indications, diabetes may occur in 10% and exocrine insufficiency in 20%–83% [27,28]. Our study has several limitations. First, we report a small number of cases due to the low frequency of pancreatic trauma. Second, we report the experience at one large, urban academic center, which may not generalize to all cases. Despite our limitations, We aim to add to a growing body of literature supporting non-operative management of these injuries in children with the recognition that further study is needed to determine which of these patients, if any, would benefit from early operation over non-operative management. We sought to highlight the emerging role of interventional endoscopy, but further follow up will be needed to delineate both the indications and the best techniques for endoscopic management of pancreatic ductal injuries.
Patient consent Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the identifica tion of the patient. Funding This research did not receive any funding or grant support. Authorship All authors attest that they meet the current ICMJE criteria for Authorship. Declaration of competing interest Author MK discloses that he receives an honorarium for his role as a consultant from BSC, Abbvie, Emcision, Pinnacle, and US Endoscopy. MK has received research and training grants for his role as an investi gator and training director from BSC, Cook, Olympus, Apollo, Conmed, GORE, ERBE. The following authors have no financial disclosures: EK, CF, JM, SS, NS. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi. org/10.1016/j.epsc.2019.101352. References [1] Jacombs AS, Wines M, Holland A, Ross FI, Shun A, Cass DT. Pancreatic trauma in children. J Pediatr Surg 2004;39:96–9. [2] Houben CH, Ade-Ajayi N, Patel S, Kane P, Karani J, Devlin J, et al. Traumatic pancreatic duct injury in children: minimally invasive approach to management. J Pediatr Surg 2007;42:629–35. [3] Mora MC, Wong KE, Friderici J, Bittner K, Moriarty KP, Patterson LA, et al. Operative vs nonoperative management of pediatric blunt pancreatic trauma: evaluation of the national trauma data bank. J Am Coll Surg 2016;222:977–82. [4] Englum BR, Gulack BC, Rice HE, Scarborough JE, Adibe OO. Management of blunt pancreatic trauma in children: review of the national trauma data bank. J Pediatr Surg 2016;51:1526–31. [5] Cigdem MK, Senturk S, Onen A, Siga M, Akay H, Otcu S. Nonoperative management of pancreatic injuries in pediatric patients. Surg Today 2011;41: 655–9. [6] Wood JH, Partrick DA, Bruny JL, Sauaia A, Moulton SL. Operative vs nonoperative management of blunt pancreatic trauma in children. J Pediatr Surg 2010;45:401–6. [7] Kouchi K, Tanabe M, Yoshida H, Iwai J, Matsunaga T, Ohtsuka Y, et al. Nonoperative management of blunt pancreatic injury in childhood. J Pediatr Surg 1999;34:1736–9. [8] Jobst MA, Canty Sr TG, Lynch FP. Management of pancreatic injury in pediatric blunt abdominal trauma. J Pediatr Surg 1999;34:818–23. discussion 823-814. [9] de Blaauw I, Winkelhorst JT, Rieu PN, van der Staak FH, Wijnen MH, Severijnen RS, et al. Pancreatic injury in children: good outcome of nonoperative treatment. J Pediatr Surg 2008;43:1640–3. [10] Rosenfeld EH, Vogel AM, Jafri M, Burd R, Russell R, Beaudin M, et al. Management and outcomes of peripancreatic fluid collections and pseudocysts following nonoperative management of pancreatic injuries in children. Pediatr Surg Int 2019;35: 861–7. [11] Keller MS, Stafford PW, Vane DW. Conservative management of pancreatic trauma in children. J Trauma 1997;42:1097–100. [12] Shilyansky J, Sena LM, Kreller M, Chait P, Babyn PS, Filler RM, et al. Nonoperative management of pancreatic injuries in children. J Pediatr Surg 1998;33:343–9. [13] Abbo O, Lemandat A, Reina N, Bouali O, Ballouhey Q, Carfagna L, et al. Conservative management of blunt pancreatic trauma in children: a single center experience. Eur J Pediatr Surg : Off J Austrian Assoc Pediatr Surg 2013;23:470–3. Zeitschrift fur Kinderchirurgie. [14] Ho VP, Patel NJ, Bokhari F, Madbak FG, Hambley JE, Yon JR, et al. Management of adult pancreatic injuries: a practice management guideline from the eastern association for the surgery of trauma. J Trauma Acute Care Surg 2017;82:185–99. [15] Naik-Mathuria BJ, Rosenfeld EH, Gosain A, Burd R, Falcone Jr RA, Thakkar R, et al. Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: a pediatric trauma society collaborative. J Trauma Acute Care Surg 2017;83:589–96. [16] Wales PW, Shuckett B, Kim PC. Long-term outcome after nonoperative management of complete traumatic pancreatic transection in children. J Pediatr Surg 2001;36:823–7.
