Journal of Pediatric Surgery 50 (2015) 335–338
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Role of ERCP in pediatric blunt abdominal trauma: A case series at a level one pediatric trauma center☆ Erin M. Garvey a, Danielle J. Haakinson a, Mark McOmber b, David M. Notrica a, c,⁎ a b c
Division of General Surgery, The Mayo Clinic, 5777 E Mayo Blvd. Phoenix, AZ 85255 USA Pediatric Gastroenterology, Phoenix Children’s Hospital, 1920 E Cambridge Ave. Phoenix, AZ 85006 USA Pediatric Surgery, Phoenix Children’s Hospital, 1920 E Cambridge Ave. Phoenix, AZ 85006 USA
a r t i c l e
i n f o
Article history: Received 19 August 2014 Accepted 22 August 2014 Key words: Pediatric Blunt abdominal trauma Pancreatic injury Biliary injury Duct stenting Endoscopic retrograde cholangiopancreatography
a b s t r a c t Background: There is no consensus regarding the appropriate use of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric trauma. We report our experience with ERCP for management of pediatric pancreatic and biliary injury following blunt abdominal trauma. Methods: A retrospective chart review was performed for pediatric patients with blunt abdominal trauma from July 2008 through December 2012 at our pediatric trauma center. For patients who underwent ERCP, demographics, injury characteristics, diagnostic details, procedures performed, length of stay, total parenteral nutrition use, and complications were reviewed. Results: There were 532 patients identified: 115 hepatic injuries, 25 pancreatic injuries and one gall bladder injury. Nine patients (mean age 7.8 years) underwent ERCP. Seven (78%) had pancreatic injuries, while two (22%) had bilateral hepatic duct injuries. The median time to diagnosis was one day (range, 0-12). Diagnostic ERCP only was performed in three patients, two of which proceeded to distal pancreatectomy. Five patients had stents placed (two biliary and three pancreatic) and four sphincterotomies were performed. Despite pancreatic stenting, one patient required distal pancreatectomy for persistent leak. Median length of stay was 11 days. Conclusions: Pediatric pancreatic and biliary ductal injuries following blunt abdominal trauma are uncommon. ERCP can safely provide definitive treatment for some patients. © 2015 Elsevier Inc. All rights reserved.
Unintentional injury is the leading cause of death for patients between the ages of one year and 44 years.[1] Motor vehicles are largely responsible for fatal injuries whereas falls or being struck by an object are responsible for nonfatal injuries.[1] All of these mechanisms can result in blunt abdominal trauma. Pancreatic injury is relatively uncommon due to the retroperitoneal location. Reported rates of significant pancreatic injury range from 0.12% to 0.7% in the pediatric trauma literature.[2–4] Consensus exists for the nonoperative management of pancreatic trauma without ductal injury (Grade I and Grade II injuries) while controversy surrounds the appropriate management of Grade III–V injuries ranging from nonoperative management to various pancreatic resections or drainage operations.[2,3,5,6] The incidence of major bile duct injury following blunt abdominal trauma in the pediatric population is likely rarer than significant pancreatic injury. In a 1989 case report and review, Bourque et al. noted 125 reported cases of extrahepatic bile duct injury in the literature, of which one third were in pediatric patients.[7] Recent studies by Kulaylat et al. and Soukup et al. demonstrated a 3.7% rate of traumatic bile leak in a series of 294 patients
☆ Presented at Western Pediatric Trauma Conference July 9–11, 2014. ⁎ Corresponding author at: Phoenix Children’s Hospital, 1920 E Cambridge Ave Suite 201, Phoenix, AZ 85006. Tel.: +1 602 254 5561; fax: +1 602 254 2185. E-mail address: [email protected] (D.M. Notrica). http://dx.doi.org/10.1016/j.jpedsurg.2014.08.017 0022-3468/© 2015 Elsevier Inc. All rights reserved.
who sustained blunt hepatic injury and a rate of 0.09% biliary tract injury in a series of 13,582 trauma patients, respectively.[8,9] Nonoperative management of hemodynamically stable pediatric patients with blunt liver injury has become the standard of care.[10] This increase in nonoperative management, coupled with the retroperitoneal location of the pancreas and the relative rare incidence of pancreatic and bile duct injuries, can lead to a delay in diagnosis. Using computed tomography (CT), pancreatic and bile duct injuries can easily be missed. The role of ERCP in the management of these pancreatic and biliary injuries can be both diagnostic and therapeutic. The purpose of our study was to review the utility of diagnostic and therapeutic ERCP in the management of blunt abdominal trauma at our single institution level one pediatric trauma center. 1. Methods Approval from the Phoenix Children’s Hospital Institutional Review Board was obtained. A prospectively maintained trauma database was used to identify all patients (≤21 years) admitted to Phoenix Children’s Hospital with a diagnosis of blunt abdominal trauma from July 1, 2008 to December 31, 2012. A retrospective chart review was performed for all patients who underwent ERCP. Patient demographics, injury characteristics, diagnostic details, procedures performed, length of stay (LOS), total parenteral nutrition (TPN) use
336
E.M. Garvey et al. / Journal of Pediatric Surgery 50 (2015) 335–338
Table 1 Patient, injury, treatment and outcome characteristics. Patient
Age/Sex
Mechanism of Injury
Definitive Diagnostic Modality
Site of Injury
Injury Grade
ERCP & Operative Intervention/PID
Other Interventions
TPN Days
LOS ICU/ Total Days
Complications
A B
8/M 7/M
Handlebars Handlebars
CT ERCP
Pancreatic Tail Hepatic ducts
III IV (liver)
ERCP stent/2 ERCP stent/11
9 23
0/12 20/31
None Bacterial tracheitis
C
9/F
Fall
MRCP
Pancreatic body
III
ERCP sphincterotomy/6
PICC PICC CVC IR Angio Peritoneal drain PICC
6
0/11
D
6/F
Handlebars
CT
Pancreatic head
IV
ERCP stent/1 Open DP/3
PICC
10
8/15
E
5/M
Fall
CT
Pancreatic tail
III
8
4/10
F
1/F
SNAT
MRCP
III
PICC
5
4/9
None
G
11/M
Handlebars
CT
Pancreatic body and tail Pancreatic tail
ERCP/1 Open DP/2 ERCP/7
UTI Acute pancreatitis Reintubation Pseudocyst rupture Mallory–Weiss tear None
III
CVC
4
3/7
H
15/M
Auto vs pedestrian
Paracentesis / ERCP
Hepatic ducts
IV (liver)
PICC
38
26/52
Readmit for high drain output Pseudocyst
Paracentesis Peritoneal drain NJ tube Chest tube None
0
0/7
None
I
9/F
Handlebars
CT
Pancreatic body and tail
III
ERCP sphincterotomy/1 Lap DP/1 ERCP stent & sphincterotomy/8 Lap washout/14
ERCP stent & sphincterotomy/2
M: male, F: female, SNAT: suspected nonaccidental trauma, ERCP: endoscopic retrograde cholangiopancreatography, MRCP: magnetic resonance cholangiopancreatography, PID: post injury day, TPN: total parenteral nutrition, LOS: length of stay, ICU: intensive care unit, PICC: peripherally inserted central catheter, CVC: centrally inserted venous catheter, IR Angio: interventional radiology angiography, NJ: nasojejunal, UTI: urinary tract infection.
