Management of childhood pancreatic disorders: a multidisciplinary approach

INTRODUCTION: Data on therapeutic endoscopy and radiologic interventions for the management of childhood pancreatic disorders are relatively limited. This study focuses on the multidisciplinary approach to the management of pancreatitis in children. PATIENTS AND METHODS: Children with pancreatic disorders were studied from January 1992 to May 2001. Acute pancreatitis (AP) was diagnosed by clinical evaluation, serum amylase more than three times normal, and morphologic abnormalities of the pancreas on imaging. Children with recurrent abdominal pain, pancreatic calcification or ductal stones on imaging, and pancreatic ductal changes on endoscopic retrograde cholangiopancreatography (ERCP) were diagnosed with chronic pancreatitis (CP). Patients were treated by gastroenterologists, surgeons, and interventional radiologists. Pancreatic exocrine insufficiency was diagnosed in appropriate settings. RESULTS: Fifteen children--6 with AP (posttrauma, 3; gallstone disease, 1; and viral, 1), 7 with CP, and 2 with pancreatic exocrine insufficiency--were diagnosed. Local complications observed in children with AP included pseudocyst in three, and infected acute fluid collection, right-sided pleural effusion, and ascites in one patient each. Complications of AP were managed with percutaneous catheter drainage (n = 3; pseudocyst, 2; infected fluid collection, 1), additional pancreatic duct stenting (n = 2), surgical drainage (n = 1), and octreotide for pleural effusion (n = 1). Signs of CP included abdominal pain (n = 7), obstructive jaundice resulting from lower common bile duct stricture (n = 2), and bleeding from gastroduodenal artery pseudoaneurysm (n = 1). Pancreatic duct stenting relieved pain in one patient, and steel coil embolization arrested bleeding from the pseudoaneurysm. Common bile duct strictures were managed by surgical bypass (n = 2), one of which required preoperative endoscopic bile duct stenting for management of cholangitis. Two other patients with CP required no intervention. CONCLUSION: A multidisciplinary approach of radiologic and endoscopic interventions and surgery are complimentary to each other in achieving successful outcomes of complicated childhood pancreatitis.     

Surgical management of major pancreatic injury in children.

INTRODUCTION: Major or complicated pancreatic trauma in children is uncommon and management strategies remain controversial. The aim of this study was to evaluate our experience with both early and delayed surgery in these pediatric cases. METHODS: We carried out a retrospective analysis of data of pediatric patients with major or complicated pancreatic injury operated on between January 1994 and December 2005 in our pediatric trauma center. RESULTS: Thirteen children (9 boys and 4 girls) with a mean age of 8.5 years (range 3 - 16 years) were operated for major or complicated pancreatic injury. The extent of injury was: grade II (major contusion without duct injury or tissue loss) in 4 children; grade III (distal transection) in 5 children and grade IV injury (proximal transection) in four patients. Pseudocyst developed in 8 children: 4 with grade II injury, 2 with grade III injury and 2 with grade IV injury (one with abdominal pseudocyst and one with an abdominal and a mediastinal pseudocyst). Early diagnosis and operation was achieved in 5 cases, while delayed diagnosis and operation occurred in 8. Three children underwent cystogastrostomy; 6 had a spleen-sparing distal pancreatectomy and 4 had resection with Roux-en-Y jejunostomy drainage. Endoscopic retrograde cholangiopancreaticography (ERCP) was the most useful diagnostic tool in assessing ductal injury. There were no deaths or long-term morbidity in our group of patients. CONCLUSIONS: Our results support the view that early operation is important in ductal pancreatic injury. We recommend transferring children with a suspected ductal injury to a tertiary center with experience in both pediatric ERCP and pancreatic surgery.     

Management of blunt pancreatic trauma in children

Blunt trauma to the abdomen accounts for the majority of abdominal injuries in children. Pancreatic injury is the fourth most common solid organ injury, following injuries to the spleen, liver and kidneys. The most common complications are the formation of pancreatic fistulae, pancreatitis and the development of pancreatic pseudocysts, which usually present several weeks after injury. The nonoperative management of minor pancreatic injury is well accepted; however, the treatment of more serious pancreatic injuries with capsular, ductal or parenchymal disruption in pediatric patients remains controversial. Based on the data presented in this literature review, although children with pancreatic injuries (without ductal disruption) do not appear to suffer increased morbidity following conservative management, patients with ductal disruption may benefit from operative intervention.     

