Nonoperative management of pancreatic injuries in pediatric patients

Operative versus non-operative management of blunt pancreatic trauma in children: Systematic review and meta-analysis

AIM

Blunt abdominal trauma is the major cause of abdominal injury in children. No clear guidelines exist for the initial management of blunt pancreatic trauma in children. The aim of this study was to perform a systematic review and meta-analysis of initially non-operative versus initially operative treatment in children with blunt pancreatic injury.

METHODS

Studies including children (<18 years) with blunt pancreatic injuries published in any language after year 1990 were included. Total of 849 studies were identified by searching PubMed, Scopus, CINAHL and Cochrane Database. After review, 42 studies met inclusion criteria and were included in this systematic review. There were 1754 patients, of whom 1095 were initially managed non-operatively (NOM), and 659 operatively (OM). Primary outcome was non-operative management success rate, and secondary outcomes were mortality, complications (including specifically pseudocysts and pancreatic fistulas), percent of patients and days on total parenteral nutrition (TPN), length of hospital stay and readmissions.

RESULTS

There was no difference in mortality between NOM and OM groups. The incidence of pseudocysts was significantly higher in NOM group compared to OM (P<0.001), especially for AAST grade III or higher (P<0.00001). Overall incidence of pancreatic fistulas was significantly lower for NOM group (p = 0.02) but no difference was observed for AAST grades III or higher (p = 0.49). There was no difference in the length of hospital stay (P = 0.31). Duration of total parenteral nutrition was not different for all AAST grades (P = 0.35), but was significantly shorter for OM group for AAST grades III and higher (p = 0.0001). There was no overall difference in readmissions (P = 0.94). Overall success rate of initial non-operative treatment was 87%.

CONCLUSIONS

Most patients with pancreatic trauma can initially be treated non-operatively, while early surgical treatment may benefit patients with lesions of the main pancreatic duct. ERCP offers both highly accurate diagnosis and potential treatment of ductal injuries.

Blunt Trauma Pancreas in Children: Is Non-Operative Management Appropriate for All Grades?

PURPOSE

Blunt trauma of pancreas in children is uncommon and its management varies from observational to early operative intervention. We analysed the feasibility and outcome of non-operative management in all grades of paediatric pancreatic injuries.

METHODS

A total of 15 patients of pancreatic trauma seen in a Paediatric Surgery Unit were retrospectively analyzed.

RESULTS

Age of the patients ranged from 3-11 years (mean, 7.7 years). The mode of injury was local trauma in 9 children. Only 3 patients had associated injuries and all were haemodynamically stable. Serum amylase levels were raised in 12 patients at admission which ranged from 400-1,000 IU. Computed tomography scan made a correct diagnosis in 14 patients. Grades of the injury varied from grade I-V (1, 3, 6, 4, 1 patients respectively). Fourteen patients were managed conservatively. One patient underwent laparotomy for suspected superior mesenteric hematoma. The average duration of enteral feeds was 3.7 days and of hospital stay was 9.4 days. Six patients formed pancreatic pseudocysts; two were managed conservatively while the other four underwent cystogastrostomy. The patients were followed up for a period of 1-12 years. All remained asymptomatic and none had exocrine or endocrine deficiencies.

CONCLUSION

Non-operative treatment for isolated blunt trauma of pancreas in children may be safely followed for all the grades of injury; if associated injuries requiring surgical intervention are ruled out with a good quality imaging and the patients are hemodynamically stable. It did not increase the hospital stay and morbidity and avoided operative intervention on acutely injured pancreas.

Operative Versus Nonoperative Management of Blunt Pancreatic Trauma in Children: A Systematic Review

The aim of this study was to compare operative versus nonoperative management of blunt pancreatic trauma in children. A systematic literature search was performed. Studies including children with blunt pancreatic injuries classified according to the American Association for the Surgery of Trauma classification were included. The primary outcome was pseudocyst formation. After screening 526 studies, 23 studies with 928 patients were included. Sufficient data were available for 674 patients (73%). Of 309 patients with grade I or II injuries, 258 (83%) were initially managed nonoperatively with a 96% success rate. Of 365 patients with grade III, IV, or V injuries, nonoperative management was initially chosen for 167 patients (46%) with an 89% success rate. Pseudocysts occurred in 18% of patients managed nonoperatively versus 4% of patients managed operatively (P < 0.01), of whom 65% were treated nonoperatively. Hospitalization was 20.5 days after nonoperative versus 15.1 days after operative management (nonparametric t test, P = 0.41). Blunt pancreatic trauma in children can be managed nonoperatively in the majority of patients with grade I or II injuries and in about half of the patients with grade III to V injuries. Although pseudocysts are more common after nonoperative management, two thirds can be managed nonoperatively.

