Punt Pass

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Punt Pass

• Pageantry

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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)

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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

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Diagnosis of Pancreatic Trauma

• Spiral CT IV contrast /- GI contrast
• MR Cholangiopancreatography (MRCP)
• Mechanism should alert to pancreatic injury
• Amylasegt200 and Lipasegt1800 exam
• Enzyme levels are not perfectly reliable

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Anatomic variant
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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

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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

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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

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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

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Assume you Punt-Management of Pseudocyst

• Many resolve without treatment
• Kouchi, et al- Japan- 20 patients
• lt10 cm, most will resolve
• gt10 cm, most will need drainage
• 1 died- TPN related
• 5 mortality

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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

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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

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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

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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

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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