5. Conclusion Non-operative management is safe and effective for pancreatic in juries in children. Interventional endoscopy is a useful adjunct in the care of these patients, and may extend the reach and improve the re covery of non-operative management of pediatric pancreatic injury.
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Journal of Pediatric Surgery Case Reports 52 (2020) 101352 [23] Canty Sr TG, Weinman D. Treatment of pancreatic duct disruption in children by an endoscopically placed stent. J Pediatr Surg 2001;36:345–8. [24] Cay A, Imamoglu M, Bektas O, Ozdemir O, Arslan M, Sarihan H. Nonoperative treatment of traumatic pancreatic duct disruption in children with an endoscopically placed stent. J Pediatr Surg 2005;40:e9–12. [25] Rutkoski JD, Segura BJ, Kane TD. Experience with totally laparoscopic distal pancreatectomy with splenic preservation for pediatric trauma–2 techniques. J Pediatr Surg 2011;46:588–93. [26] Nikfarjam M, Rosen M, Ponsky T. Early management of traumatic pancreatic transection by spleen-preserving laparoscopic distal pancreatectomy. J Pediatr Surg 2009;44:455–8. [27] Lindholm EB, Alkattan AK, Abramson SJ, Price AP, Heaton TE, Balachandran VP, et al. Pancreaticoduodenectomy for pediatric and adolescent pancreatic malignancy: a single-center retrospective analysis. J Pediatr Surg 2017;52: 299–303. [28] Marchegiani G, Crippa S, Malleo G, Partelli S, Capelli P, Pederzoli P, et al. Surgical treatment of pancreatic tumors in childhood and adolescence: uncommon neoplasms with favorable outcome. Pancreatology : Off J Int Assoc Pancreatol 2011;11:383–9.
[17] Nadler EP, Gardner M, Schall LC, Lynch JM, Ford HR. Management of blunt pancreatic injury in children. J Trauma 1999;47:1098–103. [18] Holmes JHt, Wiebe DJ, Tataria M, Mattix KD, Mooney DP, Scaife ER, et al. The failure of nonoperative management in pediatric solid organ injury: a multiinstitutional experience. J Trauma 2005;59:1309–13. [19] Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, et al. An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis. Gastroenterology 2019;156:1027–40. e1023. [20] Rescorla FJ, Plumley DA, Sherman S, Scherer 3rd LR, West KW, Grosfeld JL. The efficacy of early ercp in pediatric pancreatic trauma. J Pediatr Surg 1995;30: 336–40. [21] Moore EE, Moore FA. American association for the surgery of trauma organ injury scaling: 50th anniversary review article of the journal of trauma. J Trauma 2010; 69:1600–1. [22] Huckfeldt R, Agee C, Nichols WK, Barthel J. Nonoperative treatment of traumatic pancreatic duct disruption using an endoscopically placed stent. J Trauma 1996; 41:143–4.
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Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: http://www.elsevier.com/locate/epsc
Non-operative management of pancreatic injury Elinore J. Kaufman a, Caitlin B. Finn a, Jennifer Minneman a, Michel Kahaleh b, Shaun A. Steigman a, Nitsana A. Spigland a, * a b
NewYork-Presbyterian Hospital-Weill Cornell Medical College, Department of Surgery, 525 East 68th Street, New York, NY, 10065, USA Robert Wood Johnson Hospital, Division of Gastroenterology and Hepatology, 1 RWJ Plaza, New Brunswick, NJ, 08901, USA
A R T I C L E I N F O
A B S T R A C T
Keywords: Pancreatic injury Trauma Non-operative management Endoscopy Type of study: therapeutic Level of evidence: level IV
Background/purpose: Pancreatic injury is a rare complication of blunt abdominal trauma in pediatric populations. Non-operative management is increasingly common in pediatric pancreatic injury, using endoscopic in terventions. We report our institutional experience with non-operative management of pediatric pancreatic trauma, with a focus on the role of endoscopic interventions. Methods: We performed a retrospective review of all cases of blunt pancreatic trauma in children presenting to our urban, academic, level I pediatric trauma center from 1996 to 2016. Results: We identified six cases of blunt pancreatic trauma in children aged 2–15 years. One patient required operative intervention for duodenal perforation, but no patients underwent pancreatic surgery. Endoscopic in terventions were used in four cases to manage complications, such as pancreatic fluid collections and ductal stenosis. Conclusions: Pancreatic trauma can be managed safely and effectively using non-operative interventions in the pediatric population.