Blunt splenic injury: are early adverse events related to trauma, nonoperative management, or surgery?

PURPOSE

We aimed to compare clinical outcomes and early adverse events of operative management (OM), nonoperative management (NOM), and NOM with splenic artery embolization (SAE) in blunt splenic injury (BSI) and identify the prognostic factors.

METHODS

Medical records of 136 consecutive patients with BSI admitted to a trauma center from 2005 to 2010 were retrospectively reviewed. Patients were separated into three groups: OM, NOM, and SAE. We focused on associated injuries and early adverse events. Multivariate analysis was performed on 23 prognostic factors to find predictors.

RESULTS

The total survival rate was 97.1%, with four deaths all occurred in the OM group. The spleen salvage rate was 91% in NOM and SAE. At least one adverse event was observed in 32.8%, 62%, and 96% of patients in NOM, SAE, and OM groups, respectively (P < 0.001). We found significantly more deaths, infectious complications, pleural drainage, acute renal failures, and pancreatitis in OM and more pseudocysts in SAE. Six prognostic factors were statistically significant for one or more adverse events: simplified acute physiology score 2 ≥25 for almost all adverse events, age ≥50 years for acute respiratory syndrome, limb fracture for secondary bleeding, thoracic injury for pleural drainage, and at least one associated injury for pseudocyst. Adverse events were not related to the type of BSI management.

CONCLUSION

Patients with BSI present worse outcome and more adverse events in OM, but this is related to the severity of injury. The main predictor of adverse events remains the severity of injury.

Practice variability exists in the management of high-grade pediatric pancreatic trauma

PURPOSE

Management of high-grade pancreatic trauma in children is controversial, although recent evidence supports early operation. We sought to evaluate whether practice variability exists regarding the management of these rare and complex injuries.

METHODS

A study group of pediatric trauma centers within the Pediatric Trauma Society completed a survey following a query of their institutional database. Results are presented using descriptive statistics.

RESULTS

Over a 3-year period (2012-2014), 123 pancreatic injuries (grades II-IV) were reported from 19 pediatric trauma centers (median 6, range 1-22). Sixty-two injuries involving injury to the pancreatic duct (clear/suspected) were reported (median 1, range 0-9). Of these, 49 % were managed with non-operative management (NOM) and 51 % with operative management. Surgeons at the majority (63 %) of institutions used both approaches. Of the operative cases, 21 % were laparoscopic. There was wide variability in clinical management of NOM patients: the most common feeding strategy was reported by 52 % of centers, percutaneous drainage of traumatic pseudocyst by 42 % and ERCP (early/after pseudocyst) by 72 %.

CONCLUSION

Wide practice variability exists among North American pediatric surgeons regarding both the initial approach to high-grade pancreatic injury and non-operative management. These results highlight the need for a prospective trial to determine the optimal strategy for these patients.

Early endoscopic treatment of blunt traumatic pancreatic injury

Blunt pancreatic trauma is a rare and challenging situation. In many cases, there are other associated injuries that mandate urgent operative treatment. Morbidity and mortality rates are high and complications after acute pancreatic resections are common. The diagnosis of pancreatic injuries can be difficult and often requires multimodal approach including Computed Tomography scans, Magnetic resonance imaging and Endoscopic retrograde cholangiopancreaticography (ERCP). The objective of this paper is to review the application of endoprothesis in the settings of pancreatic injury. A review of the English literature available was conducted and the experience of our centre described. While the classical recommended treatment of Grade III pancreatic injury (transection of the gland and the pancreatic duct in the body/tail) is surgical resection this approach carries high morbidity. ERCP was first reported as a diagnostic tool in the settings of pancreatic injury but has in recent years been used increasingly as a treatment option with promising results. This article reviews the literature on ERCP as treatment option for pancreatic injury and adds further to the limited number of cases reported that have been treated early after the trauma.