and complications were reviewed. Pancreatic injury grades were assigned based on the organ scaling injury guidelines from the American Association for the Surgery of Trauma.[11] A core group of 10 pediatric surgeons managed all injured children at Phoenix Children’s Hospital during the study period, and three surgeons performed the four operations. All ERCPs were performed by one pediatric interventional gastroenterologist. Descriptive statistical analysis was performed. 2. Results During the 4.5 year study period, there were 532 patients with a diagnosis of blunt abdominal trauma including 115 hepatic injuries (21.6%), 25 pancreatic injuries (4.7%) and one gallbladder injury (0.19%). The mean age was 9 years (range, 2 months to 19 years). Nine patients underwent ERCP (1.7%). The mean age was 7.8 years (range, 17 months to 15 years). Five patients (55.6%) were male. The mean weight was 26.4 kg (range, 9.96 to 50.3 kg). The majority of patients, 5/9 (55.6%), had handlebar-related injuries. The other four injuries comprised falls (n = 2), suspected non-accidental trauma (n = 1) and auto versus pedestrian (n = 1) (Table 1). Of the nine patients who underwent ERCP, pancreatic injuries were identified in 7/9 (77.8%) and the remaining two patients were found to have bilateral hepatic duct injuries (22.2%). Only 4/9 (44.4%) of injuries were suggested on day of presentation based on CT findings of pancreatic fracture or transection. CT definitively diagnosed pancreatic duct injury in 5/7 (71.4%) pancreatic injury patients. The remaining two were diagnosed by MRCP. The breakdown of pancreatic injury grades is shown in Table 2. The two patients with hepatic duct injury had Grade IV liver lacerations on CT, but definitive diagnosis of the hepatic duct injuries occurred with ERCP. The median time to diagnosis was 1 day (range, 0 to 12 days). The median time to ERCP was post-injury day 2 (range, 1 to 11 days). For the seven ERCP patients with pancreatic injuries, two proceeded directly to the operating room for distal pancreatectomy
(one laparoscopic [Grade III], one open [Grade IV]). One patient was found to have pancreatic duct compression without extravasation and was managed nonoperatively. Of the four pancreatic injuries managed with ERCP intervention, one treated with pancreatic stenting went to the operating room two days after ERCP due to persistent leak. The remaining three patients were managed successfully with ERCP interventions alone including one stent, one sphincterotomy and one patient who had both a stent and a sphincterotomy. Thus, of the pancreatic patients who underwent attempted definitive management with ERCP intervention, 3/4 (75%) were successful. Of the two bile duct injuries, one patient was managed successfully with ERCP stenting alone, but the other required a laparoscopic washout and drain placement six days after ERCP with stenting and sphincterotomy due to persistent ascites and peritonitis; no duct repair, however, was required. Thus, both avoided the need for ductal repair, but 1/2 (50%) required a minimally invasive operative intervention. In addition to ERCP, most patients required other interventions for management of their injury. The two patients with hepatic duct injuries required multiple interventional radiology (IR) procedures. Patient B underwent IR embolization of a superior branch from the right hepatic artery and placement of a peritoneal drain. Patient H underwent paracentesis (which prompted ERCP resulting in the diagnosis of bile leak), placement of a peritoneal drain, nasojejunal
Table 2 American association for the surgery of trauma pancreatic injury grading. Grade
Pancreatic Injury
N
I II III IV V
Minor contusion Major contusion Distal transection or parenchyma and duct injury Proximal transection or parenchyma and duct injurya Massive disruption of pancreatic head
0 0 6 1 0
a Proximal pancreas is defined as the portion to the right of portal vein/superior mesenteric vein.
E.M. Garvey et al. / Journal of Pediatric Surgery 50 (2015) 335–338
feeding tube placement and chest tube insertion due to a pleural effusion. The mean number of interventions per patient including ERCP, operative and IR procedures (excluding venous access procedures) needed for management of the injury was 2.2 (range, 1 to 6), and the mean number of general anesthesia inductions was 2.1 (range, 1 to 4). All but one patient required TPN and therefore needed central venous access. Six patients had peripherally inserted central catheter (PICC) lines, one had a central line, and one patient had both a PICC and central line during his hospitalization. The median TPN duration was 8 days (range, 0 to 38 days) with a median of 6 days (range, 2 to 19 days) until initiation of enteral feeds, and 9 days (range, 3 to 34 days) until full enteral feeds were achieved. No patient required TPN at discharge. The median LOS for all patients in the series was 11 days (range, 7 to 52 days) with a median LOS in the ICU of 4 days (range, 0 to 26 days). The median number of ventilator dependent (VD) days was 0 and the average was 1.3 days (range, 0 to 8 days). The median LOS for those four patients who underwent interventional ERCP was 11.5 days (range, 7 to 15 days), with a median of 0 ICU days (range, 0 to 8 days) and 0 VD days (range, 0 to 4 days). The two patients who proceeded directly to the operating room after ERCP had a median LOS of 8.5 days (range, 7 to 10 days), a median 3.5 ICU days (range, 3 to 4 days) and 0 VD day. The one patient who had a diagnostic ERCP had a 9 day LOS, 4 days of which were in the ICU, with no VD days. The two patients with bile duct injuries had the longest LOS at 31 and 52 days, with the longest ICU stays at 20 and 26 days, with 8 and 0 VD days, respectively. Five patients experienced complications. Two patients developed pancreatic pseudocysts and Patient D required readmission 1.5 months after discharge due to pseudocyst rupture resulting in nausea and vomiting causing a Mallory–Weiss tear. Patient C was also readmitted two years after discharge for an episode of acute pancreatitis. There were no mortalities. 3. Discussion Pancreatic injury is uncommon secondary to the retroperitoneal location of the pancreas, and the diagnosis of pancreatic injury is frequently delayed due to limitations of standard imaging modalities. [12,13] ERCP is considered the most accurate method to diagnose pancreatic duct disruption and has the added benefit of identifying the exact location and extent of the injury.[13,14] Treatment for pancreatic ductal injury, however, remains controversial. Recently, operative management has been shown to result in better outcomes than nonoperative management for higher grade injuries.[6] The potential advantages of ERCP as an adjunct to nonoperative management might include reduction in pseudocyst formation, shortening hospital stays and quicker return to enteral intake. Common potential risks of nonoperative management include pancreatic duct strictures, atrophy of the distal duct despite intervention, post-ERCP pancreatitis and the need for future interventions.