腹部闭合伤致儿童胰腺外伤的诊治探讨

目的 探讨儿童腹部闭合性损伤导致胰腺外伤的病因及诊断和治疗方法.方法 回顾性分析我院1999年1月至2008年5月间收治14例闭合性腹部损伤导致胰腺外伤患儿的临床资料.结果 男11例,女3例,男∶女=3.7∶1.致伤原因依次为自行车把致伤5例、交通事故4例、踢伤或殴伤3例、跌伤2例.临床表现有腹痛、腹部压痛、白细胞及血清淀粉酶升高和发热.实验室检查14例均有不同程度白细胞升高.10例(71.5%)血清淀粉酶升高,二者升高水平与胰腺损伤程度无关;重复血清淀粉酶值测定对胰腺外伤具有诊断意义.11例(78.6%)CT检查发现胰腺损伤6例(54.5%),5例CT检查正常但剖腹探查胰腺外伤2例;12例B超检查发现胰腺损伤8例;内镜逆行胰胆管造影(ERCP)检查1例.保守治疗成功9例,包括轻微损伤6例,远端胰管损伤1例,入院时有胰管损伤但未发现2例.剖腹探查及胰腺外引流术5例.胰腺假性囊肿形成后手术4例.结论 胰腺外伤在儿童腹部闭合性损伤中并不常见.诊断以血清淀粉酶升高、CT及B超检查为主,少数需剖腹探查.白细胞及血清淀粉酶升高水平与胰腺损伤程度无关.重复血清淀粉酶测定及CT检查对胰腺外伤具有诊断意义.大多数胰腺创伤包括胰管近端损伤儿童可以先保守治疗而不是冒风险手术干预,如果形成假性囊肿再后期引流.胰管远端损伤(Ⅲ级)最好选择保脾胰尾切除术.剖腹探查术中发现轻微胰腺损伤而采用腹部闭式引流措施意义不大.     

Delayed presentation of complete pancreatic ductal transection in children: management of two cases without resection

Pancreatic ductal injuries in children are rare, and ductal transections presenting in a delayed or subacute fashion are seldom reported. We describe two cases of traumatic pancreatic ductal transection secondary to physical abuse, both of which presented late to medical care. Both were managed successfully without pancreatic resection. Judicious application of non-resectional management can yield favorable outcomes in this subset of pediatric patients.     

Pancreatic ascites in children

We report on three children with pancreatic ascites confirmed by endoscopic retrograde cholangiopancreaticography (ERCP) and treated with surgery. The children presented with ascites, malnutrition and severe weight loss. Pancreatic ascites was diagnosed by elevated ascitic fluid and serum amylase levels. ERCP demonstrated a pseudocyst and the site of disruption of the pancreatic duct, but not the etiology of the pancreatitis. Following a period of nutritional support, surgery was carried out. Two of the children underwent a stented transgastric drainage of the pseudocyst; a recurrent pseudocyst in one of the children required a revision cystojejunostomy. The third child was treated with a Roux-en-Y cystojejunostomy. All the children are pain-free and without ascites and are doing well on long-term follow-up. We conclude that pancreatic ascites must be considered in the differential diagnosis of intractable ascites in children. An ERCP is essential in planning management and cystoenterostomy is the definitive treatment.     

Laparoscopic diagnosis of blunt abdominal trauma in children

This study evaluates the safety and role of laparoscopy in the diagnosis of blunt abdominal trauma in children. Laparoscopy was performed in five patients aged 3 to 13 years because of persistent abdominal pain after blunt trauma. A laparotomy was not indicated from the physical examination, laboratory data, or radiologic findings. With the patient under general anesthesia, a 10-mm trocar was inserted through the umbilical fossa and the intra-abdominal organs were observed for 10–60 min under an insufflation pressure of 10–12 mmHg. The patients remained hemodynamically stable without pneumothorax development. Three patients underwent laparatomies: one, who had blood in the omental sac, had a duodenal injury with hemorrhagic necrosis and underwent a resection; one with ascites and high amylase levels had an injury of the main pancreatic duct and underwent resection of the pancreatic tail; and one who had fresh blood in the upper abdomen and Douglas' pouch had a splenic hemorrhage and underwent hemostasis. The other two had serous or serosanguinous ascites and recovered without surgery. In patient 1, the same amount of information might have been obtained from a barium study. In patient 2, the pancreatic transection might have been diagnosed from ascites shown on serial computed tomograms. Patient 3 might also have been treated successfully non-surgically. It hus appears that laparoscopy may be a safe diagnostic method for blunt abdominal trauma in children, however, this small series has yielded insufficient information to assess its usefulness in making the diagnosis and the decision for laparotomy. Further studies are required to ascertain whether it will make any significant difference in the form of management.     