1. Introduction Pancreatic injury is rare in children, occurring in just 2% of blunt abdominal injuries, most commonly motor vehicle crashes with inade quate passenger restraints, or handlebar injuries [1,2]. Mortality has been reported as high as 50%, though this is often due to associated injuries [1]. Over the last few decades, management has shifted away from operative intervention toward a trial of non-operative manage ment, even for the most severe injuries. A recent review of that National Trauma Data Bank found that approximately half of pediatric pancreatic injuries in the United States are managed nonoperatively, with equiva lent or superior outcomes to operative intervention [3,4]. Many series in the literature report successful non-operative management of pediatric patients with severe pancreatic injuries with no increase in mortality [1, 4–10]. Non-operative management consists of nasogastric tube (NGT) decompression and total parenteral nutrition (TPN) for an average of 14 days [1], as well as somatostatin analogs [1]. Non-operative manage ment may be associated with increased pancreatic complications, pri marily development of pancreatic fluid collections (PFC) [6]. Of children with grade III-IV injuries, 10–44% of those managed
non-operatively have gone on to develop PFCs, which are generally managed with non-operative drainage [1,8–15]. Although imaging may demonstrate pancreatic atrophy, pancreatic insufficiency has not been reported [1,16]. For patients requiring surgery, intervention within 48 h has been associated with shorter length of stay and fewer complications than delayed surgery. Therefore, a trial of non-operative management might worsen outcomes if unsuccessful [14,17]. Failure of non-operative management and delayed surgery has been associated with ductal injury and increased injury severity score [18]. Holmes et al. found that failure of non-operative management generally occurred within the first 12 h [18]. In this study, pancreatic injury was an independent predictor of failure of nonoperative management in pediatric abdominal injury. Endoscopic drainage of PFCs and stenting of the pancreatic duct has been demonstrated efficacious in the adult population [19], but as this technology continues to evolve, evidence remains limited on its role in pediatric pancreatic trauma. Several series have reported the use of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric pancreatic injury, though many series have used ERCP only as a diag nostic adjuvant with positive results leading to operative intervention, or have not described the intervention [4,6,20]. In this study, we review
* Corresponding author. New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th Street, New York, NY, 10065, USA. E-mail address: [email protected] (N.A. Spigland). https://doi.org/10.1016/j.epsc.2019.101352 Received 25 September 2019; Received in revised form 12 November 2019; Accepted 13 November 2019 Available online 16 November 2019 2213-5766/© 2019 The Authors. Published by Elsevier Inc. This is an open access (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Journal of Pediatric Surgery Case Reports 52 (2020) 101352
our institutional experience with pediatric pancreatic transection, with emphasis on the role of endoscopic intervention.
Table 2 Patient characteristics and outcomes.
2. Methods In this single-institution case series we reviewed the charts of all pediatric patients with blunt pancreatic trauma presenting to our urban, academic, level I pediatric trauma center from 1996 to 2016. Patients were included if they had an International Classification of Diseases, version 9 or 10, code indicating pancreatic injury (Table 1) confirmed by evidence of pancreatic injury on abdominal imaging (see Table 2). Data extracted from the medical record included patient histories, exam findings, and clinical course, procedure reports, laboratory values, and imaging findings at admission and follow-up. Injuries were graded according to the American Association for the Surgery of Trauma Organ Injury Scaling guidelines [21]. Case histories were summarized.
