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Management of pancreatic injury in pediatric blunt abdominal trauma
Insights
Pediatric pancreatic injuries are uncommon, and initial amylase levels don't predict severity. Most pancreatic injuries in children can be managed nonoperatively, with specific approaches for proximal versus distal duct injuries.
Area of Science:
- Pediatric Surgery
- Trauma Surgery
- Gastrointestinal Surgery
Background:
- Management of major pancreatic parenchymal or ductal injury in children is controversial.
- Nonoperative management of low-grade pancreatic injury is widely accepted in adults.
- This study reviews management strategies and outcomes for pediatric pancreatic injuries based on injury type and location.
Purpose of the Study:
- To review management strategies for pediatric pancreatic injuries.
- To correlate management with injury site and type.
- To evaluate outcomes of different management approaches.
Main Methods:
- Retrospective review of 11,794 pediatric trauma admissions (1984-1997).
- Identification of children with pancreatic injury using serum amylase, CT, US, ERCP, and surgical/postmortem reports.
- Analysis of 56 identified pediatric pancreatic injuries.
Main Results:
- Pancreatic injury occurred in 56 children (blunt trauma); initial amylase was elevated in 71% but didn't correlate with severity.
- CT scans identified injury in 57% of cases; 12 injuries were found intraoperatively, and 7 with normal initial CT scans were diagnosed later.
- Nonoperative management was used for 26 children (including proximal duct injuries). Distal duct injuries (7 patients) were managed with spleen-sparing distal pancreatectomy. Seven pseudocysts developed, with 5 treated by delayed drainage.
Conclusions:
- Pediatric pancreatic injuries are rare, and initial serum amylase is not a reliable indicator of injury severity.
- The majority of pediatric pancreatic injuries can be managed nonoperatively.
- Proximal duct injuries benefit from nonoperative management allowing delayed pseudocyst drainage, while distal duct injuries require prompt spleen-sparing distal pancreatectomy.
Background/Purpose:
Nonoperative management of low-grade pancreatic injury is widely accepted. Management of major pancreatic parenchymal or ductal injury in children remains controversial. This study will review management strategies as they relate to site and type of pancreatic injury and their outcomes.
Methods:
A total of 11,794 consecutive admissions to a regional pediatric trauma center from 1984 to 1997 were reviewed to identify children with pancreatic injury as documented by serum amylase; imaging by computed tomographic (CT) scan, ultrasonography (US), and endoscopic retrograde cholangiopancreatography (ERCP); and surgical or postmortem reports.
Results:
Pancreatic injury was documented in 56 children, age 2 months to 14 years, with blunt mechanisms of injury. Serum amylase level was elevated on admission in 40 (71%), and no correlation was found between admission amylase values and severity of pancreas injury. An admission CT scan was obtained in 44 (79%) patients and was positive for pancreatic injury in 25 (57%). Twelve children, who had diagnoses of other intraabdominal injury by CT scan, had pancreatic injuries discovered on exploratory laparotomy. Seven children with normal admission CT scans, and the 12 children who did not undergo imaging on admission, had pancreatic injuries that were later documented by imaging, exploration, or autopsy. Thirty children were treated with immediate exploration, 17 for nonpancreatic indications and 13 with pancreatic injuries on admission CT scan. Of 19 minor injuries noted in the operating room, only three were treated with external drainage. Seven patients with distal duct injuries underwent distal pancreatectomy with splenic preservation. Twenty-six children were treated nonoperatively, including 19 with minor pancreas injuries, three with proximal pancreatic duct injuries, and four with duct injuries that were missed at admission. There were no advantages or complications of external drainage versus nondrainage of minor pancreatic injuries. There were seven deaths (overall mortality rate, 12.5%), none related to pancreatic injury. Of the seven patients in whom pseudocysts developed (two not imaged at admission, two from known proximal duct injuries treated nonoperatively, and three from injuries missed by initial studies), five were treated by delayed internal drainage and recovered promptly, and two resolved spontaneously. Pancreas-related complications included one persistent fistula and one prolonged hyperamylasemia, both of which resolved.
Conclusions:
Pancreatic injuries are uncommon in children. Initial serum amylase level does not correlate with the severity of pancreatic injury. The majority of pancreatic injuries can be managed nonoperatively. Initial nonoperative management of injuries of the proximal pancreatic duct allows for the formation and uneventful delayed drainage of a pseudocyst, rather than the risks of early radical interventions. Distal duct injuries are best managed by prompt spleen-sparing distal pancreatectomy. There is no benefit of closed drainage for management of minor pancreatic injuries discovered at laparotomy.