儿童Ⅲ型胰腺外伤六例治疗体会

目的 探讨儿童Ⅲ型胰腺外伤的治疗方法.方法 回顾性分析2010年1月至2015年6月收治的6例Ⅲ型胰腺外伤患儿的临床资料.本组均为男孩,年龄6岁4个月～11岁5个月.入院时均有不同程度腹痛,伴呕吐2例,伴发热1例;血淀粉酶(695.83±264.07) U/L,尿淀粉酶(4 163.67±5 546.53)U/L.CT检查,均提示胰管损伤可能,其中3例分别合并脾挫伤、左肾上腺挫伤加肺挫伤、左肾上腺挫伤.患儿均先给予生长抑素、禁食、静脉营养等保守治疗,但症状控制不满意.待血流动力学稳定后行逆行胰胆管造影(ERCP)加内镜鼻胰管引流术或胰管支架引流术.结果 6例ERCP造影提示1例胰头部、4例胰体部、1例体尾部主胰管损伤.行13次ERCP引流,2例经7次ERCP引流治愈;另4例6次ERCP引流症状控制不佳,3例穿刺引流,1例开放引流后治愈.6例随访胰管均修复、恢复通畅;2例超声检查示胰腺有局部细小囊性改变,无临床症状,淀粉酶恢复正常.结论 单独ERCP引流治疗儿童Ⅲ型胰腺外伤疗效不满意,有待更多临床总结;结合经皮穿刺引流和开放引流效果确切.儿童Ⅲ型胰腺外伤使用药物治疗加确切引流就能取得良好预后,应尽量避免复杂手术.     

Acute and chronic pancreatitis: surgical management

Pancreatitis is becoming increasingly prevalent in children, posing new challenges to pediatric health care providers. Although some general adult treatment paradigms are applicable in the pediatric population, diagnostic workup and surgical management of acute and chronic pancreatitis have to be tailored to anatomic and pathophysiological entities peculiar to children. Nonbiliary causes of acute pancreatitis in children are generally managed nonoperatively with hydration, close biochemical and clinical observation, and early initiation of enteral feeds. Surgical intervention including cholecystectomy or endoscopic retrograde cholangiopancreatography is often required in acute biliary pancreatitis, whereas infected pancreatic necrosis remains a rare absolute indication for pancreatic debridement and drainage via open, laparoscopic, or interventional radiologic procedure. Chronic pancreatitis is characterized by painful irreversible changes of the parenchyma and ducts, which may result in or be caused by inadequate ductal drainage. A variety of surgical procedures providing drainage, denervation, resection, or a combination thereof are well established to relieve pain and preserve pancreatic function.     

Idiopathic fibrosing pancreatitis presenting with obstructive jaundice in a child.

Idiopathic fibrosing pancreatitis (IFP) is a rare cause of obstructive jaundice in children. The obstruction is caused by circumferential compression of the intrapancreatic portion of the common bile duct (CBD). Various forms of biliary decompression, including surgical sphincteroplasty, choledochoduodenostomy, and Roux-en-Y choledochojejunostomy are employed as a treatment. We report a 14-year-old boy with IFP who was successfully treated by a temporary drainage of compressed CBD with the help of a stent placed by endoscopic retrograde cholangiopancreatography (ERCP). The diagnosis of IFP was confirmed histologically after open surgery. The patient remains well after 3.5 years of follow-up with no evidence of pancreatic insufficiency. This report offers an additional case of IFP causing obstructive jaundice treated by temporary internal drainage of CBD, which is safer and less invasive than biliodigestive surgical decompression.     

儿童严重胰腺闭合性损伤的诊治探讨

目的探讨按照美国创伤外科协会（AAST）胰腺创伤分级为Ⅲ～Ⅳ级的儿童闭合性胰腺损伤的最佳治疗方案。方法回顾性分析2008年9月至2012年10月我们收治的12例Ⅲ～Ⅳ级闭合性胰腺损伤患儿临床资料,对其治疗方法进行分析,比较不同方法的临床疗效。结果12例患儿中,2例子保守治疗,5例行开腹外引流手术,5例行ERCP诊断及胰管支架置人,随访3～51个月,均预后良好,无死亡及胰腺内外分泌不足的表现。手术组及ERCP组治疗后血淀粉酶下降及恢复经口喂养时间无明显差异,但优于保守治疗组。2例保守治疗患儿伴〉8cm的胰腺假性囊肿,于半年后自行吸收。2例外引流无效者经ERCP治疗成功,ERCP在血流动力学稳定伴主胰管破裂患儿中应用安全,显著缩短了病程。结论儿童Ⅲ-Ⅳ级胰腺闭合性损伤患儿可以不行胰腺切除术或胰腺胃肠吻合术获痊愈,部分可保守治疗痊愈。当保守治疗或外引流术不能控制病情时,ERCP可作为首选。远期预后需大量样本进一步随访。     