3 Deep venous thrombosis (2), malfunction (3), infection (1) Pancreatic duct stricture and recurrent pancreatitis (1) None (1), ERCP with no intervention (1), Cystgastrostomy (2), Pancreatic duct stenting (3)
3.2. Case 2 Case 2 was a healthy 2-year-old boy who ran into an open, metal cellar door, hitting his abdomen on the edge. Initial evaluation by his pediatrician was negative, but he developed worsening abdominal pain over the next day and was referred to the emergency department (ED). He presented to an outside hospital, where computed tomography (CT) scan of the abdomen showed moderate free fluid in the pelvis and a linear hypodensity in the distal pancreatic body. He was transferred to our institution for a higher level of care. On presentation, he was he modynamically stable, with epigastric tenderness and a large ecchy mosis of the left abdomen. His labs showed elevated amylase and lipase to 605 U/L and 714 U/L, respectively. Repeat imaging confirmed tran section of the pancreatic body (Fig. 1D). A nasogastric (NG) tube and PICC line were placed and TPN was initiated. He gradually improved, and after 6 weeks he was discharged to a rehabilitation facility for continuation of TPN with normal exam and labs. He was readmitted twice for PICC malfunction, but recovered well. At 3 months, he un derwent magnetic resonance cholangiopancreatography (MRCP), which showed decreased signal in the pancreatic tail consistent with distal ductal stricture and a small pseudocyst (Fig. 1E), but no other abnor malities. Oral feeding was commenced, and he recovered well thereafter with CT showing a healed pancreatic duct. (Fig. 1F).
Case 1 was a previously healthy 7-year-old boy who was transferred from an outside hospital after a bicycle accident. He was diagnosed with duodenal perforation and contusion to the head of the pancreas. At operative exploration, the duodenum was repaired with primary duo denoduodenostomy. No pancreatic resection was performed, and drains were placed in the area. He was kept nil per os (NPO) and given octreotide and total parenteral nutrition (TPN) via a peripherallyinserted central venous catheter (PICC). He had persistently high output from his peripancreatic drain, and repeat imaging demonstrated an additional undrained collection for which he underwent percuta neous drainage by interventional radiology (IR). At the time of the procedure, this collection was found to communicate with the main pancreatic duct to the right of the superior mesenteric vessels. At the time, pediatric ERCP was not available at our institution, and the patient was transferred to another hospital, where ERCP demonstrated com plete transection of the pancreatic duct (Fig. 1A and B). He developed a pseudocyst at two months post-injury, which was 3.1 � 7.0 � 5.6 cm, and ultimately resorbed without additional drainage (Fig. 1C). He
3.3. Case 3 Case 3 was a 9-year-old boy with a history of asthma and attention deficit hyperactivity disorder who was admitted after falling from the monkey bars while playing, striking his abdomen on an iron bar. On presentation, he had normal vital signs and complained only of abdominal pain and vomiting. His abdomen was soft with moderate epigastric tenderness without distension or rebound. Admission amylase was 558 U/L and lipase was 201 U/L. CT showed laceration at the junction of pancreatic body and tail and moderate peripancreatic and left upper quadrant fluid (Image 1G). Upper GI endoscopy was per formed with no evidence of duodenal injury. NG tube and PICC line were placed and TPN was initiated. Pancreatic enzymes doubled on hospital day (HD) 3, and MRCP demonstrated a fluid collection at the transection site with a normal pancreatic duct. However, his bowel function resumed and the NGT was removed on post-injury day 9. Follow up ultrasound showed two <5 cm peripancreatic collections. He was asymptomatic, and his activity was gradually advanced and he was discharged to a facility for continuation of TPN on day 14. He was readmitted one month post-injury with dehydration due to
Table 1 International classification of diseases codes for pancreatic injury. ICD-9 Injury to pancreas, head, without mention of open wound into cavity Injury to pancreas, body, without mention of open wound into cavity Injury to pancreas, tail, without mention of open wound into cavity Injury to pancreas, multiple and unspecified sites, without mention of open wound into cavity Injury to pancreas, head, with open wound into cavity Injury to pancreas, body, with open wound into cavity Injury to pancreas, tail, with open wound into cavity Injury to pancreas, multiple and unspecified sites, with open wound into cavity
ICD-10 Unspecified injury of Unspecified injury of Unspecified injury of Unspecified injury of
11 (2–15) 5 1 Sports collision (2), fall while playing (2) fall from horse, bicycle accident II (2), III (4) 2.5 months (4 days–5 months)
remained NPO on TPN for a total of 5 months, at which point follow up imaging demonstrated complete healing of the pancreatic duct. He was followed for five years post-injury with a normal pancreas on ultra sound, normal growth and development and no symptoms.
3.1. Case 1
S36.200A S36.201A S36.202A S36.209A
Age (median, range) Male (n) Female (n) Mechanism (n)
Chronic complications (n) Interventions (n)
We identified 6 patients with blunt pancreatic injuries at our center over this time period, 5 males and 1 female. Ages ranged from 2 to 15 at presentation. Mechanisms of injury were all blunt, including fall from horse, sports, bicycle accident, and fall. Patient characteristics are dis played in Table 1. One patient underwent abdominal exploration for duodenal perforation; no patients underwent operative intervention for pancreatic injury. There were no deaths.
