Category Archives: General

Pancreatic Injury Part 4 – Nonop Management For Kids?

Over the past 30 years or so, we’ve made major advances in managing many injuries without operation. Blunt injuries to liver, spleen, and kidney, along with some penetrating injuries to the liver come to mind. But as we have seen many times in medicine, the pendulum sometimes swings too far.

Hopefully, I’ve impressed upon you how strange and potentially treacherous the pancreas is. In recent years, some centers have dabbled with nonoperative management of the pancreas in children. The belief has been that, since kids heal so much better than adults, maybe the pancreas will be more forgiving in that age group. Unfortunately, the only studies to date have been small, single center work.

But now, a collaborative Pancreatic Injuries In Children Study Group has published results of a multi-institutional retrospective review which will hopefully lay this debate to rest (at least for a while).

Here are the factoids:

  • The study reviewed data from 1195-2012 (18 years!) on patients less than 18 years old. Only grade II or III injuries were selected. Grade was determined by CT, ERCP, MRCP or at operation.
  • Fourteen centers participated, submitting data on 167 patients. These are huge numbers for this uncommon injury!
  • 57 underwent distal pancreatectomy, 95 were managed without operation. The remainder were drained and were studied separately.
  • Diet was resumed significantly more quickly (8 days vs 15 days) in the resection group
  • More endoscopic and interventional procedures were needed due to pseudocyst formation in the nonoperative group (26% vs 2%)
  • Patients with Grade III injuries (distal duct) had fewer complications after resection (33% vs 61%)
  • Hospital stay was significantly shorter in the resection group (13 vs 18 days)

Bottom line: Operative resection of distal pancreatic injury in children is the way to go, just as it is in adults. Persistent attempts to treat without surgery keeps the child in the hospital longer, exposes them to additional invasive procedures, and is fraught with more complications. You may think you’re saving them the pain of major abdominal surgery, but you are just prolonging the torture with endoscopy, IR drainage, repeated blood draws, and starvation.

Related posts:

Reference: Operative vs nonoperative management for blunt pancreatic transection in children: multi-institutional outcomes. J Am Coll Surg 218(2):157-162, 2014.

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January Newsletter Released To Subscribers Tonight!

Due to my heavy travel schedule last month, I’ve been slow in getting the January newsletter together. But it’s now ready! The topic is Pediatric Trauma. Articles include:

  • Pediatric ATV injuries
  • DVT in children
  • Identifying sick pediatric trauma patients early
  • Pneumothorax in children
  • Pediatric pneumomediastinum

Anyone on the subscriber list as of 8PM tonight (CST) will receive it by email tonight. I’ll release it to everyone else next Monday via the blog. So sign up for early delivery now by clicking here!

Pick up back issues here!

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Pancreatic Injury Part 3 – Management

I hate the pancreas. It just doesn’t play by the rules. No matter how good your operation is, there are frequent complications caused by this organ. Thus, my management recommendations are based on simplicity. Easy stuff is good. No anastomoses are better than one or more.

So you’ve already figured out the location and presence or absence of ductal injury, meaning that you know the grade. Let’s look at what you can do by grade.

  • Grade I – somebody rubbed the pancreas. Really, you only need to worry about a little “pancreas sweat”, secretions from roughed up surfaces on the gland. I recommend placing a nice drain in the vicinity to carry this fluid away. This is especially important if there are bowel injuries / anastomoses in nearby areas.
  • Grade II – somebody punched the pancreas. This can also be caused by anatomic issues when removing the spleen. Once again, drainage of (non-ductal) secretions is key, so a nice big fat drain is in order.
  • Grade III – distal duct injury. A simple, distal pancreatectomy is in order. I like to do this with a linear stapler, and I typically do not try to spare the spleen. It just takes too long, and you may push your badly injured trauma patient down the damage control route if you persist with saving the spleen for too long.
  • Grade IV – injury to the proximal pancreas with duct. You can get fancy here and do resections and roux-en-y limbs and all kinds of stuff. But I try to keep it simple, and if the destruction is not too bad, I’ll just drain it. External drains are good, but in some more severe cases I will drain internally via a roux limb (shudder). On rare occasion, a proximal pancreatectomy with roux drainage of the distal portion may be considered. 
  • Grade V – shattered head plus/minus duodenum. Oh crap! The only way out of this is with a pancreaticoduodenectomy, and it’s tough to find a good time with major trauma patients. If they are well-behaved during the initial operation, get started with it. If they are not, or start to have problems during, you can continue to the first damage control takeback. But, to ensure the best quality tissue for anastomoses, you must finish at the first takeback! And expect complications. They always get them.