[2,5,14] ERCP and the expertise needed to perform this procedure in the pediatric population may not be readily available and can limit the utilization of ERCP at smaller centers. A 2009 review by Bhasin et al. cites a number of adult studies demonstrating the utility of ERCP including diagnosing pancreatic duct injury, stratifying patients into operative versus nonoperative treatment approaches and treating select pancreatic injuries with duct stenting and/or sphincterotomy for hemodynamically stable trauma patients.[14] Most of these studies are from small case series with retrospective data, and the literature for the pediatric population is even sparser. However, ERCP has been recommended for consideration in all children with blunt abdominal trauma from as early as 1986, based on the experience from four patients with delayed main pancreatic duct injury identified by ERCP in a series by Hall et al.[15] Shortly thereafter, from 1988 to 1993, Rescoria et al. reviewed the role of ERCP in six patients (aged 2.5 to 8 years) who developed persistent
337
pancreatic drainage after percutaneous drainage (n = 2) or laparotomy (n = 1); with large lesser sac fluid collections (n = 2); and with severe abdominal pain with a CT suggestive of pancreatic injury (n = 1), and deemed ERCP to be safe in pediatric patients and effective in delineating pancreatic ductal anatomy.[16] Canty et al. identified 18 patients (aged 2 months to 13 years) with major pancreatic duct injury, two of which underwent ERCP. The first was a 9 year old female who sustained a handlebar injury to the abdomen and was found to have a side hole injury of the main pancreatic duct which was treated with a 5 French stent. At ERCP for stent removal and at one year follow up, a narrowing of the duct at the site of injury was noted but the patient remained clinically asymptomatic. The second patient was an 8 year old male who was struck and run over by a van who also had a side hole injury of the main pancreatic duct which was treated with a transampullary decompressing stent. He had no evidence of stricture and remained asymptomatic at the time of stent removal and at one year follow up.[2] Diagnostic ERCP was performed in 12 patients (aged 7 to 16 years) in a larger series by Houben et al. from the United Kingdom. Nine of these patients underwent pancreatic duct stent placement: three stents were placed into the duct while six were placed into the pseudocyst itself. Stent placement failed in two patients secondary to a tortuous duct and pancreas divisum. Minor complications included transient rise in serum amylase and exacerbation of epigastric pain, and two patients developed pseudocysts. Overall, their study suggests ERCP has a role for management of traumatic pancreatic injuries.[17] In the present study, the majority, 4/7 (57%), of pancreatic duct injuries were a result of handlebar injuries, and the majority of injuries were detected with CT scan, 5/7 (71%). The CT diagnosis is similar to other series, but our study has a higher rate of handlebar injury than many pediatric series.[17–19] In our series, like the Canty et al. series, ERCP was performed earlier (median post-injury day 2) compared to a median of 5 days in the Houben studies.[2,17] ERCP proved to be diagnostic in all cases, and therapeutic in our series with three of four patients successfully managed with stenting and/or sphincterotomy, with one patient requiring operative intervention despite stenting. Our LOS was similar to Canty’s cases, and shorter than for the patients who underwent nonoperative management in the Iqbal series (mean 11.25 days for our ERCP intervention patients compared to a mean of 15 days).[2,6] This small number of patients in our series also compares favorably with laparoscopic distal pancreatectomy.[19] The shorter LOS compared to the Houben ERCP study (28 days) was likely due to earlier ERCP and quicker initiation of enteral feeds in our series. [17] Complication rates were similar with two pseudocysts in each series. There were no ERCP-related complications. Our study and the series by Houben et al. would suggest ERCP is safe and has a role in the management of early and delayed pancreatic duct injuries in children with blunt abdominal trauma. Major bile duct injuries caused by blunt abdominal trauma appear extremely rare, even compared to pancreatic injury, and are usually associated with liver parenchymal injuries. There is often a delay in diagnosis, especially with nonoperative management of blunt liver injuries, or even missed diagnosis during laparotomy.[7,20–22] Almaramhi et al. described a series of five patients with bile duct injuries (two intrahepatic and three extrahepatic) who underwent ERCP after laparotomy/laparotomies for persistent bile leak. The median number of days before diagnosis was 22.5 days. The three patients with extrahepatic bile duct injuries were treated successfully with ERCP, stenting and percutaneous drainage. Two of these patients developed infection of the bile collections, but were successfully treated with intravenous antibiotics. The median LOS was 25.5 days. [21] Castagnetti et al. described another series of five patients with intrahepatic bile duct injury identified by ERCP and treated with biliary stenting (n = 5) with the addition of sphincterotomy in two of the five patients. ERCP was performed at a median of 15 days. Four patients required percutaneous drainage and two underwent laparoscopic
338
E.M. Garvey et al. / Journal of Pediatric Surgery 50 (2015) 335–338
lavage. One patient developed a bile duct stricture that was successfully managed with endoscopic dilation. The median hospital LOS was 43 days.[23] A more recent study by Kulaylat et al. demonstrated a 3.7% rate of traumatic bile leak in their series of 294 patients and utilized ERCP to diagnose and treat nine intrahepatic and two extrahepatic bile duct injuries (a rate of 0.68% extrahepatic and 3.1% intrahepatic injury) with sphincterotomy and/or stent placement. All bile leaks resolved at a median of 13 days (range, 3 to 64 days) and median LOS was 10 days (range, 5 to 31 days). There were two complications. One patient developed cholangitis due to a retained biliary stent after being lost to follow up, and another patient had a pneumothorax and effusion after placement of an imaging guided percutaneous drain.