Pediatr Surg Int (2014) 30:1107–1110 DOI 10.1007/s00383-014-3599-2
ORIGINAL ARTICLE
Multi-institutional experience with penetrating pancreatic injuries in children Hanna Alemayehu • Kuojen Tsao • Mark L. Wulkan • Saleem Islam • Robert T. Russell • Todd A. Ponsky • Daniel C. Cullinane • Adam Alder Shawn D. St. Peter • Corey W. Iqbal
•
Accepted: 9 September 2014 / Published online: 21 September 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Penetrating pancreatic injuries in children are uncommon and are not well described in the literature. We report a multi-institutional experience with penetrating pancreatic injuries in children. Methods A retrospective review of children sustaining penetrating pancreatic injuries was performed at eight pediatric trauma centers. Results Sixteen patients were identified. Eleven patients were male; (mean ± SE) age was 11.7 ± 1.2 years. The mechanism of injury was gun-shot wound in 14 patients and mean injury-severity score was 18 ± 3. All patients
H. Alemayehu S. D. St. Peter C. W. Iqbal (&) Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA e-mail: [email protected] K. Tsao University of Texas Health Science Center at Houston and Children’s Memorial Hermann Hospital, Houston, TX, USA M. L. Wulkan Children’s Healthcare of Atlanta at Egleston, Atlanta, GA, USA S. Islam University of Florida, Gainesville, FL, USA R. T. Russell University of Alabama Birmingham, Birmingham, AL, USA T. A. Ponsky Akron Children’s Hospital, Akron, OH, USA D. C. Cullinane Marshfield Clinic, Marshfield, WI, USA A. Alder Children’s Medical Center, Dallas, TX, USA
had associated injuries, most frequently small bowel injuries (n = 9). Patients had either grade I (n = 4), grade II (n = 7), or grade III (n = 4) injuries; there was a single grade V injury. All patients underwent exploratory celiotomy. Drainage of the injured pancreas was performed in 11 patients, and 2 patients underwent pancreatorrhaphy in addition to drainage; 3 underwent resection for grade III (n = 2) and grade V (n = 1) injuries. Thirteen patients required other intra-abdominal procedures. All patients required intensive care over a mean 11.0 ± 3.0 days. Mean duration of stay was 30.1 ± 5.6 days. Post-operative morbidity was 62.5 % with no mortalities. Conclusions Penetrating pancreatic injuries in children are uncommon and most often due to firearms. There is a high association with other injuries particularly hollow viscous perforation. Keywords Pediatric trauma Pancreatic trauma Penetrating trauma Children
Introduction The incidence of pancreatic injury in the setting of abdominal trauma ranges from 3 to 12 % [1–3]. In children, blunt force injury is the most common mechanism for pancreatic injury, whereas in adults up to 70–75 % of traumatic pancreatic injuries are due to penetrating trauma [4, 5]. Consequently, penetrating pancreatic injuries have been well described in the adult trauma literature [6–9]. However, a similar description of penetrating pancreatic injuries in the pediatric population where penetrating injuries are much less frequently encountered is lacking. We report a multi-institutional review of penetrating pancreatic injuries in children.
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Table 1 Patient characteristics N (%) Male sex
11 (69)
Gun-shot wound
14 (88)
Associated Injuries
16 (100)
Preoperative computed tomography scan
7 (44)
Grade of Injurya Grade I
4 (25)
Grade II
7 (44)
Grade III
4 (25)
Grade IV
0 (0)
Grade V
1 (6) Mean ± SE
Mean ISS
17.9 ± 2.9
Mean age (years)
11.7 ± 1.2
Presenting serum amylase (U/L)
118.8 ± 19.2
Presenting serum lipase (U/L)
562.8 ± 156.0
a Grading per the American Association for the Surgery of Trauma Classification
Methods A multi-institutional, retrospective review was conducted at eight pediatric trauma centers (seven level-I, a single level-II) from 1995 through 2012 of all patients B18 years of age who sustained a pancreatic injury as a result of penetrating trauma. IRB approval was obtained at each participating institution. Demographic and pre-hospital data were collected in addition to the initial diagnostic work-up, treatment, and outcomes. Grade of pancreatic injury was classified according to the American Association for the Surgery of Trauma grading system [10]. All continuous data are expressed as the mean ± standard error and all nominal data are expressed as percentages unless otherwise stated.