Blunt Abdominal Trauma in the Pediatric Patient

Timely diagnosis and a rational approach to operative versus nonoperative management of intra-abdominal injuries in children are critical to providing optimal pediatric trauma care. Suspicion of IAI is based on the mechanism of injury and findings on examination. Subsequent evaluation and management of IAI is influenced by the patient's hemodynamic status and the presence of extra-abdominal injuries. The hemodynamically unstable patient with suspected IAI requires emergent laparotomy. The hemodynamically stable patient is evaluated using laboratory and imaging studies, most importantly, CT of the abdomen. Stable patients with hepatic or splenic injuries are almost always managed nonoperatively, whereas small bowel, colon, and pancreatic injuries with main duct disruption require laparotomy.     

小儿慢性胰腺炎12例

目的总结小儿慢性胰腺炎的临床经验,探讨其诊断与手术治疗方法。方法回顾性分析12例慢性胰腺炎患儿的临床资料,其中男性9例,女性3例。平均年龄11.4岁,病程17.1个月。均因反复发作上腹痛入院。B超、CT或MRCP显示存在胰腺钙化2例,胰管扩张4例,胰管结石4例,胰腺假性囊肿5例。6例1期患儿予保守治疗;6例2期患儿予手术治疗,其中胰管切开取石、胰管空肠侧侧吻合术3例,胰体尾、脾切除术2例,腹腔引流术1例。结果 6例保守治疗患儿症状完全缓解后出院。6例手术治疗患儿中,除1例胰头部结石嵌顿未能取尽外,其余均恢复良好。12例患儿均获得6个月至5年随访,平均随访时间2.4年,其中3例复发腹痛,其余无临床症状。结论小儿慢性胰腺炎多依靠影像学检查确诊。合并胰管结石者首选胰管切开取石、大口径胰管空肠吻合术,可有效缓解疼痛,创伤小,并发症少。     

Benefits of primary surgical resection for symptomatic urethral prolapse in children

ObjectiveUrethral prolapse (UP) is a complete eversion of the distal urethral mucosa through the external meatus. UP must be distinguished by examination from trauma, prolapsed ureterocele, tumors or sexual abuse. Its management remains controversial. The aim of the study was to promote the benefits of primary surgical management for UP.MethodsA retrospective multicenter review of children who received surgery for UP between 1991 and 2011 was carried out. Non-complicated UP was primarily treated conservatively. A total of 19 patients were referred for complicated UP and underwent resection of the prolapsed urethral mucosa.ResultsThe mean delay in diagnosis was 2.2 days (range 1–6) and the most common symptoms were vaginal spotting and bleeding. No predisposing factor was found, but most patients had a mean weight, height and BMI greater than the 50th percentile. All patients underwent surgery successfully. One patient experienced a complication, i.e., dysuria. There was no case of recurrence after a mean 28 months of follow-up.ConclusionEarly detection is based on bedside examination. The first-line treatment strategy for uncomplicated UP should be conservative management. Surgical resection is safe and effective for patients with significant symptoms.     

儿童腹部损伤的诊断与治疗

目的 探讨儿童腹部损伤的保守治疗及手术探查的指征,提高儿童腹部损伤的诊疗水平.方法 回顾性分析我院89例腹部损伤患儿的临床资料,根据损伤部位情况进行分类,并逐一对其进行分析.结果 (1)89例腹部损伤患儿中,25例肝损伤,1例行剖腹探查;48例脾损伤,46例保守治疗,1例行脾切除术,1例予修补;14例胃肠道损伤,4例急诊剖腹探查,1例住院4 d后出现迟发穿孔;8例胰腺损伤,6例肾、肾上腺挫伤,予保守治疗;1例子宫、膀胱损伤,急诊手术治疗.(2)与成人不同,肝脾损伤患儿绝大多数经保守治疗能治愈,静脉补液后输血仍超过40 ml/kg,且血压不稳定者应及时手术探查.(3)CT检查对怀疑有胃肠道损伤,而不宜行腹部X线立位平片者有重要临床意义,合并气腹或腹胀明显加重,或出现腹膜炎表现的患儿,应及时手术探查,尤其注意迟发消化道穿孔的可能.(4)排除有胰腺横断的患儿,胰腺损伤多应保守治疗.(5)膀胱及子宫损伤患儿,外伤多较严重,需及时剖腹探查.结论 基层医院儿童腹部损伤应高度重视,实质脏器损伤导致的内出血是患儿死亡的最主要原因,空腔脏器损伤延误诊治是导致患儿死亡的另一重要原因,因此,早期准确诊断,积极治疗,以及综合处理其他严重的合并伤、并发症是成功救治该类患儿的关键.     

