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Initial resection of potentially viable tissue is not optimal treatment for grades II-IV pancreatic injuries
Dennis W Vane1, Armin Kiankhooy, Kennith H Sartorelli
1Division of Pediatric Surgery, Vermont Children's Hospital, University of Vermont College of Medicine, FAHC, 267 FL4, MC Campus, 111 Colchester Avenue, Burlington, VT 05401, USA. Dennis.Vane@vtmednet.org
Insights
Pediatric pancreatic injuries require tailored treatment. Grade II injuries benefit from observation, while grades III-IV are managed with drainage, avoiding resection. Early intervention improves outcomes.
Area of Science:
- Pediatric Surgery
- Trauma Management
- Gastrointestinal Surgery
Background:
- Pancreatic injuries in children are uncommon but can lead to significant morbidity.
- Optimal diagnostic and therapeutic strategies for pediatric pancreatic trauma remain debated.
Purpose of the Study:
- To determine the best diagnostic methods and treatments for children experiencing pancreatic injuries.
- To evaluate the outcomes of different management approaches for pediatric pancreatic trauma.
Main Methods:
- A prospective study of children (0-17 years) with pancreatic injury from 2001-2007.
- Data collected included injury grade, diagnostic imaging (CT scan), treatment, and patient outcomes.
- Analysis of treatment strategies including observation, drainage, and pancreatectomy.
Main Results:
- Fourteen children with grade II-V pancreatic injuries were identified.
- Grade II injuries were successfully managed nonoperatively.
- Grades III-IV injuries were treated with operative external drainage, without pancreatectomy or stent placement, leading to excellent outcomes and normal pancreatic function.
- One grade V injury resulted in mortality due to associated injuries.
Conclusions:
- Nonoperative management is effective for pediatric grade II pancreatic injuries.
- Expeditious drainage is a successful treatment for pediatric grades III-IV pancreatic injuries, avoiding routine pancreatectomy or stenting.
- Early drainage positively impacts hospital stay and patient outcomes.
- Grade V injuries have high mortality due to associated trauma, warranting further multi-institutional research.
Purpose:
This study was designed to ascertain the optimal therapy and diagnostics for children with pancreatic injury.
Methods:
From January 1, 2001 to January 1, 2007, all children (newborn to 17 years) who presented to this Level I trauma center with demonstrated pancreatic injury were prospectively entered into the TRACS IV system and reviewed for injury type, diagnostics, therapy, demographics, and outcome.
Results:
Fourteen children sustained grade II or higher pancreatic injury during this period. CT scan was performed for diagnosis in all cases. There were 11 boys and 3 girls, and mean age was 6.9 (range, 2-16) years. There were five grade II injuries, four grade III injuries, four grade IV injuries, and one grade V injury. All grade II injuries were treated successfully nonoperatively with observation. The nine grade III-IV injuries all underwent operative external drainage without pancreatectomy or stent placement. The single grade V injury died of multiple associated injuries after operative intervention. No pseudocysts developed in these children. All children have normal pancreatic function, and all except one have normal anatomy on follow-up scans. Early exploration and drainage directly reduces length of stay.
Conclusion:
Grade II pancreatic injuries do not require routine surgical exploration in children. Grade III and IV injuries in this series were treated with expeditious drainage of the pancreatic bed and did not require routine pancreatectomy or endoscopic stent [corrected] placement as some have recommended. Early drainage shortens hospital stay, and outcomes from this therapy are excellent. Pancreatic resection of exocrine defunctionalized segments of pancreas may be performed safely electively after acute injury if necessary, but anecdotal information from this series indicates that too may not be necessary. Grade V injuries often are accompanied by multiple other organ injuries and are associated with a significant mortality rate. A multi-institutional investigation is warranted to reassess optimal therapy for pancreatic injury in children.
