Latest / Behind The Knife: The Surgery Podcast / Mattox Conference Pro-Con Debate 2026: Management of Pediatric Pancreatic Injuries
Transcript
- debate 1 audio === Speaker: [00:00:00] Well, good morning everyone. Welcome to what I'd like to describe as the main event. It's the moment you've all been waiting for. Live from the grand stage, the annual ACS debates. Presented by Caesars Entertainment, KLM Productions, and Red Star Deadline Management for everyone except for Jen Gurney. We're proud to bring you session number 14. I'll be your moderator managing the squared circle in this grand fight of ideas this morning, and so I'd like to open right away with the first debate. This fight is scheduled for one fall, and I'd like to introduce first, fighting out of the pro position in the red corner, a master of data, a tactician of trauma care, and coming out of Austin, Texas, Dr. Carlos Brown. He'll be f- Hold on. Hold on. He'll be fighting. And his opponent, who'll be fighting out of the blue corner in the con position, bringing [00:01:00] precision, power, and pediatric fury to the fight. Out of Salt Lake City, Utah, Dr. Katie Russell. Be it resolved, be it resolved, pediatric pancreatic injuries can be managed non-operatively. Carlos Speaker 2: All right. Good morning. Uh, thanks Alex. Thanks for everyone who's still here on the last day in the morning. Uh, thanks Dr. Maddox and Mary, uh, as always, for a great conference. So I have the, uh, can be managed non-operatively side, and I've already, uh, come to the realization I'm gonna lose this debate. Dr. Russell is smarter than I am, prettier than I am. She's a pediatric surgeon. She's funnier than I am. I've, I've already given up, so I'm just gon- I'm not even gonna bring any, any dirty tactics into this. I'm just gonna tell you about Dr. Russell, about my side, and we'll see how it goes. So, um, I am up against a pediatric surgery superstar, right? She's-- Her education is unmatched. Brown University for undergrad, USC for medical school, [00:02:00] um, Utah for residency, Children's Hospital Philadelphia for her pediatric surgery fellowship. So the best of the best across the entire education system. Uh, she's now an academic surgeon at University of Utah, uh, and incredibly productive for as young as she is. Hundred and forty-three publications with an H-index of twenty-one. So her papers are not only high volume, but they're also high impact across the literature. She works at Intermountain, uh, Primary Children's Hospital. It's not just any children's hospital. It's one of the best children's hospitals in the entire country on multiple, uh, categories, right? And she's the trauma director at that hospital, so she's a pediatric trauma expert. She's also on the board of the Pediatric Trauma Society. So we're just gonna realize right now she is an expert in pediatric pancreatic injury. I am not. Okay? So just remember that as we go through this talk. So our objectives are talk about pediatric pancreatic injuries, management of these injuries So they're uncommon. You'll see how uncommon they are when I show you the literature. Uh, blunt trauma, age-dependent. Younger kids are gonna be blunt trauma. [00:03:00] Teenagers are gonna get shot, but generally blunt trauma. Uh, the associated-- The pancreas is not gonna kill the kid, right? It's gonna be the associated injuries that are gonna have the impact on mortality. And they're, they're difficult to diagnose and can be difficult to manage. Um, what are we talking about? Grade I is a nothing injury to the pancreas. Grade II is a j-- little bit more than nothing injury to the pancreas. But these are non-operative all the time, every single time. Grade III is a transection of the pancreas, including the duct, left of the vessels. Four is right of the vessels, and five is a catastrockt- catastrophic destructive injury to the head of the pancreas. So what we're talking about is Grade III and IV. Grade I and II are always non-operative, and I think Dr. Russell will even agree with that. Grade V basically don't happen, and when they do, it's a giant operative, uh, intervention, either at the initial operation or delayed. So we're really talking about Grade III and IV injuries where the, where the duct is transected. Diagnosis is tough. It's hidden away in the retroperitoneum. The H&P is super vague. [00:04:00] They just had a trauma. Uh, labs don't, don't even bother. They're not gonna help you at all. The CT scan is actually not sensitive for ductal injury. It's really not. You may see a, a hematoma of the pancreas, but you're not gonna see the duct very well, and you may need an MRI or MRCP to make that diagnosis. So what about the literature? Well, there's really not much literature on pediatric pancreatic injuries. This study out of NTDB in two thousand and sixteen looked at six hundred and seventy-four pediatric pancreatic injuries. A hundred and sixty went to the OR, five hundred non-operative manage- management. And the operative cases had more complications, longer length of stay, right? So here's the