Friday, I’ll talk about the (foolhardy) idea of trying to treat this injury nonoperatively in children.

Related posts:

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Pancreatic Injury Part 2 – Diagnosis

Yesterday, I outlined the AAST organ injury scale for the pancreas. Today, I’ll go through diagnosis of the the injury in adults. 

First, there are two ways of detecting this injury. In stable patients, it is usually identified on CT. Hematoma around an area of the pancreas, combined with linear changes in the density of the gland are typical. It may be difficult to detect in very thin patients without a lot of contrasting fat (although this situation is becoming very uncommon). And obviously, CT is only to be used for stable patients.

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The other way this injury is discovered is in the OR during the trauma exploration. This is the most common situation in patients taken directly to OR due to hemodynamic status.

Even if the diagnosis has been made by CT, the diagnostic process continues in the OR. So in all cases, the usual approach to trauma laparotomy applies (large midline incision, control of hemorrhage, control of contamination in that order). Only then can a full inspection be carried out, and damage control principles should be followed. If a pancreatic injury is suspected but the laparotomy must be terminated for damage control reasons, a simple drain should be placed over the pancreas, and the injury addressed on the first takeback.

The two keys to deciding what to do in pancreatic injury are injury grade and duct status, which go hand in hand. Sometimes it is difficult to evaluate the duct and there are two ways to approach this in the OR: extra-ductal and intra-ductal. The former is the easiest, and involves direct inspection of the gland. Careful, gentle dissection coupled with close review with magnification will frequently show obvious leakage of clear fluid. The latter involves injecting contrast into the duct. This can be accomplished via either end of the pancreas (directly into the papilla via duodenotomy, into the distal end via distal pancreatectomy), or through on-table ERCP. Neither of the invasive methods are for the faint of heart, and will be discussed in future blog posts. And ERCP can be challenging because patient positioning with an open abdomen is difficult.

Once the grade and duct status have been identified, it’s time to think about fixing the problem. That’s the topic for tomorrow.

Related posts:

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Pancreatic Injury Part 1 – Grading

The pancreas is a weird and mysterious organ. It’s considered a solid organ, but it doesn’t follow any of the usual rules. Today, I’ll review the grading system for injuries to this organ. Then over the next few days, I’ll review pancreatic injury management in adults and children.

The AAST has developed quite a few organ injury grading schemes over the years (32 to be exact). These are actually important to know, because they help us accomplish several things:

  • Objectively describe the degree of injury
  • Choose management strategies
  • Develop research cohorts so meaningful studies can be constructed

There are 5 grades that follow the usual AAST schema (numbered I-V). Unfortunately, I have not been able to find any quality diagrams, so you’ll just have to use your imagination.

image

  • Grade I: Minor contusion or laceration of the parenchyma without duct involvement
  • Grade II: Major contusion or laceration of the parenchyma without duct involvement
  • Grade III: Distal duct laceration or transection. Distal means to the left of the superior mesenteric vein
  • Grade IV: Proximal transection or parenchymal injury not involving the ampulla (note that this was corrected after publication of the original scale in 1990, which omitted the word not)
  • Grade V: Massive disruption of the pancreatic head

Tomorrow I’ll delve into diagnosis and management options in adults.

Related posts:

Reference: Pancreatic organ injury scale. J Trauma 30:1427–1429, 1990.

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