Surgical reconstruction and endoscopic pancreatic stent for traumatic pancreatic duct disruption

Nonoperative management is acceptable treatment for minor pancreatic injuries. However, management of major pancreatic duct injury in children remains controversial. We present our experience in treating isolated pancreatic duct injury. We describe the cases of three male patients treated for complete pancreatic duct disruption in the past 5 years at our institution. We performed pancreatic duct repair to avoid distal pancreatectomy and to maintain normal pancreatic function. All patients underwent enhanced computed tomography and endoscopic retrograde cholangiopancreatography in the early period. The injuries were classified as grade III according to the American Association for the Surgery of Trauma classification. In two cases, we performed end-to-end anastomosis of the pancreatic duct during the delayed period. In the third case, we placed a stent across the disruption to the distal pancreatic duct. The patients' postoperative courses were uneventful, and the average hospitalization was 25.6 days after the procedure. At a median follow-up of 36 months (range 14-54 months), all patients remain asymptomatic, with normal pancreatic function, but with persistent distal pancreatic duct dilatation. We suggest that distal pancreatectomy should not be routinely performed in patients with isolated pancreatic duct injury.

Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review

INTRODUCTION

Reliability of serum pancreatic enzyme levels in predicting pancreatic injuries has been a parameter of interest and the present recommendations on its utility are based primarily on anecdotal observations. The aim of this study was to evaluate the utility of serum pancreatic enzyme assessment in predicting blunt pancreatic injury with imaging and surgical correlation and compare our results with a systematic review of literature till date.

METHODS

A prospective cohort study conducted over 4 years in a tertiary care referral centre with 164 consecutive patients who presented to the emergency department with a history of blunt abdominal trauma and had serum pancreatic enzyme assessment, USG and subsequent diagnostic CECT were analyzed. The CT findings and AAST grade of pancreatic injury, various intra-abdominal injuries and time elapsed since injury and other associated factors were correlated with serum pancreatic enzyme levels. For systematic review of literature MEDLINE database was searched between 1940 and 2012, also the related citations and bibliographies of relevant articles were analyzed and 40 articles were included for review. We compared our results with the systematic critique of literature till date to formulate recommendations.

RESULTS

33(21%) patients had pancreatic injury documented on CT and were graded according to AAST. Statistically significant elevated serum amylase levels were observed in patients with pancreatic and bowel injuries. However, elevated serum lipase was observed specifically in patients with pancreatic injury with or without bowel injury. Combined serum amylase and lipase showed 100% specificity, 85% sensitivity in predicting pancreatic injury. Elevated (n=28, 85%) vs. normal (n=5, 15%) serum amylase and lipase levels showed sole statistically significant association with time elapse since injury to admission, with a cutoff of 3h.

CONCLUSIONS

Based on our results and the systematic review of the literature till date we conclude, persistently elevated or rising combined estimation of serum amylase and lipase levels are reliable indicators of pancreatic injury and is time dependent, nondiagnostic within 6h or less after trauma. In resource constrained countries where CT is not available everywhere it may support a clinical suspicion of pancreatic injury and can be reliable and cost-effective as a screening tool.

Camel-related pancreatico-duodenal injuries: a report of three cases and review of literature

BACKGROUND

Human pancreatico-duodenal injuries caused by camels are extremely rare.

OBJECTIVE

We report three patients who sustained camel-related pancreatico-duodenal injuries and review the literature on this topic.

RESULTS

A 32-year camel caregiver was kicked by a camel which then stepped on his abdomen trying to kill him. The patient's abdomen was soft and lax. CT scan of the abdomen showed free retroperitoneal air. Laparotomy revealed a complete tear of the anterior wall of the second part of duodenum which was primarily repaired. A 40-year camel caregiver was directly kicked into his abdomen by a camel. He developed traumatic pancreatitis which was treated conservatively. A 31-year-old male fell down on his abdomen while riding a camel. Abdominal examination revealed tenderness and guarding. Abdominal CT Scan showed complete transection of the neck of the pancreas which was confirmed by laparotomy. The patient had distal pancreatectomy with preservation of the spleen. All patients were discharged home in good condition.

CONCLUSION

These cases demonstrate the misleading presentation of the camel-related pancreatico-duodenal injuries and their unique mechanism of injury.