Over the past 30 years or so, we’ve made major advances in managing many injuries without operation. Blunt injuries to liver, spleen, and kidney, along with some penetrating injuries to the liver come to mind. But as we have seen many times in medicine, the pendulum sometimes swings too far.
Hopefully, I’ve impressed upon you how strange and potentially treacherous the pancreas is. In recent years, some centers have dabbled with nonoperative management of the pancreas in children. The belief has been that, since kids heal so much better than adults, maybe the pancreas will be more forgiving in that age group. Unfortunately, the only studies to date have been small, single center work.
But now, a collaborative Pancreatic Injuries In Children Study Group has published results of a multi-institutional retrospective review which will hopefully lay this debate to rest (at least for a while).
Here are the factoids:
- The study reviewed data from 1195-2012 (18 years!) on patients less than 18 years old. Only grade II or III injuries were selected. Grade was determined by CT, ERCP, MRCP or at operation.
- Fourteen centers participated, submitting data on 167 patients. These are huge numbers for this uncommon injury!
- 57 underwent distal pancreatectomy, 95 were managed without operation. The remainder were drained and were studied separately.
- Diet was resumed significantly more quickly (8 days vs 15 days) in the resection group
- More endoscopic and interventional procedures were needed due to pseudocyst formation in the nonoperative group (26% vs 2%)
- Patients with Grade III injuries (distal duct) had fewer complications after resection (33% vs 61%)
- Hospital stay was significantly shorter in the resection group (13 vs 18 days)
Bottom line: Operative resection of distal pancreatic injury in children is the way to go, just as it is in adults. Persistent attempts to treat without surgery keeps the child in the hospital longer, exposes them to additional invasive procedures, and is fraught with more complications. You may think you’re saving them the pain of major abdominal surgery, but you are just prolonging the torture with endoscopy, IR drainage, repeated blood draws, and starvation.
Reference: Operative vs nonoperative management for blunt pancreatic transection in children: multi-institutional outcomes. J Am Coll Surg 218(2):157-162, 2014.