863.91 863.92 863.93 863.94
Sample Description (N ¼ 6)
Injury grade (n) NPO/TPN duration (median, range) Pseudocyst PICC complications (n)
3. Results
863.81 863.82 863.83 863.84
Patient Characteristics
head of pancreas, initial encounter body of pancreas, initial encounter tail of pancreas, initial encounter unspecified part of pancreas
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Fig. 1. Images from cases 1-4. Case 1: A. ERCP image showing contrast extravasation from main pancreatic duct to fill collection. B. Endoscopic ultrasound images re-demonstrating pseudocyst. C. CT showing pseudocyst formation following injury. Case 2: D. CT showing hypodensity of the pancreas consistent with laceration. E. Follow up MRCP demonstrating stricture and small pseudocyst. F. Subsequent CT showing healing of the pancreatic duct. Case 3: G. CT demonstrating pancreatic laceration at the time of injury. H. Pseudocyst six weeks following injury. I. Ultrasound showing resolution of fluid collection following endoscopic drainage. Case 4: J. CT demonstrating laceration of the distal pancreas. K. MRI showing transection of the pancreatic tail with injury to the distal pancreatic duct.
PICC dysfunction, and on repeat imaging, the two small collections had coalesced into a pseudocyst measuring 5.1 cm (Image 1H). Six weeks post-injury, this pseudocyst increased in size to 7.2 cm, abutting the patent splenic vein. He was transferred to our sister institution for endoscopic drainage with cystgastrostomy and pancreatic duct stenting. On return transfer, his diet was advanced, TPN was stopped, and PICC was removed. He was discharged home on a low-fat diet 2 months postinjury. Follow-up ultrasound showed a normal pancreas, with mild ductal dilation up to 2 mm and no fluid collection (Image 1I). The pancreatic duct stent was subsequently removed. He was followed for 5 years post injury with no evidence of pancreatic issues.
3.4. Case 4 Case 4 was an otherwise healthy 15-year-old boy who was hit in the abdomen while playing basketball. Later that day, he developed severe abdominal pain and was brought to an outside ED. Labs showed a lipase of 2600 U/L, and CT showed a laceration to the tail of the pancreas (Image 1J). He was transferred to our institution for further manage ment. He had no other symptoms and no evidence of additional injuries. He was hemodynamically stable, and his exam was notable for a soft abdomen with tenderness to palpation in the epigastrium without rebound or guarding. Admission labs showed a lipase of 565 U/L. MRCP demonstrated transection of the pancreatic tail with injury to the distal 3
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knee to the abdomen. He initially presented to an outside hospital, where an ultrasound was positive for free fluid. On transfer to our institution, he was hemodynamically stable and his abdomen was tender to palpation in the epigastrium. Admission white blood cell count was 12.0, hemoglobin was 11.2, and amylase was 274 U/L. CT of the abdomen and pelvis showed moderate hemoperitoneum with a contu sion of the right lobe of the liver and complete transection of the pancreas distal to the superior mesenteric vessels (Fig. 2D). He was kept NPO and his abdominal pain and tenderness improved, though amylase and lipase tripled over the first 2 hospital days. A PICC was placed and TPN and octreotide were begun, though this was complicated by a PICCassociated DVT. Given his slow improvement, on HD 10, he was taken for ERCP with sphincterotomy. The endoscopist was not able to cross the transected duct with a wire. A stent was placed in the proximal duct to augment drainage. Repeat ultrasound on HD 12 showed a pseudocyst with in ternal debris that was displacing the stomach medially. MRI confirmed a 7 cm pseudocyst (Fig. 2E). On HD 14, he developed new fever and abdominal pain. Given concern for infected pseudocyst, endoscopic ultrasound-guided cystgastrostomy was performed with placement of a lumen apposing metal stent (Axios, Boston Scientific, Natick, MA). Pseudocyst fluid cultures grew streptococcus viridans and streptococcus sanguinis, for which he received a 3-week course of meropenem. Fevers and pain improved, and repeat endoscopy showed a clean pseudocyst cavity with granulation and no necrosis. On HD 20, he had a repeat MRI that showed resolution of the pseudocyst. However, he subsequently developed recurrent epigastric pain and vomiting. Ultrasound showed minimal change, but he under went repeat ERCP. At this point, the endoscopy team was able to cross the ductal transection with a wire and 5 French plastic stent was placed to seal the disruption. His pain and nausea resolved and he was dis charged on TPN on HD 32. Ultrasound performed one week postdischarge showed a partially healed pancreatic laceration, and MRCP two weeks later showed further healing with no collection (Fig. 2F). His diet was advanced, and a repeat ERCP 3 months post injury showed normal filling of the pancreatic duct with atrophy of the pancreatic tail. The pancreatic stent was removed and the patient has continued to thrive.