first evidence that operations are bad for pediatric pancreatic injuries. But this study looked at all pancreatic injuries. Right? What we, we already talked about, we really care about the duct. The pancreatic duct is what we care about. So what about the duct itself? What about that? So this great study at-- in the Journal of Pediatric Surgery in 2025, Prospective Outcomes of Standardized Nonoperative Management of Pancreatic Trauma with Ductal [00:05:00] Injury in Children: Less Is More. So this, this study completely supports my side of this, of this debate and this argument. Prospective multicenter trial from 2018 to 2022. There were 13 pediatric trauma centers, right? And w-- And pediatric was defined as less than 18. Obviously, a lot of us-- Like, I work in an adult center, I take care of kids down to 15. But this is-- used less than 18, and probably to recruit more patients 'cause it's not a very common injury. And they talked about blunc- blunt pancreatic injury grade III and IV. So exactly what we're talking about, grade III and IV injuries where the duct is transected is what they're talking about. They were, uh, only patients who needed no urgent operation, right? So if they came in with peritonitis, went to the OR, they were excluded. Hemodynamic instability, went to the OR, they were excluded. So they needed no urgent operation. And then they developed a standard protocol on how to take care of these patients. We're gonna work off the premise that we're not gonna operate on them, so what do we do? So super complicated protocol. You can't see this at all. Um, it, it, uh-- You can [00:06:00] pull it up in the, in the syllabus. However, if I blow it up for you, the beginning of this protocol says, "You diagnose a grade III or IV blunt pancreatic injury, you obtain some labs, and you admit them for pain control." Super simple. The next step is you feed 'em, you see how they do, and then you send 'em home. Super simple, right? So you take a patient with a pancreatic tr-- a known pancreatic transection, you admit 'em, you feed 'em, you send 'em home. That's the protocol. If it doesn't work, if they're a little bit symptomatic, a little bit slow to get better, um, then you're gonna sort of, um, uh, a-about a week, you're gonna obtain an ultrasound and an amylase, right? So now they've been lingering in the hospital, not getting better. You're still not gonna operate on 'em. You're gonna get an ultrasound and an amylase. And the reason you're gonna get that ultrasound is you're looking for peripancreatic fluid collections. If you find a fluid collection, uh, you're gonna hold that diet until symptoms improve and consider intervention or, uh, continued observation. So in that intervention is not the operating room. It is [00:07:00] an intervention, a percutaneous drain of that fluid, right? And then one of two things is gonna happen. They're going to get better and on this side of the protocol again, feed 'em and send 'em home. Or at any point during this, uh, protocol, operation may be considered if the ch-child has a clinical deterioration at any time. So anywhere along this protocol, you can take him to the OR for the pancreatic injury. So let's see what we found 22 patients enrolled, okay? That tells you, it was 13 centers over four years. There were only 22 patients enrolled, so that tells you how uncommon this injury is. It just does not happen very often. Um, and the, the kind of a, a, a good pediatric population here was seven and a half years old, which is great, 'cause that's a good representative pattern. I think a lot of studies that talk about pedes include teenagers, and those aren't really the same patients. These are little kids, mostly male, mostly white, non-Hispanic. 64% handlebar injuries, so that's probably the th- the biggest tip-off you should have in your history and physicals. A handlebar injury should really [00:08:00] increase your suspicion for a pancreatic injury. 21 patients had successful non-operative management, 95%. Full stop, 95%, right? What do we do in our practice that works 95% of the time? Very little. This protocol, non-operative management, works 95% of the time. One failure on day three, patient developed peritonitis after an ERCP and stent and underwent a distal pancreatectomy. So 21 out of 22 patients were managed non-operatively, did fine, and were sent home. They got clear liquids on day two, regular diet on day four. They did require TPN. Some of those that would linger out for a while and not get better got TPN. A third required an ERCP and stent, and the discharge was on day eight. So a ho- a week in the hospital with no surgery on-- no incision on their belly, and they go home doing well. Now, pseudocyst was a complication, right? So a third of them developed a pseudocyst d- during their stay. Two of these were managed [00:09:00] with percutaneous drains, four with a cystgastrostomy, uh, endoscopically, um, and one was resolved. Pancreatic cyse- pancreatic ascites, uh, on that initial CT scan is a risk for pseudocyst. So you should pay attention