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Conservative management of pancreatic trauma in children
M S Keller1, P W Stafford, D W Vane
1Department of Surgery, Children's Hospital of Philadelphia, Pennsylvania, USA.
Insights
Nonoperative management is effective for most pediatric pancreatic injuries. Careful observation, rather than immediate surgery, is recommended for lower-grade injuries, avoiding unnecessary procedures.
Area of Science:
- Pediatric Surgery
- Trauma Management
- Gastrointestinal Surgery
Background:
- Nonoperative management is common for abdominal injuries in children.
- Outcomes of nonoperative management for pediatric pancreatic injuries are not well-established.
- Pancreatic injuries require specific diagnostic and treatment considerations in pediatric trauma.
Purpose of the Study:
- To analyze current treatment patterns for pancreatic injuries in children.
- To evaluate the efficacy of nonoperative management for pediatric pancreatic injuries.
- To compare operative versus nonoperative approaches for different grades of pancreatic injury in pediatric patients.
Main Methods:
- Retrospective review of the National Pediatric Trauma Registry (49,540 patients).
- Inclusion of children (<19 years) with pancreatic injury (ICD-9 codes 863.81-863.84, 863.91-863.94) from two Level I pediatric trauma centers.
- Analysis of injury grades, surgical interventions, and pseudocyst management over a 7-year period.
Main Results:
- 154 children with pancreatic injury were identified; 80% had lower-grade (I/II) and 20% severe (III-V) injuries.
- 79% of lower-grade injuries were successfully managed nonoperatively; only 21% required pancreatic-specific surgery.
- Severe injuries had a higher rate of operative intervention (52%); no deaths were attributed to pancreatic injury.
Conclusions:
- Nonoperative management is a safe and effective approach for most pediatric pancreatic injuries, particularly lower-grade ones.
- Early surgical intervention for pediatric pancreatic injury is often unwarranted without clinical deterioration or major ductal involvement.
- Observation and conservative management should be considered as a primary strategy for pediatric pancreatic injuries, challenging traditional adult treatment paradigms.
Abstract:
Many adults and most children with a solid-organ abdominal injury can be managed nonoperatively. To date, however, little is known about the outcome of nonoperative management of pancreatic injury. To analyze current treatment patterns of pancreatic injury in children, all children (age < 19 years) identified in the National Pediatric Trauma Registry (49,540 patients) and admitted to two level I pediatric trauma centers with a diagnosis of injury to the pancreas (International Classification of Disease-9 codes 863.81-863.84 and 863.91-863.94) were reviewed. Over a 7-year period, 154 children were identified with pancreatic injury. Thirty-one (20%) sustained severe injuries (grades III, IV, or V) and 123 (80%) sustained lower-grade injuries (grades I and II). Sixteen (52%) of the children sustaining grades III, IV, or V injury required pancreatic procedures (9 distal resections, 3 simple repairs, 2 enteric anastomoses, 2 others). Only 26 (21%) of the grades I and II injuries required surgical intervention specific to the pancreas (11 resections, 9 catheter drainage of pseudocysts, 2 enteric anastomoses, 4 others). Ninety-seven (79%) grades I and II injuries were successfully managed conservatively. Overall, 15 (10%) children required drainage procedures for pseudocyst. The frequency of operative intervention decreased during the last 4 years of the study (18 vs. 26%, p > 0.05), coinciding with a decrease in the frequency of drainage procedures for pseudocysts. The need for surgical intervention was not influenced by age, Injury Severity Score, or Pediatric Trauma Score (p > 0.05). Associated abdominal injuries were common but did not influence operations on the pancreas (p > 0.05). No deaths were attributed to the pancreatic injury. These data indicate that early intervention for pancreatic injury, in the absence of clinical deterioration or major ductal injury (grades III, IV, or V), is unwarranted, and careful observation may supplant the conventional surgical therapy recommended for adults.