pancreatic duct and retroperitoneal fluid, but no organized collection (Image 1K). He was made NPO, and his diet was advanced to a low-fat diet over 4 days. He was discharged home in good condition on HD 7. Follow up ultrasound again demonstrated transection of the pancreatic tail with no fluid collection or free fluid. He recovered well, resumed a regular diet, and returned to basketball 5 weeks post-injury. 3.5. Case 5 Case 5 was a 13-year-old otherwise healthy girl who presented to the ED with abdominal pain five days after falling twice from a horse, landing on her back and stomach. She was hemodynamically stable. At presentation, her abdomen was soft and diffusely tender to palpation with no rebound or guarding. Admission amylase was 373 U/L. CT of the abdomen and showed peripancreatic fluid tracking into the bilateral paracolic gutters. Given high suspicion for pancreatic injury, MRCP was performed which showed a laceration and contusion of the pancreatic body, and possible laceration of the tail, but was not able to clearly assess the integrity of the pancreatic duct (Fig. 2A). A PICC line was placed and TPN was initiated. Her abdominal pain improved gradually over the next four days and bowel function resumed. She was discharged home with TPN. Repeat imaging 3 months post-injury showed resolu tion of her pancreatic lacerations with no residual peripancreatic fluid and no pseudocyst development, and she tolerated a regular diet and activity. Six months after her initial injury, she returned to the ED with abdominal pain after colliding with another player during a volleyball game the previous day. She was found to have recurrent, traumatic pancreatitis (Fig. 2B). She was initially maintained on TPN, which was complicated by PICC-associated deep vein thrombosis (DVT) requiring enoxaparin and PICC removal. However, when she was unable to advance her diet after 2 months of TPN, re-imaging with MRCP demonstrated chronic pancreatitis with an ultrashort stricture of the main pancreatic duct (Fig. 2C). This was treated successfully by ERCP with sphincterotomy and stenting of the stricture. She was then able to advance her diet, but had several recurrent episodes of pancreatitis requiring ERCP with dilations and stent revisions. She is currently stent free for the last 18 months.
4. Discussion
3.6. Case 6
In this series, we report our institutional experience with pancreatic injury in children, a rare consequence of blunt abdominal trauma. We
Case 6 was a 14-year-old boy who sustained blunt abdominal trauma after colliding with another player during a baseball game and taking a
Fig. 2. Images from cases 4-5. Case 5: A. MRI showing pancreatic lacera tion and peripancreatic fluid. B. MRCPs demonstrating pancreatic laceration small pseudocyst after a second trauma. C. MRCP showing pancreatic duct stricture. Case 6: D. Initial CT showing laceration through body of pancreas. E. MRIs showing development of 7 cm pancreatic pseudocyst two weeks following initial injury. F. MRCP showing resolution following ERCP.