to that pancreatic ascites. If they have a belly full of fluid, of pancreatic fluid, uh, during their imaging, they're gonna be at risk for pseudocyst. So that's a good con- co- conversation to have with the patient and, and the parents, obviously. So our conclusions, pediatric pancrea- pancreatic injuries are rare, really rare. We're just not gonna see very man- very many of them. They're hard to diagnose, and they're uncommon, and the management is clearly non-operative. Without question, non-operative management is the way to go. Remember, don't listen to me. I'm not a pediatric surgery expert. Listen to the expert. She's the expert, right? So I want you to listen to her based on the l- my next few slides. Awesome education. Rising academic trauma superstar, pediatric trauma. Works at the greatest pediatric [00:10:00] trauma center in the world. She's the trauma director there. Clearly, she's an expert. So let's look at this paper again. I'm gonna blow this up for you just a little bit. Here are the authors. Oh my goodness. Katie Russell says in this paper that you should manage these non-operatively. She's the expert. Listen to her. I rest my case. Thank you. Speaker: You stay right there. Thank you, Dr. Brown. We will, uh, proceed to the blue corner, and then we'll have a brief rebuttal period after that. Dr. Russell Speaker 3: All right, guys. Well, despite that, I am now gonna convince you all that we should be putting the pancreas in the bucket So clearly there's some major LA County roots at this conference, and I think in [00:11:00] trauma in general, and I was there. This is the only photo I could dig up from back in the day, but I was actually Dr. Brown's medical student. And let me tell you, he is a hero. You know, I think he is Saint Carlos. I look up to him so much, and there was a d- a debate here a couple years ago with Dr. Martin, who made this great argument about, "Look at all this crazy trauma we're seeing in LA, and Dr. Brown, what are you doing out line dancing in Austin, Texas?" Now, I don't really think I have that angle, because I think a lot of people could probably make fun of me for my current life decisions sitting in Salt Lake City, Utah. I remember out at LA County when these people, you know, they were innocently staying at the bus stop, waiting on the way to go to church, and all of a sudden they got shot. Well, the people that I'm taking care of, they actually are at church. But I do have some credibility here, because I am a pediatric surgeon, and I [00:12:00] do see this injury pattern. So this is a handlebar right to the epigastrium, and I'll tell you, we see this all the time, and you should be very concerned about the pancreas if you see this injury in a child. Now, as pediatric surgeons, we talked about it yesterday, we take our non-operative management real seriously, right? So this goes back to 1968. Couple pediatric surgeons from Toronto, and they really wrote this landmark paper. Observations during this study emphasize that splenic rupture in children, it's just different than it is in adults. After isolated injury to the spleen, there is a remarkable absence of clinical signs and blood loss. By the time we do a laparotomy, the bleeding has just stopped. So this is my TQIP report, and if you look here, we got 83 spleens in the last reporting period. We didn't take any of them out. If you look over, we didn't embo any of them either. But we're not talking about the spleen. We're not talking about the liver. We're not talking about the [00:13:00] kidney. We're talking about the pancreas, and if you've got this injury, this needs to go in the bucket. Now, clearly, I know I'm on this paper, right? I see myself there. I was part of this, but let me tell you a little bit more about this paper, and in no way am I throwing shade at my colleagues or all of us that have put a lot of effort into this paper. But this paper has been going for nine years, so this is an interim analysis of this prospective pancreatic study that we've been doing through the Pediatric, uh, Trauma Society, and it's been going for nine years. We've only enrolled 49 patients. That's, like, half of our power calculation, and I think that when we designed the study, we didn't design it as good as we could have. This is a prospective observational study, but you have to get consent in order to enroll patients in the study, so we're just not accruing. It's not that it's- it's not that common. I actually have 30 grade III pancreas injuries at [00:14:00] my institution only in the last 10 years. I've only put two patients in this study. So I would say while I am on this study, I think we could have done a better job, and I do not actually believe that this study answers these questions. Dr. Brown did me the favor of going through this protocol so we don't have to do it again. The conclusion of this study, again, it's an interim analysis of a study that is still ongoing nine years later, is that 75% of these patients with ductal injury got better. We have no idea if that is true because a big