[8] Another recent study by Soukup et al. identified 12 patients with biliary injuries, six of which were evaluated with ERCP. Two of the six patients who had stent placement alone (one patient was managed initially with ERCP and the other underwent ERCP after an exploratory laparotomy and cholecystectomy for gall bladder avulsion) developed delayed strictures requiring multiple repeat ERCPs and/or a laparotomy with left hepatectomy. One of the six patients presented with a delayed common bile duct injury three weeks after being discharged for a blunt pancreatic injury from handlebars and underwent ERCP with sphincterotomy and stenting during the second hospitalization. This patient had post sphincterotomy bleeding requiring repeat ERCP and also developed a stricture. One patient was unable to have stent placement, and the remaining two patients were treated successfully with initial ERCP and stenting. A HIDA (hepatobiliary iminodiacetic acid) scan was also used in six of the 12 patients in the Soukup series and is felt to be an excellent screening test when the index of suspicion for biliary injury is high and has the advantage of not requiring a general anesthetic. [9] However, if the clinic suspicion for biliary injury is high, the HIDA scan lacks the benefit of therapeutic intervention and could delay therapeutic procedures allowing for further bile peritoneal injury. Elevated serum direct bilirubin or peritoneal fluid bilirubin suggests duct disruption and expedited ERCP could allow for both diagnostic and therapeutic treatment, lessening further peritoneal injury. In our series, two patients had bilateral hepatic duct injuries. Both patients had Grade IV liver lacerations on CT scan and had a delay in diagnosis of bile duct injury at 12 and 7 days, diagnosed via ERCP but suggested by paracentesis in one patient. Both patients had biliary stent placement and the patient who underwent a paracentesis also had a sphincterotomy and later, laparoscopic washout with drain placement six days after ERCP due to generalized peritonitis and ascites. The LOS for these patients was 31 and 52 days. The results from our study and the recent series by Kulaylat et al. are encouraging; however, the literature for the role of ERCP in bile duct injury in the pediatric population is extremely limited. Although three of our patients in the early years of the study group were treated with stenting alone, it is our preference to perform a judicious sphincterotomy and stent placement for maximal decompression of the duct injury. Patients treated with sphincterotomy alone in this series could not have stents placed safely. Our anecdotal experience with stent placement alone in small pediatric patients results in duct obstruction and frequently necessitates additional procedures. The rate of long-term post ERCP stricture is not well documented in the literature. The risk of bleeding, stricture formation and the possibility of requiring more interventions must be weighed against the need to adequately treat the injured duct. 4. Conclusion Selected pancreatic injuries resulting from blunt abdominal trauma may be managed with ERCP, but a moderate rate of failure is expected. Major blunt pediatric bile duct injuries appear to be extremely rare and
can be difficult to diagnose. ERCP for diagnosis, definitive therapy, or as a method to avoid laparotomy may be beneficial in some cases and should be considered for evaluation of grade III or higher pancreatic injuries. ERCP in the pediatric population is safe, and may serve as an adjunctive or definitive treatment modality in blunt abdominal trauma. As seen in this series, some patients may still require operative intervention despite therapeutic ERCP.
5. Summary statement The experience with ERCP in the diagnosis or management of blunt abdominal trauma in the pediatric literature is sparse. ERCP can be used safely in the pediatric population and can be valuable as both diagnostic and therapeutic for pancreatic and bile duct injuries following blunt abdominal trauma.
References [1] National Center for Injury Prevention and Control: Web-based Injury Statistics and Query System (WISQARS). Center for Disease Control and Prevention. Available at: http://www.cdc.gov/injury/wisqars. [Accessed May 17, 2014]. [2] Canty TG, Weinmann D. Management of major pancreatic duct injuries in children. J Trauma 2001;50:1001–7. [3] Meier DE, Coln CD, Hicks BA, et al. Early operation in children with pancreas transection. J Pediatr Surg 2001;36:341–4. [4] Jobst MA, Canty TG, Lyng FP. Management of pancreatic injury in pediatric blunt abdominal trauma. J Pediatr Surg 1999;34:18–23. [5] Wales PW, Shuckett B, Kim PCW. Long-term outcome after nonoperative management of complete traumatic pancreatic transection in children. J Pediatr Surg 2001;36:823–7. [6] Iqbal CW, St Peter SD, Tsao K, et al. Operative vs nonoperative management for blunt pancreatic transection in children: multi-institutional outcomes. J Am Coll Surg 2014;218(2):157–62. [7] Bourque MD, Spigland N, Bensoussan AL, et al. Isolated complete transection of common bile duct due to trauma in a child; review of literature. J Pediatr Surg 1989;24:1068–70. [8] Kulaylat AN, Stokes AL, Engbrecht BW, et al. Traumatic bile leaks from blunt liver injury in children: a multidisciplinary and minimally invasive approach to management. J Pediatr Surg 2014;49:424–7. [9] Soukup ES, Russell KW, Metzger R, et al. Treatment and outcome of traumatic biliary injuries in children. J Pediatr Surg 2014;49:345–8. [10] Stylianos S, the APSA liver/spleen trauma study group. Prospective validation of evidence based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatr Surg 2002;37:453–6. [11] Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling, II: pancreas, duodenum, small bowel, colon and rectum. J Trauma 1990;30:1427–9. [12] Jurkovich GJ, Carrico CJ. Panceatic trauma. Surg Clin North Am 1990;70:575–93. [13] Subramanian A, Dente CH, Feliciano DV. The management of pancreatic trauma in the modern era. Surg Clin North Am 2007;87:1515–32. [14] Bhasin DK, Rana SS, Rawal P. Endoscopic retrograde pancreatography in pancreatic trauma: need to break the mental barrier. J Gastroenterol Hepatol 2009;24:720–8. [15] Hall RI, Lavelle MI, Venables CW. Use of ERCP to identify the site of traumatic injuries of the main pancreatic duct in children. Br J Surg 1986;73:411–2. [16] Rescoria FJ, Plumley DA, Sherman S, et al. The efficacy of early ERCP in pediatric pancreatic trauma. J Pediatr Surg 1995;30:336–40. [17] Houben CH, Ade-Ajayi N, Patel S, et al. Traumatic pancreatic duct injury in children: minimally invasive approach to management. J Pediatr Surg 2007;42(4): 629–35. [18] Borkon MJ, Morrow SE, Koehler EA, et al. Operative intervention for complete pancreatic transection in children sustaining blunt abdominal trauma: revisiting an organ salvage technique. Am Surg 2011;77(5):612–20. [19] Iqbal CW, Levy SM, Tsao K, et al. Laparoscopic versus open distal pancreatectomy in the management of traumatic pancreatic disruption. J Laparoendosc Adv Surg Tech A 2012;22(6):595–8. [20] Yahip S, Rabeeah A, Samarraie A. An unusual bile duct injury in a child after blunt abdominal trauma. J Pediatr Surg 1999;34:1161–3. [21] Almaramhi H, Al-Qahtani. Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention. J Pediatr Surg 2006;71: 943–5. [22] Sharif K, Pimalwar AP, John P, et al. Benefits of early diagnosis and preemptive treatment of biliary tract complications after major blunt liver trauma in children. J Pediatr Surg 2002;37:1287–92. [23] Castagnetti M, Houben C, Patel S, et al. Minimally invasive management of bile leaks after blunt liver trauma in children. J Pedaitr Surg 2006;41:1539–44.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Role of ERCP in pediatric blunt abdominal trauma: A case series at a level one pediatric trauma center☆ Erin M. Garvey a, Danielle J. Haakinson a, Mark McOmber b, David M. Notrica a, c,⁎ a b c
