Management of major pancreatic duct injuries in children

Background: The operative versus nonoperative management of major pancreatic ductal injuries in children remains controversial. The computed tomographic (CT) scan may not be accurate for determination of location and type of injury. We report our experience with ductal injury including the recent use of acute endoscopic retrograde cholangiopancreatography (ERCP) for definitive imaging, and an endoscopically placed stent as definitive treatment. This has not been reported in children. Methods: In review of 14,245 admissions to a regional pediatric trauma center over a 14-year period, 18 patients with major ductal injuries from blunt trauma were noted. Records were reviewed for mechanism of injury, method of diagnosis, management, and outcome. Results: There were 10 girls and 8 boys, ranging in age from 2 months to 13 years. The most common mechanisms of injury were motor vehicle and bicycle crashes. Admission CT scan in 16 children was suggestive of injury in 11, and missed the injury in 5. Distal pancreatectomy was carried out in eight patients with distal duct injuries: one died of central nervous system injury. Nonoperative management in three proximal duct injuries suggested by initial CT scan and in three missed distal duct injuries resulted in pseudocyst formation in five survivors; one patient died of central nervous system injuries. Two children with minimal abdominal pain, normal initial serum amylase, and no initial imaging developed pseudocysts. Two of seven pseudocysts spontaneously resolved and five were treated by delayed cystogastrostomy. Two recent children with suggestive CT scans were definitively diagnosed by acute ERCP and treated by endoscopic stenting. Clinical and chemical improvement was rapid and complete and the stents were removed. Follow-up ERCP, CT scan, and serum amylase levels are normal 1 year after injury. Conclusion: Pancreatic ductal injuries are rare in pediatric blunt trauma. CT scanning is suggestive but not accurate for the diagnosis of type and location of injury. Acute ERCP is safe and accurate in children, and may allow for definitive treatment of ductal injury by stenting in selected patients. If stenting is not possible, or fails, distal injuries are best treated by distal pancreatectomy; proximal injuries may be managed nonoperatively, allowing for the formation and uneventful drainage of a pseudocyst.