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identified six cases, all managed non-operatively despite the presence of complex injuries. Our results are consistent with several previous studies that found low rates of failure of non-operative management in this population. In 1996, Huckfeldt et al. published the first case report of a patient with a traumatic pancreatic transection successfully treated with endoscopic stenting [22]. Canty et al. published two more cases in 2001, with endoscopic stenting of major pancreatic duct injuries. In both cases, ERCP was performed for acute worsening abdominal pain on initial presentation and both patients avoided resection without subsequent complication [23]. In 2005, Cay et al. reported a similar case in an 11-year-old child [24], and Wood reported one additional case [6]. Houben et al. reported on 14 cases of pediatric pancreatic injury with initial non-operative management [2]. Twelve underwent ERCP, and 9 stents were placed, 3 across a ductal injury and 6 to drain a pseudocyst. Management was successful, with no delayed operations or mortalities, though median length of TPN and hospital stay were long (28 and 41 days, respectively) [2]. Other multi-center studies have shown that peri-pancreatic and psudocyst formation is common following blunt trauma [15], requiring drainage in 1/3 of cases with fluid collections [10]. However, there was no difference between those who underwent drainage procedures compared with observation in TPN use, time to tolerate a regular diet, hospital length of stay, or failure of non-operative management [10]. As endoscopic management of the pancreas continues to advance, we believe that the indications for operation in these patients will continue to narrow; even severe injuries can be managed without laparotomy in the absence of concomitant abdominal injuries that mandate surgery. Concern about nonoperative management has centered on peripancreatic collection and pseudocyst formation. Half of our patients developed pseudocysts, consistent with published rates. These too, however, can be managed nonoperatively with acceptable risk profiles. While the disincentive to operate may be reduced as distal ductal disruption has been managed with laparoscopic, spleen-preserving distal pancreatectomy [25,26], short- and long-term complications of operative management must be considered. Avoiding operation in these patients likely limits risk not only of short-term perioperative morbidity but also of long-term sequela of exocrine or endocrine insufficiency. Acute complications are common after blunt pancreatic injury, and are similar among management strategies. A recent review of NTDB data found adjusted complication rates of 21.5% in non-operative and 17.5% in early operative management, with no significant difference [3]. Pseudocysts were more common in non-operative management, while infections were more common in operative patients, and length of stay was similar [3]. To our knowledge, long-term follow-up data are not available on children after blunt pancreatic injury. However, in children undergoing elective pancreatic resection for other indications, diabetes may occur in 10% and exocrine insufficiency in 20%–83% [27,28]. Our study has several limitations. First, we report a small number of cases due to the low frequency of pancreatic trauma. Second, we report the experience at one large, urban academic center, which may not generalize to all cases. Despite our limitations, We aim to add to a growing body of literature supporting non-operative management of these injuries in children with the recognition that further study is needed to determine which of these patients, if any, would benefit from early operation over non-operative management. We sought to highlight the emerging role of interventional endoscopy, but further follow up will be needed to delineate both the indications and the best techniques for endoscopic management of pancreatic ductal injuries.
Patient consent Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the identifica tion of the patient. Funding This research did not receive any funding or grant support. Authorship All authors attest that they meet the current ICMJE criteria for Authorship. Declaration of competing interest Author MK discloses that he receives an honorarium for his role as a consultant from BSC, Abbvie, Emcision, Pinnacle, and US Endoscopy. MK has received research and training grants for his role as an investi gator and training director from BSC, Cook, Olympus, Apollo, Conmed, GORE, ERBE. The following authors have no financial disclosures: EK, CF, JM, SS, NS. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi. org/10.1016/j.epsc.2019.101352. References [1] Jacombs AS, Wines M, Holland A, Ross FI, Shun A, Cass DT. Pancreatic trauma in children. J Pediatr Surg 2004;39:96–9. [2] Houben CH, Ade-Ajayi N, Patel S, Kane P, Karani J, Devlin J, et al. Traumatic pancreatic duct injury in children: minimally invasive approach to management. J Pediatr Surg 2007;42:629–35. [3] Mora MC, Wong KE, Friderici J, Bittner K, Moriarty KP, Patterson LA, et al. Operative vs nonoperative management of pediatric blunt pancreatic trauma: evaluation of the national trauma data bank. J Am Coll Surg 2016;222:977–82. [4] Englum BR, Gulack BC, Rice HE, Scarborough JE, Adibe OO. Management of blunt pancreatic trauma in children: review of the national trauma data bank. J Pediatr Surg 2016;51:1526–31. [5] Cigdem MK, Senturk S, Onen A, Siga M, Akay H, Otcu S. Nonoperative management of pancreatic injuries in pediatric patients. Surg Today 2011;41: 655–9. [6] Wood JH, Partrick DA, Bruny JL, Sauaia A, Moulton SL. Operative vs nonoperative management of blunt pancreatic trauma in children. J Pediatr Surg 2010;45:401–6. [7] Kouchi K, Tanabe M, Yoshida H, Iwai J, Matsunaga T, Ohtsuka Y, et al. Nonoperative management of blunt pancreatic injury in childhood. J Pediatr Surg 1999;34:1736–9. [8] Jobst MA, Canty Sr TG, Lynch FP. Management of pancreatic injury in pediatric blunt abdominal trauma. J Pediatr Surg 1999;34:818–23. discussion 823-814. [9] de Blaauw I, Winkelhorst JT, Rieu PN, van der Staak FH, Wijnen MH, Severijnen RS, et al. Pancreatic injury in children: good outcome of nonoperative treatment. J Pediatr Surg 2008;43:1640–3. [10] Rosenfeld EH, Vogel AM, Jafri M, Burd R, Russell R, Beaudin M, et al. Management and outcomes of peripancreatic fluid collections and pseudocysts following nonoperative management of pancreatic injuries in children. Pediatr Surg Int 2019;35: 861–7. [11] Keller MS, Stafford PW, Vane DW. Conservative management of pancreatic trauma in children. J Trauma 1997;42:1097–100. [12] Shilyansky J, Sena LM, Kreller M, Chait P, Babyn PS, Filler RM, et al. Nonoperative management of pancreatic injuries in children. J Pediatr Surg 1998;33:343–9. [13] Abbo O, Lemandat A, Reina N, Bouali O, Ballouhey Q, Carfagna L, et al. Conservative management of blunt pancreatic trauma in children: a single center experience. Eur J Pediatr Surg : Off J Austrian Assoc Pediatr Surg 2013;23:470–3. Zeitschrift fur Kinderchirurgie. [14] Ho VP, Patel NJ, Bokhari F, Madbak FG, Hambley JE, Yon JR, et al. Management of adult pancreatic injuries: a practice management guideline from the eastern association for the surgery of trauma. J Trauma Acute Care Surg 2017;82:185–99. [15] Naik-Mathuria BJ, Rosenfeld EH, Gosain A, Burd R, Falcone Jr RA, Thakkar R, et al. Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: a pediatric trauma society collaborative. J Trauma Acute Care Surg 2017;83:589–96. [16] Wales PW, Shuckett B, Kim PC. Long-term outcome after nonoperative management of complete traumatic pancreatic transection in children. J Pediatr Surg 2001;36:823–7.
5. Conclusion Non-operative management is safe and effective for pancreatic in juries in children. Interventional endoscopy is a useful adjunct in the care of these patients, and may extend the reach and improve the re covery of non-operative management of pediatric pancreatic injury.
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Journal of Pediatric Surgery Case Reports 52 (2020) 101352 [23] Canty Sr TG, Weinman D. Treatment of pancreatic duct disruption in children by an endoscopically placed stent. J Pediatr Surg 2001;36:345–8. [24] Cay A, Imamoglu M, Bektas O, Ozdemir O, Arslan M, Sarihan H. Nonoperative treatment of traumatic pancreatic duct disruption in children with an endoscopically placed stent. J Pediatr Surg 2005;40:e9–12. [25] Rutkoski JD, Segura BJ, Kane TD. Experience with totally laparoscopic distal pancreatectomy with splenic preservation for pediatric trauma–2 techniques. J Pediatr Surg 2011;46:588–93. [26] Nikfarjam M, Rosen M, Ponsky T. Early management of traumatic pancreatic transection by spleen-preserving laparoscopic distal pancreatectomy. J Pediatr Surg 2009;44:455–8. [27] Lindholm EB, Alkattan AK, Abramson SJ, Price AP, Heaton TE, Balachandran VP, et al. Pancreaticoduodenectomy for pediatric and adolescent pancreatic malignancy: a single-center retrospective analysis. J Pediatr Surg 2017;52: 299–303. [28] Marchegiani G, Crippa S, Malleo G, Partelli S, Capelli P, Pederzoli P, et al. Surgical treatment of pancreatic tumors in childhood and adolescence: uncommon neoplasms with favorable outcome. Pancreatology : Off J Int Assoc Pancreatol 2011;11:383–9.
[17] Nadler EP, Gardner M, Schall LC, Lynch JM, Ford HR. Management of blunt pancreatic injury in children. J Trauma 1999;47:1098–103. [18] Holmes JHt, Wiebe DJ, Tataria M, Mattix KD, Mooney DP, Scaife ER, et al. The failure of nonoperative management in pediatric solid organ injury: a multiinstitutional experience. J Trauma 2005;59:1309–13. [19] Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, et al. An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis. Gastroenterology 2019;156:1027–40. e1023. [20] Rescorla FJ, Plumley DA, Sherman S, Scherer 3rd LR, West KW, Grosfeld JL. The efficacy of early ercp in pediatric pancreatic trauma. J Pediatr Surg 1995;30: 336–40. [21] Moore EE, Moore FA. American association for the surgery of trauma organ injury scaling: 50th anniversary review article of the journal of trauma. J Trauma 2010; 69:1600–1. [22] Huckfeldt R, Agee C, Nichols WK, Barthel J. Nonoperative treatment of traumatic pancreatic duct disruption using an endoscopically placed stent. J Trauma 1996; 41:143–4.
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