Division of General Surgery, The Mayo Clinic, 5777 E Mayo Blvd. Phoenix, AZ 85255 USA Pediatric Gastroenterology, Phoenix Children’s Hospital, 1920 E Cambridge Ave. Phoenix, AZ 85006 USA Pediatric Surgery, Phoenix Children’s Hospital, 1920 E Cambridge Ave. Phoenix, AZ 85006 USA
a r t i c l e
i n f o
Article history: Received 19 August 2014 Accepted 22 August 2014 Key words: Pediatric Blunt abdominal trauma Pancreatic injury Biliary injury Duct stenting Endoscopic retrograde cholangiopancreatography
a b s t r a c t Background: There is no consensus regarding the appropriate use of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric trauma. We report our experience with ERCP for management of pediatric pancreatic and biliary injury following blunt abdominal trauma. Methods: A retrospective chart review was performed for pediatric patients with blunt abdominal trauma from July 2008 through December 2012 at our pediatric trauma center. For patients who underwent ERCP, demographics, injury characteristics, diagnostic details, procedures performed, length of stay, total parenteral nutrition use, and complications were reviewed. Results: There were 532 patients identified: 115 hepatic injuries, 25 pancreatic injuries and one gall bladder injury. Nine patients (mean age 7.8 years) underwent ERCP. Seven (78%) had pancreatic injuries, while two (22%) had bilateral hepatic duct injuries. The median time to diagnosis was one day (range, 0-12). Diagnostic ERCP only was performed in three patients, two of which proceeded to distal pancreatectomy. Five patients had stents placed (two biliary and three pancreatic) and four sphincterotomies were performed. Despite pancreatic stenting, one patient required distal pancreatectomy for persistent leak. Median length of stay was 11 days. Conclusions: Pediatric pancreatic and biliary ductal injuries following blunt abdominal trauma are uncommon. ERCP can safely provide definitive treatment for some patients. © 2015 Elsevier Inc. All rights reserved.
Unintentional injury is the leading cause of death for patients between the ages of one year and 44 years.[1] Motor vehicles are largely responsible for fatal injuries whereas falls or being struck by an object are responsible for nonfatal injuries.[1] All of these mechanisms can result in blunt abdominal trauma. Pancreatic injury is relatively uncommon due to the retroperitoneal location. Reported rates of significant pancreatic injury range from 0.12% to 0.7% in the pediatric trauma literature.[2–4] Consensus exists for the nonoperative management of pancreatic trauma without ductal injury (Grade I and Grade II injuries) while controversy surrounds the appropriate management of Grade III–V injuries ranging from nonoperative management to various pancreatic resections or drainage operations.[2,3,5,6] The incidence of major bile duct injury following blunt abdominal trauma in the pediatric population is likely rarer than significant pancreatic injury. In a 1989 case report and review, Bourque et al. noted 125 reported cases of extrahepatic bile duct injury in the literature, of which one third were in pediatric patients.[7] Recent studies by Kulaylat et al. and Soukup et al. demonstrated a 3.7% rate of traumatic bile leak in a series of 294 patients
☆ Presented at Western Pediatric Trauma Conference July 9–11, 2014. ⁎ Corresponding author at: Phoenix Children’s Hospital, 1920 E Cambridge Ave Suite 201, Phoenix, AZ 85006. Tel.: +1 602 254 5561; fax: +1 602 254 2185. E-mail address: [email protected] (D.M. Notrica). http://dx.doi.org/10.1016/j.jpedsurg.2014.08.017 0022-3468/© 2015 Elsevier Inc. All rights reserved.
who sustained blunt hepatic injury and a rate of 0.09% biliary tract injury in a series of 13,582 trauma patients, respectively.[8,9] Nonoperative management of hemodynamically stable pediatric patients with blunt liver injury has become the standard of care.[10] This increase in nonoperative management, coupled with the retroperitoneal location of the pancreas and the relative rare incidence of pancreatic and bile duct injuries, can lead to a delay in diagnosis. Using computed tomography (CT), pancreatic and bile duct injuries can easily be missed. The role of ERCP in the management of these pancreatic and biliary injuries can be both diagnostic and therapeutic. The purpose of our study was to review the utility of diagnostic and therapeutic ERCP in the management of blunt abdominal trauma at our single institution level one pediatric trauma center. 1. Methods Approval from the Phoenix Children’s Hospital Institutional Review Board was obtained. A prospectively maintained trauma database was used to identify all patients (≤21 years) admitted to Phoenix Children’s Hospital with a diagnosis of blunt abdominal trauma from July 1, 2008 to December 31, 2012. A retrospective chart review was performed for all patients who underwent ERCP. Patient demographics, injury characteristics, diagnostic details, procedures performed, length of stay (LOS), total parenteral nutrition (TPN) use
336
E.M. Garvey et al. / Journal of Pediatric Surgery 50 (2015) 335–338
Table 1 Patient, injury, treatment and outcome characteristics. Patient
Age/Sex
Mechanism of Injury
Definitive Diagnostic Modality
Site of Injury
Injury Grade
ERCP & Operative Intervention/PID
Other Interventions
TPN Days
LOS ICU/ Total Days
Complications
A B
8/M 7/M
Handlebars Handlebars
CT ERCP
Pancreatic Tail Hepatic ducts
III IV (liver)
ERCP stent/2 ERCP stent/11
9 23
0/12 20/31
None Bacterial tracheitis
C
9/F
Fall
MRCP
Pancreatic body
III
ERCP sphincterotomy/6
PICC PICC CVC IR Angio Peritoneal drain PICC
6
0/11
D
6/F
Handlebars
CT
Pancreatic head
IV
ERCP stent/1 Open DP/3
PICC
10
8/15
E
5/M
Fall
CT
Pancreatic tail
III
8
4/10
F
1/F
SNAT
MRCP
III
PICC
5
4/9
None
G
11/M
Handlebars
CT
Pancreatic body and tail Pancreatic tail
ERCP/1 Open DP/2 ERCP/7
UTI Acute pancreatitis Reintubation Pseudocyst rupture Mallory–Weiss tear None
III
CVC
4
3/7
H
15/M
Auto vs pedestrian
Paracentesis / ERCP
Hepatic ducts
IV (liver)
PICC
38
26/52
Readmit for high drain output Pseudocyst
Paracentesis Peritoneal drain NJ tube Chest tube None
0
0/7
None
I
9/F
Handlebars
CT
Pancreatic body and tail
III
ERCP sphincterotomy/1 Lap DP/1 ERCP stent & sphincterotomy/8 Lap washout/14
ERCP stent & sphincterotomy/2
M: male, F: female, SNAT: suspected nonaccidental trauma, ERCP: endoscopic retrograde cholangiopancreatography, MRCP: magnetic resonance cholangiopancreatography, PID: post injury day, TPN: total parenteral nutrition, LOS: length of stay, ICU: intensive care unit, PICC: peripherally inserted central catheter, CVC: centrally inserted venous catheter, IR Angio: interventional radiology angiography, NJ: nasojejunal, UTI: urinary tract infection.
