Operative vs nonoperative management for blunt pancreatic transection in children: multi-institutional outcomes.
BACKGROUND
The management of traumatic pancreatic transection remains controversial.


METHODS
A multi-institutional review from 1995 to 2012 was conducted comparing operative with nonoperative management for grades II and III blunt pancreatic injuries in patients younger than 18 years.


RESULTS
Fourteen pediatric trauma centers participated, yielding 167 patients; 57 underwent distal pancreatectomy and 95 were managed nonoperatively. Fifteen patients treated with operative drain placement only were studied separately. Patients undergoing resection had a shorter time to goal oral feeds (7.8 ± 0.7 days vs 15.1 ± 2.5 days; p = 0.007) and a lower rate of pseudocyst formation (0% vs 18%; p = 0.001). Pseudocyst formation resulted in a greater need for endoscopic and interventional radiologic procedures (26% vs 2%; p = 0.002) in the nonoperative group, as well as a longer time to complete resolution (38.6 ± 6.4 days vs 22.6 ± 5.0 days; p = 0.05) compared with resection. When looking at those patients with clear evidence of main duct injury at presentation, those undergoing resection also had fewer complications (33% vs 61%; p = 0.05) and fewer total days in-hospital (12.6 ± 8.4 days vs 17.5 ± 9.7 days; p = 0.04) compared with nonoperative management.


CONCLUSIONS
In children with blunt pancreatic injury, distal pancreatectomy is superior to nonoperative management with more rapid resumption of diet, fewer repeat interventions, and a shorter period to complete resolution. When the main duct is involved, the benefits to operative resection also include lower morbidity and fewer days of hospitalization. Therefore, assessing the status of the pancreatic duct is paramount in determining management.
Division of General and Thoracic Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO. Electronic address: ciqbal@cmh.edu.
Corey W
CW
Iqbal
Division of General and Thoracic Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO.
Shawn D
SD
St Peter
Department of Pediatric Surgery, University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX.
Kuojen
K
Tsao
Division of Trauma Surgery, Marshfield Clinic, Marshfield, WI.
Daniel C
DC
Cullinane
Division of Surgery, Children's Hospital of Wisconsin, Milwaukee, WI.
David M
DM
Gourlay
Department of Pediatric Surgery, Akron Children's Hospital, Akron, OH.
Todd A
TA
Ponsky
Division of Pediatric Surgery, Children's Healthcare of Atlanta at Egleston, Atlanta, GA.
Mark L
ML
Wulkan
Division Pediatric General Surgery, Duke University, Durham, NC.
Obinna O
OO
Adibe
D000007:Abdominal Injuries / Q000175:diagnosis / Q000601:surgery*; D002648:Child; D002760:Cholangiopancreatography, Endoscopic Retrograde; D049448:Cholangiopancreatography, Magnetic Resonance; D004322:Drainage / Q000379:methods*; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D010179:Pancreas / Q000293:injuries*; D010180:Pancreatectomy / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000175:diagnosis / Q000601:surgery*