The efficacy of early ERCP in pediatric pancreatic trauma

Abstract

Recognition of pancreatic injuries is frequently delayed, and optimal treatment is often controversial. The use of endoscopic retrograde cholangiopancreatography (ERCP) has allowed accurate delineation of pancreatic ductal injuries; however, the small size of children and the concern with inducing pancreatitis and/or lesser sac contamination have limited its use in children. In 1988, the authors began using ERCP for selected pancreatic injuries. This report describes their experience with this technique and examines the role of ERCP in pediatric pancreatic injuries. Six children with pancreatic transections resulting from blunt trauma were treated between 1988 and 1993. The age range was 2 1 2 to 8 years, and the weight range was 13.6 to 27.9 kg. The average period from injury to referral to the hospital was 14 days (range, 2 to 30 days). All six children presented with chemical evidence of pancreatitis and had an initial computed tomography (CT) scan; five scans were interpreted as being normal. Five of the six patients had subsequent CT scans, which showed lessersac fluid collection. Three patients were treated with drainage (2 percutaneous, 1 open [outside hospital]), and when this failed, ERCP was performed, at 13.6 days (average) after presentation. These three patients underwent ERCP relatively early in the course (an average of 3 days after presentation). All six children had major ductal transections documented through ERCP. After ERCP, the serum amylase level remained elevated in three, increased in one, and normal in one. (It was not measured in one of the recent cases taken for immediate operation.) Two children had increased abdominal pain for 12 to 18 hours after ERCP, and one had an elevated temperature (>38°C). There were no serious adverse effects related to ERCP. All six patients underwent distal pancreatectomy with splenic salvage. Five were released an average of 11 days after resection, and one had a pseudocyst and fistula that resolved after 48 days' treatment with drainage and total parenteral nutrition. The authors conclude that ERCP is safe and effective in children with suspected pancreatic injury and allows early detection of duct transection and institution of definitive surgical management.