and complications were reviewed. Pancreatic injury grades were assigned based on the organ scaling injury guidelines from the American Association for the Surgery of Trauma.[11] A core group of 10 pediatric surgeons managed all injured children at Phoenix Children’s Hospital during the study period, and three surgeons performed the four operations. All ERCPs were performed by one pediatric interventional gastroenterologist. Descriptive statistical analysis was performed. 2. Results During the 4.5 year study period, there were 532 patients with a diagnosis of blunt abdominal trauma including 115 hepatic injuries (21.6%), 25 pancreatic injuries (4.7%) and one gallbladder injury (0.19%). The mean age was 9 years (range, 2 months to 19 years). Nine patients underwent ERCP (1.7%). The mean age was 7.8 years (range, 17 months to 15 years). Five patients (55.6%) were male. The mean weight was 26.4 kg (range, 9.96 to 50.3 kg). The majority of patients, 5/9 (55.6%), had handlebar-related injuries. The other four injuries comprised falls (n = 2), suspected non-accidental trauma (n = 1) and auto versus pedestrian (n = 1) (Table 1). Of the nine patients who underwent ERCP, pancreatic injuries were identified in 7/9 (77.8%) and the remaining two patients were found to have bilateral hepatic duct injuries (22.2%). Only 4/9 (44.4%) of injuries were suggested on day of presentation based on CT findings of pancreatic fracture or transection. CT definitively diagnosed pancreatic duct injury in 5/7 (71.4%) pancreatic injury patients. The remaining two were diagnosed by MRCP. The breakdown of pancreatic injury grades is shown in Table 2. The two patients with hepatic duct injury had Grade IV liver lacerations on CT, but definitive diagnosis of the hepatic duct injuries occurred with ERCP. The median time to diagnosis was 1 day (range, 0 to 12 days). The median time to ERCP was post-injury day 2 (range, 1 to 11 days). For the seven ERCP patients with pancreatic injuries, two proceeded directly to the operating room for distal pancreatectomy
(one laparoscopic [Grade III], one open [Grade IV]). One patient was found to have pancreatic duct compression without extravasation and was managed nonoperatively. Of the four pancreatic injuries managed with ERCP intervention, one treated with pancreatic stenting went to the operating room two days after ERCP due to persistent leak. The remaining three patients were managed successfully with ERCP interventions alone including one stent, one sphincterotomy and one patient who had both a stent and a sphincterotomy. Thus, of the pancreatic patients who underwent attempted definitive management with ERCP intervention, 3/4 (75%) were successful. Of the two bile duct injuries, one patient was managed successfully with ERCP stenting alone, but the other required a laparoscopic washout and drain placement six days after ERCP with stenting and sphincterotomy due to persistent ascites and peritonitis; no duct repair, however, was required. Thus, both avoided the need for ductal repair, but 1/2 (50%) required a minimally invasive operative intervention. In addition to ERCP, most patients required other interventions for management of their injury. The two patients with hepatic duct injuries required multiple interventional radiology (IR) procedures. Patient B underwent IR embolization of a superior branch from the right hepatic artery and placement of a peritoneal drain. Patient H underwent paracentesis (which prompted ERCP resulting in the diagnosis of bile leak), placement of a peritoneal drain, nasojejunal
Table 2 American association for the surgery of trauma pancreatic injury grading. Grade
Pancreatic Injury
N
I II III IV V
Minor contusion Major contusion Distal transection or parenchyma and duct injury Proximal transection or parenchyma and duct injurya Massive disruption of pancreatic head
0 0 6 1 0
a Proximal pancreas is defined as the portion to the right of portal vein/superior mesenteric vein.
E.M. Garvey et al. / Journal of Pediatric Surgery 50 (2015) 335–338
feeding tube placement and chest tube insertion due to a pleural effusion. The mean number of interventions per patient including ERCP, operative and IR procedures (excluding venous access procedures) needed for management of the injury was 2.2 (range, 1 to 6), and the mean number of general anesthesia inductions was 2.1 (range, 1 to 4). All but one patient required TPN and therefore needed central venous access. Six patients had peripherally inserted central catheter (PICC) lines, one had a central line, and one patient had both a PICC and central line during his hospitalization. The median TPN duration was 8 days (range, 0 to 38 days) with a median of 6 days (range, 2 to 19 days) until initiation of enteral feeds, and 9 days (range, 3 to 34 days) until full enteral feeds were achieved. No patient required TPN at discharge. The median LOS for all patients in the series was 11 days (range, 7 to 52 days) with a median LOS in the ICU of 4 days (range, 0 to 26 days). The median number of ventilator dependent (VD) days was 0 and the average was 1.3 days (range, 0 to 8 days). The median LOS for those four patients who underwent interventional ERCP was 11.5 days (range, 7 to 15 days), with a median of 0 ICU days (range, 0 to 8 days) and 0 VD days (range, 0 to 4 days). The two patients who proceeded directly to the operating room after ERCP had a median LOS of 8.5 days (range, 7 to 10 days), a median 3.5 ICU days (range, 3 to 4 days) and 0 VD day. The one patient who had a diagnostic ERCP had a 9 day LOS, 4 days of which were in the ICU, with no VD days. The two patients with bile duct injuries had the longest LOS at 31 and 52 days, with the longest ICU stays at 20 and 26 days, with 8 and 0 VD days, respectively. Five patients experienced complications. Two patients developed pancreatic pseudocysts and Patient D required readmission 1.5 months after discharge due to pseudocyst rupture resulting in nausea and vomiting causing a Mallory–Weiss tear. Patient C was also readmitted two years after discharge for an episode of acute pancreatitis. There were no mortalities. 3. Discussion Pancreatic injury is uncommon secondary to the retroperitoneal location of the pancreas, and the diagnosis of pancreatic injury is frequently delayed due to limitations of standard imaging modalities. [12,13] ERCP is considered the most accurate method to diagnose pancreatic duct disruption and has the added benefit of identifying the exact location and extent of the injury.[13,14] Treatment for pancreatic ductal injury, however, remains controversial. Recently, operative management has been shown to result in better outcomes than nonoperative management for higher grade injuries.[6] The potential advantages of ERCP as an adjunct to nonoperative management might include reduction in pseudocyst formation, shortening hospital stays and quicker return to enteral intake. Common potential risks of nonoperative management include pancreatic duct strictures, atrophy of the distal duct despite intervention, post-ERCP pancreatitis and the need for future interventions.