proportion of these kids, you know, 36% never got an ERCP or an MRCP, so we don't actually know if they had a duct injury. You know, Dr. Brown nicely made that point for me that CT's not good. Well, most of these kids in the study only have a CT scan. So the rate of ductal injury is actually unknown. Those kids that did-- were treated non-operatively had endoscopic procedure after endoscopic procedure. You know, only 43% had follow-up, and there [00:15:00] is in that follow-up group that a close to a quarter of them have this chronic pain So I wanna bring attention to this study. So I think this is a very important study in terms of pancreatic injuries. It's the double ASD, uh, double ASD update of the grading scale led by my colleague, a pediatric surgeon, Dr. Nitrika. And if you summarize it, you gotta look at the duct. Like, that's what comes out of this study. And in this new grading system, agree with Dr. Brown, grade 1, like bruise on the pancreas, who cares? Grade 2, little tiny cut, who cares? But this is where we get interesting, and grade 3 and 4, the vast majority are grade 3s, so I'm gonna be talking about grade 3s. But if we look at these injuries, N is you didn't look. So I would argue that a lot of those kids in that s- non-operative study is N. It's 3N. We never looked. We don't actually really know if it's a grade 3 injury. Uh, then an A is the main pancreatic duct is injured, but it's still attached, and then a B is it's [00:16:00] a complete transection. So let's get to the distal pancreatectomy. Like, what are... This is a great operation. You know, what are we afraid of? I have found myself in the middle of the night doing this. I'm not sure why, 'cause really you can wait. Like, let's wait until the sun rises. You can do this laparoscopically. We all love doing laparoscopic surgery. You can save the spleen. You can take the spleen if you can't save it. I haven't gotten into this, but I know a lot of people in the audience are big on the robot. I heard this is a great robotic case. So what are we trying to prevent by not doing this distal pancreatectomy? Um, I guess we're trying to prevent long-term diabetes and exocrine dysfunction, but can somebody please show me that data? Because I certainly cannot find it. You know, here's Dr. Dimitriadis strikes again. In 80 pancreatic injuries, the majority of these patients got distal pancreatectomies. Nobody's on insulin when they're discharged. So early [00:17:00] data, there's not any. I looked for long-term data. This is the best paper I can find, and let's say it leaves, it leaves a little room for improvement. 14 patients had long-term follow-up. Of those, you know, one person got a Whipple. They needed insulin. But also, there was a patient that never even got a resection that needed insulin after a drain. Two distal panics needed a little metformin. Well, a person that had Um, an injury that was drained also needed metformin. So in my opinion, this doesn't say anything except for that we need a long-term study to look actually what are the complications after distal pancreatectomy for trauma. So I'm telling you guys, you know, that there's not really any data, so I'm gonna show you some cases that have happened at my institution that really drive me to wanna take the pancreas out. So this kid, that was a grade III injury. We were heroes. Sent him home post-op day five, no operation. Chronic pain, multiple imaging, multiple [00:18:00] endoscopic procedures. He got a distal pancreatectomy one year out, and you can see this chronic little ischemic pancreas that was causing him pain I really wish we would have managed this patient differently. So this is a 16-year-old high-speed motor vehicle crash, came down with an open abdomen from up north 'cause there was a bowel injury that needed to be repaired, some bleeding needed to be stopped. I think you can see the arrow pointing to that huge rent in the pancreas. So even though we had an open abdomen, we did the pediatric surgery thing and decided that we were gonna observe this. So we closed the abdomen. A couple days later, we got an ERCP, could not transverse that. It was a complete transection of that pediatric duct. This kid sits around in the hospital. You can see here on day 42, we're still leaking from the pancreas, and he ends up getting a distal pancreatectomy that was difficult at, you know, six weeks out instead of right up front where we already had an open abdomen. One more case, a little different. You can [00:19:00] see that big rent in the pancreas, um, on that top arrow. The spleen's also out, as is the kidney. In this patient, what should we-- Should we observe that patient? So we gave it a shot. We observed the patient until we got an MRCP and an ERCP on day five, where we actually could transverse this injury with a stent, so the duct was somewhat still intact. Unfortunately, this kid by day 10 got SIRS, respiratory failure, shock. We ended up going to surgery after this CT scan, where we did a big kinda left upper quadrantectomy, took the, the pancreas, the kidney, and also