胰腺胸膜瘘致反复大量血性胸腔积液一例

目的 介绍胰腺胸膜瘘引起大量血性胸腔积液患儿的早期临床特点及诊治要点.方法 报道1例胰腺胸膜瘘患儿临床症状、体征、辅助检查及诊治方法.结果 4岁男孩,间断发热、咳嗽、胸闷和胸痛1个月,胸腔闭式引流3次均为血性胸液,腹部无阳性体征,腹部B超提示胰腺回声粗糙,血和胸腔积液胰淀粉酶分别为495 U/L和35 938 U/L,开胸探查发现有一瘘管从胸腔通向胰腺,经全胃肠外营养、静脉滴注生长抑素以及内镜逆行胰胆管造影在胰管内放置支架治愈.结论 胰腺胸膜瘘患儿早期以呼吸症状为主,缺乏腹部症状,易造成诊治延迟.胸腔积液中胰淀粉酶显著增高是诊断本病的重要线索和依据,本病如保守治疗失败需行内镜逆行胰胆管造影检查和治疗.     

The role of the accessory pancreatic duct of Santorini in pancreatic drainage in children (with emphasis on choledochal cyst patients)

Pancreatic drainage patterns have been studied by endoscopic retrograde cholangiopancreatography (ERCP) in four children with choledochal cyst (CC). The first two had mild or chemical pancreatitis; the third had a history of recurrent cholangitis and was diagnosed as chronic pancreatitis. The fourth manifested with severe, acute pancreatitis. All children were found to have an impaired flow through the papilla of Vater. In the first three cases, the duct of Santorini (DS) seemed to play an important role in the pancreatic drainage. In the fourth case, however, the duct was found to be absent. ERCP findings in additional eleven children without CC also were reviewed, and in this group the DS did not seem to play any significant role in pancreatic drainage. These results indicate that in children with common bile duct (CBD) anomalies, the DS may relieve the obstruction and ameliorate the pancreatitis.     

小儿闭合性胰,十二指肠严重外伤的外科处理：附12例报告

探讨小儿闭合性胰、十二指肠严重外伤的诊治特点。本组小儿闭合性胰断裂２例，十二指肠破裂４例，胰、十二指肠复合伤６例。手术探查并采取远端胰切除及十二指肠“憩室化”（Ｂｅｒｎｅ１９７４年首先提出，其手术方法为：修补十二指肠损伤，切除胃窦，关闭十二指肠，行胃空肠吻合术。同时可行胆总管Ｔ型管引流，再作十二指肠插管造口术及双侧迷走神经干切断术）。３例术前确诊，另９例为手术探查后确诊。治愈８例，死亡４例，其中２例与术式选择不当有关。术前确诊困难，主张早期探查。推荐注射美蓝法寻找断裂胰管。根据不同伤情选择创伤小、安全可靠的术式。     

Successful management of a posttraumatic pancreatic fistula with somatostatin analog in a young child

The use of somatostatin to manage a persistent posttraumatic pancreatic fistula in a young child has not been previously reported. A 3-year-old, 20-kg female who sustained blunt trauma to the abdomen causing mesenteric, duodenal, and pancreatic injuries developed a posttraumatic pancreatic pseudocyst treated with external drainage. An external pancreatic fistula developed that was refractory to management with bowel rest and hyperalimentation. Synthetic somatostatin analog was administered subcutaneously over 11 days with a progressive decrease in fistula output. After 4 days the fistula output ceased and ultrasound examination documented that there were no undrained fluid collections. At 3-month follow-up she has remained completely asymtomatic, tolerating a regular diet without recurrence of the pseudocyst, and her serum amylase, liver function studies, and blood sugar values are normal. This case report demonstrates that external pancreatic fistulas in children can be successfully treated non-operatively with somatostatin analog.