[2,5,14] ERCP and the expertise needed to perform this procedure in the pediatric population may not be readily available and can limit the utilization of ERCP at smaller centers. A 2009 review by Bhasin et al. cites a number of adult studies demonstrating the utility of ERCP including diagnosing pancreatic duct injury, stratifying patients into operative versus nonoperative treatment approaches and treating select pancreatic injuries with duct stenting and/or sphincterotomy for hemodynamically stable trauma patients.[14] Most of these studies are from small case series with retrospective data, and the literature for the pediatric population is even sparser. However, ERCP has been recommended for consideration in all children with blunt abdominal trauma from as early as 1986, based on the experience from four patients with delayed main pancreatic duct injury identified by ERCP in a series by Hall et al.[15] Shortly thereafter, from 1988 to 1993, Rescoria et al. reviewed the role of ERCP in six patients (aged 2.5 to 8 years) who developed persistent
337
pancreatic drainage after percutaneous drainage (n = 2) or laparotomy (n = 1); with large lesser sac fluid collections (n = 2); and with severe abdominal pain with a CT suggestive of pancreatic injury (n = 1), and deemed ERCP to be safe in pediatric patients and effective in delineating pancreatic ductal anatomy.[16] Canty et al. identified 18 patients (aged 2 months to 13 years) with major pancreatic duct injury, two of which underwent ERCP. The first was a 9 year old female who sustained a handlebar injury to the abdomen and was found to have a side hole injury of the main pancreatic duct which was treated with a 5 French stent. At ERCP for stent removal and at one year follow up, a narrowing of the duct at the site of injury was noted but the patient remained clinically asymptomatic. The second patient was an 8 year old male who was struck and run over by a van who also had a side hole injury of the main pancreatic duct which was treated with a transampullary decompressing stent. He had no evidence of stricture and remained asymptomatic at the time of stent removal and at one year follow up.[2] Diagnostic ERCP was performed in 12 patients (aged 7 to 16 years) in a larger series by Houben et al. from the United Kingdom. Nine of these patients underwent pancreatic duct stent placement: three stents were placed into the duct while six were placed into the pseudocyst itself. Stent placement failed in two patients secondary to a tortuous duct and pancreas divisum. Minor complications included transient rise in serum amylase and exacerbation of epigastric pain, and two patients developed pseudocysts. Overall, their study suggests ERCP has a role for management of traumatic pancreatic injuries.[17] In the present study, the majority, 4/7 (57%), of pancreatic duct injuries were a result of handlebar injuries, and the majority of injuries were detected with CT scan, 5/7 (71%). The CT diagnosis is similar to other series, but our study has a higher rate of handlebar injury than many pediatric series.[17–19] In our series, like the Canty et al. series, ERCP was performed earlier (median post-injury day 2) compared to a median of 5 days in the Houben studies.[2,17] ERCP proved to be diagnostic in all cases, and therapeutic in our series with three of four patients successfully managed with stenting and/or sphincterotomy, with one patient requiring operative intervention despite stenting. Our LOS was similar to Canty’s cases, and shorter than for the patients who underwent nonoperative management in the Iqbal series (mean 11.25 days for our ERCP intervention patients compared to a mean of 15 days).[2,6] This small number of patients in our series also compares favorably with laparoscopic distal pancreatectomy.[19] The shorter LOS compared to the Houben ERCP study (28 days) was likely due to earlier ERCP and quicker initiation of enteral feeds in our series. [17] Complication rates were similar with two pseudocysts in each series. There were no ERCP-related complications. Our study and the series by Houben et al. would suggest ERCP is safe and has a role in the management of early and delayed pancreatic duct injuries in children with blunt abdominal trauma. Major bile duct injuries caused by blunt abdominal trauma appear extremely rare, even compared to pancreatic injury, and are usually associated with liver parenchymal injuries. There is often a delay in diagnosis, especially with nonoperative management of blunt liver injuries, or even missed diagnosis during laparotomy.[7,20–22] Almaramhi et al. described a series of five patients with bile duct injuries (two intrahepatic and three extrahepatic) who underwent ERCP after laparotomy/laparotomies for persistent bile leak. The median number of days before diagnosis was 22.5 days. The three patients with extrahepatic bile duct injuries were treated successfully with ERCP, stenting and percutaneous drainage. Two of these patients developed infection of the bile collections, but were successfully treated with intravenous antibiotics. The median LOS was 25.5 days. [21] Castagnetti et al. described another series of five patients with intrahepatic bile duct injury identified by ERCP and treated with biliary stenting (n = 5) with the addition of sphincterotomy in two of the five patients. ERCP was performed at a median of 15 days. Four patients required percutaneous drainage and two underwent laparoscopic
338
E.M. Garvey et al. / Journal of Pediatric Surgery 50 (2015) 335–338
lavage. One patient developed a bile duct stricture that was successfully managed with endoscopic dilation. The median hospital LOS was 43 days.[23] A more recent study by Kulaylat et al. demonstrated a 3.7% rate of traumatic bile leak in their series of 294 patients and utilized ERCP to diagnose and treat nine intrahepatic and two extrahepatic bile duct injuries (a rate of 0.68% extrahepatic and 3.1% intrahepatic injury) with sphincterotomy and/or stent placement. All bile leaks resolved at a median of 13 days (range, 3 to 64 days) and median LOS was 10 days (range, 5 to 31 days). There were two complications. One patient developed cholangitis due to a retained biliary stent after being lost to follow up, and another patient had a pneumothorax and effusion after placement of an imaging guided percutaneous drain.