the spleen. So to quote my colleague, Dr. Kastenberg, who has done a liver transplant fellowship after his pediatric surgery fellowship, for us pediatric surgeons, this non-operative pendulum has swung way too far. So I'll ask you, Dr. Brown, you don't like to operate? You know, we're not talking about the spleen here. Like, the spleen, it-- the vessel spasms, the blood clots, and it [00:20:00] doesn't need to come out. But this pancreas, it's a different beast, and you gotta know when it's time to go to the hoop, and if my daughter has this injury, it's coming out. Uh, here's a protocol that we put together, um, at our institution to help us with this. It basically says early ERCP and evaluate the duct. If you can get a stent across it, you can try to manage it non-operatively 'cause the duct's controlled with that stent. If you can't, the pancreas needs to come out. Here's Dr. Brown showing up to a ski race in his snowshoes. I appreciate you guys so much. Thanks for the opportunity. Speaker: Definitely, definitely never show up to a ski race in your snowshoes. That's gonna stick. Hey, uh, can we have the table microphones on in just, uh... We have, I don't know, a minute or two here. Carlos, any rebuttal to that? I mean, she makes a compelling case. Speaker 2: Uh, she, she does. She does make a compelling case. Uh, [00:21:00] you know, I think the, the study that we both referenced, I think that is really the best study we have for non-operative management, but all the patients that have been excluded, um, uh, for whatever reason have, ha- makes it a, a challenging to draw conclusions from. However, the patients that have been enrolled, so if you do go down the non-operative route, it does work. I mean, it works. And my, you know, the, the... When I re- quoted the study, it was 95%. Looks like the follow-up's now 75%, but still the majority of patients, if you go down that route, you're gonna be okay. Now, full disclosure, if I have a teenager, so I take, I take care of patients who are 15, 16, 17, with that pancreatic duct transection, they're getting a distal pancreatectomy. Gonna try to save the spleen if I can. Uh, I think now with the ligature it's a lot easier to do a, a spleen-preserving distal pancreatectomy, especially in a kid, if you can. But if you go down the non-omo- non-operative route, it is a safe option that you can do, and if they fail, they get an operation. I will say, fa- if you're gonna fail, fail early. Go to the OR early. Don't wait months to, to keep dragging this out. If [00:22:00] they're failing, fail early and go take the pancreas out. And then the question I have for everybody in the audience as far as who's gonna win the debate, my kids are all adults now, but when my kids were seven and a half years old and I could g- have something that works 95% of the time, I would at least try non-operative management and see if it would be successful. And I would ask you, if you had a seven, seven-year-old, needed, uh, had a handlebar injury, pancreatic transection, what would you want for your kid? I would want non-operative management. Speaker: I don't know. It seemed like the audience was headed towards what would Katie do, but I'm not sure. So let's hear. Dr. Russell, you said you would, your, your daughter would, you would absolutely want a pancreatectomy for your daughter if that was the case. Speaker 3: Yeah, I mean, I, I think really what it comes down to is evaluating the duct, you know? And I think when we started this, so that study that we're referencing, it started 10 years ago. There's also been a... We didn't-- We used to not be able to get ERCPs. You know, there was no GI doctors that could do an ERCP for us on these little kids. That's changing. You [00:23:00] know, I think the big pediatric centers now have GI colleagues that can help us. So I would say I think the real change is you've gotta really look at the duct. You know, if the duct's intact, absolutely, like, leave the pancreas alone. It's gonna be okay. Um, also they have tiny stents now, so even in like a five or seven-year-old, they could probably stent across that. I think you really have to control that duct. Speaker: Great. Thank you. All right, if we can have the lights up just a little bit. There's no free rides at the ACS debates at the Maddox meeting, so I'm gonna need some audience participation If you think this debate was carried by Dr. Brown in the pro corner, hoot, holler, cheer, or put up your hands right now That's, that's tepid at best, but I'm not sure if that's 'cause it's Tuesday morning or what. Wednesday morning, excuse me. It's- If it... Yeah, that's the problem. If you think that [00:24:00] Dr. Russell won this debate and you wanna let us know, please raise your hands or hoot and holler Ladies and gentlemen, while the judges scored the bout 10-9, I think the winner by unanimous decision this morning is Dr. Katie Russell All right, thank you. We'll move into the second topic as the panelists make their way up to the stage. Thanks, guys. Thanks, guys. Awesome. Yeah, solid. Thanks