[8] Another recent study by Soukup et al. identified 12 patients with biliary injuries, six of which were evaluated with ERCP. Two of the six patients who had stent placement alone (one patient was managed initially with ERCP and the other underwent ERCP after an exploratory laparotomy and cholecystectomy for gall bladder avulsion) developed delayed strictures requiring multiple repeat ERCPs and/or a laparotomy with left hepatectomy. One of the six patients presented with a delayed common bile duct injury three weeks after being discharged for a blunt pancreatic injury from handlebars and underwent ERCP with sphincterotomy and stenting during the second hospitalization. This patient had post sphincterotomy bleeding requiring repeat ERCP and also developed a stricture. One patient was unable to have stent placement, and the remaining two patients were treated successfully with initial ERCP and stenting. A HIDA (hepatobiliary iminodiacetic acid) scan was also used in six of the 12 patients in the Soukup series and is felt to be an excellent screening test when the index of suspicion for biliary injury is high and has the advantage of not requiring a general anesthetic. [9] However, if the clinic suspicion for biliary injury is high, the HIDA scan lacks the benefit of therapeutic intervention and could delay therapeutic procedures allowing for further bile peritoneal injury. Elevated serum direct bilirubin or peritoneal fluid bilirubin suggests duct disruption and expedited ERCP could allow for both diagnostic and therapeutic treatment, lessening further peritoneal injury. In our series, two patients had bilateral hepatic duct injuries. Both patients had Grade IV liver lacerations on CT scan and had a delay in diagnosis of bile duct injury at 12 and 7 days, diagnosed via ERCP but suggested by paracentesis in one patient. Both patients had biliary stent placement and the patient who underwent a paracentesis also had a sphincterotomy and later, laparoscopic washout with drain placement six days after ERCP due to generalized peritonitis and ascites. The LOS for these patients was 31 and 52 days. The results from our study and the recent series by Kulaylat et al. are encouraging; however, the literature for the role of ERCP in bile duct injury in the pediatric population is extremely limited. Although three of our patients in the early years of the study group were treated with stenting alone, it is our preference to perform a judicious sphincterotomy and stent placement for maximal decompression of the duct injury. Patients treated with sphincterotomy alone in this series could not have stents placed safely. Our anecdotal experience with stent placement alone in small pediatric patients results in duct obstruction and frequently necessitates additional procedures. The rate of long-term post ERCP stricture is not well documented in the literature. The risk of bleeding, stricture formation and the possibility of requiring more interventions must be weighed against the need to adequately treat the injured duct. 4. Conclusion Selected pancreatic injuries resulting from blunt abdominal trauma may be managed with ERCP, but a moderate rate of failure is expected. Major blunt pediatric bile duct injuries appear to be extremely rare and
can be difficult to diagnose. ERCP for diagnosis, definitive therapy, or as a method to avoid laparotomy may be beneficial in some cases and should be considered for evaluation of grade III or higher pancreatic injuries. ERCP in the pediatric population is safe, and may serve as an adjunctive or definitive treatment modality in blunt abdominal trauma. As seen in this series, some patients may still require operative intervention despite therapeutic ERCP.
5. Summary statement The experience with ERCP in the diagnosis or management of blunt abdominal trauma in the pediatric literature is sparse. ERCP can be used safely in the pediatric population and can be valuable as both diagnostic and therapeutic for pancreatic and bile duct injuries following blunt abdominal trauma.
References [1] National Center for Injury Prevention and Control: Web-based Injury Statistics and Query System (WISQARS). Center for Disease Control and Prevention. Available at: http://www.cdc.gov/injury/wisqars. [Accessed May 17, 2014]. [2] Canty TG, Weinmann D. Management of major pancreatic duct injuries in children. J Trauma 2001;50:1001–7. [3] Meier DE, Coln CD, Hicks BA, et al. Early operation in children with pancreas transection. J Pediatr Surg 2001;36:341–4. [4] Jobst MA, Canty TG, Lyng FP. Management of pancreatic injury in pediatric blunt abdominal trauma. J Pediatr Surg 1999;34:18–23. [5] Wales PW, Shuckett B, Kim PCW. Long-term outcome after nonoperative management of complete traumatic pancreatic transection in children. J Pediatr Surg 2001;36:823–7. [6] Iqbal CW, St Peter SD, Tsao K, et al. Operative vs nonoperative management for blunt pancreatic transection in children: multi-institutional outcomes. J Am Coll Surg 2014;218(2):157–62. [7] Bourque MD, Spigland N, Bensoussan AL, et al. Isolated complete transection of common bile duct due to trauma in a child; review of literature. J Pediatr Surg 1989;24:1068–70. [8] Kulaylat AN, Stokes AL, Engbrecht BW, et al. Traumatic bile leaks from blunt liver injury in children: a multidisciplinary and minimally invasive approach to management. J Pediatr Surg 2014;49:424–7. [9] Soukup ES, Russell KW, Metzger R, et al. Treatment and outcome of traumatic biliary injuries in children. J Pediatr Surg 2014;49:345–8. [10] Stylianos S, the APSA liver/spleen trauma study group. Prospective validation of evidence based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatr Surg 2002;37:453–6. [11] Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling, II: pancreas, duodenum, small bowel, colon and rectum. J Trauma 1990;30:1427–9. [12] Jurkovich GJ, Carrico CJ. Panceatic trauma. Surg Clin North Am 1990;70:575–93. [13] Subramanian A, Dente CH, Feliciano DV. The management of pancreatic trauma in the modern era. Surg Clin North Am 2007;87:1515–32. [14] Bhasin DK, Rana SS, Rawal P. Endoscopic retrograde pancreatography in pancreatic trauma: need to break the mental barrier. J Gastroenterol Hepatol 2009;24:720–8. [15] Hall RI, Lavelle MI, Venables CW. Use of ERCP to identify the site of traumatic injuries of the main pancreatic duct in children. Br J Surg 1986;73:411–2. [16] Rescoria FJ, Plumley DA, Sherman S, et al. The efficacy of early ERCP in pediatric pancreatic trauma. J Pediatr Surg 1995;30:336–40. [17] Houben CH, Ade-Ajayi N, Patel S, et al. Traumatic pancreatic duct injury in children: minimally invasive approach to management. J Pediatr Surg 2007;42(4): 629–35. [18] Borkon MJ, Morrow SE, Koehler EA, et al. Operative intervention for complete pancreatic transection in children sustaining blunt abdominal trauma: revisiting an organ salvage technique. Am Surg 2011;77(5):612–20. [19] Iqbal CW, Levy SM, Tsao K, et al. Laparoscopic versus open distal pancreatectomy in the management of traumatic pancreatic disruption. J Laparoendosc Adv Surg Tech A 2012;22(6):595–8. [20] Yahip S, Rabeeah A, Samarraie A. An unusual bile duct injury in a child after blunt abdominal trauma. J Pediatr Surg 1999;34:1161–3. [21] Almaramhi H, Al-Qahtani. Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention. J Pediatr Surg 2006;71: 943–5. [22] Sharif K, Pimalwar AP, John P, et al. Benefits of early diagnosis and preemptive treatment of biliary tract complications after major blunt liver trauma in children. J Pediatr Surg 2002;37:1287–92. [23] Castagnetti M, Houben C, Patel S, et al. Minimally invasive management of bile leaks after blunt liver trauma in children. J Pedaitr Surg 2006;41:1539–44.