Results A total of 20 patients were identified with pancreatic trauma resulting from penetrating trauma—this was out of a total of 310 children with pancreatic injury over the same time period for a rate of 7 % of pancreatic trauma attributable to penetrating trauma and 93 % due to blunt injury. Sixteen patients had complete medical records available and data are reported for these patients. Most patients were male (69 %) and the mean age at injury was 11.7 ± 1.2 years. Gun-shot wound (GSW) was the most common mechanism of injury resulting in pancreatic injury in 14 of 16 patients (88 %)—there was one patient whose
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injury occurred in a boating accident, and one patient who sustained a stab injury (Table 1). The mean injury severity score (ISS) was 18 ± 3 with a median of 17 (range 9–54), and a mode of 9. There was a 100 % rate of associated injuries which are outlined in Table 2. Injury to the small intestine was the most frequently encountered associated injury occurring in more than half of patients. Altogether, hollow viscous injury was seen in 12 patients and solid organ injury in 9. Major vascular injuries were primarily intra-abdominal: inferior vena cava (n = 2), splenic vein (n = 1), and left renal vein (n = 1). A single patient suffered a femoral artery laceration from multiple GSWs. All patients underwent exploratory celiotomy. Most pancreatic injuries were managed with operative drainage (Table 3). Two patients underwent distal pancreatectomy for grade III injuries. Another patient underwent pancreaticoduodenectomy for a grade V pancreatic injury—this was the only patient with a grade V injury. Fourteen patients required other intra-abdominal procedures due to associated injuries. There were no deaths in this series however, post-operative morbidity was 69 % and the mean duration of hospitalization was 30.1 ± 5.6 days. All patients required intensive care over a mean 11.0 ± 3.0 days. The most frequent post-operative complication was infectious (19 %). There were two patients (13 %) who developed pseudocysts after operative drainage of grade II pancreatic injuries. The remainder of the post-operative complications is outlined in Table 3. There were no clinically significant pancreatic fistulae.
Discussion Penetrating pancreatic injuries are exceedingly rare in the injured child accounting for only 6 % of all pancreatic injuries making blunt abdominal trauma, the most common cause of pancreatic injury in children. The rarity of this injury has resulted in a lack of literature regarding penetrating pancreatic trauma in children, although blunt pancreatic injuries in children have been well studied. When this uncommon injury does occur, it is almost always due to firearms and has a 100 % rate of associated injuries. This high rate of associated injuries is not surprising given the anatomic location of the pancreas, the propensity for high velocity projectiles to ricochet causing collateral damage, and the risk for more than one entry site from multiple GSWs or injuries related to ammunition that sprays such as a shotgun blast. Despite this high rate of associated injuries, there were no mortalities in this series, contrary to significant mortality rates in adult patients with penetrating pancreatic injuries [6–9].
Pediatr Surg Int (2014) 30:1107–1110 Table 2 Associated injuries
1109
Site of injury
N (%)
Small intestine
9 (56)
Hepatobiliary
6 (38)
Major vascular injury
5 (31)
Renal
5 (31)
Gastric
5 (31)
Colon
5 (31)
Spleen
4 (25)
Spine
3 (19)
Thoracic
3 (19)
Extremity
3 (19)
Diaphragm
3 (19)
Duodenum
2 (13)
Table 3 Management and outcomes N (%) Operative drainage
11 (69)
Operative drainage with pancreatorraphy
2 (13)
Operative resection
3 (19)
Distal pancreatectomy
2 (13)
Pancreaticoduodenectomy
1 (6)
Mortality
0 (0)
Morbidity
11 (7)
Infection
3 (19)
Pancreatic pseudocyst Pancreatitis
2 (13) 1 (6)
Pancreatic leak (after resection)
1 (6)
Pulmonary embolus
1 (6)
Wound dehiscence
1 (6)
Fasciitis (non-surgical)
1 (6)
Biloma
1 (6)
Need for intensive care
16 (100)
Mean duration of intensive care (days)
11.0 ± 3.0
Mean duration of hospitalization (days)
30.1 ± 5.5
While operative versus non-operative management is controversial for blunt pancreatic injuries, there is little argument against emergent exploration for penetrating abdominal trauma, especially that from a firearm. All patients in this series underwent celiotomy including more than half who were taken directly to the operating room without pre-operative axial imaging. Presenting serum pancreatic enzyme levels were only moderately elevated and may not be a reliable indicator of pancreatic injury. If pre-operative imaging is obtained and a pancreatic injury is recognized, then the surgeon can expect a very high likelihood of encountering injuries to both the hollow viscera and solid organs. Delaying operative exploration to assess for pancreatic injury radiologically is probably not
necessary, even with elevated enzymes, given the low likelihood of pancreatic injury in this population. Furthermore, the indication to explore patients with penetrating abdominal injuries is to treat other, life-threatening injuries. Yet in patients with penetrating injuries who have not undergone pre-operative imaging, the lesser sac should be explored to rule out a pancreatic injury as it has been reported that a missed pancreatic injury can be quite morbid due to the risk for pancreatic fistula and pseudocyst development [11]. Definitive management of pancreatic injuries is highly controversial. It has been shown that non-operative preservation of the pancreas after blunt injury is feasible [12, 13]. However, when the main pancreatic duct is involved, the outcomes for blunt injury have been shown to favor resection with distal pancreatectomy [14–16]. It is not clear if that data are applicable to penetrating trauma where there is such a high association with other intra-abdominal injuries. Adult retrospective reviews have indicated similar controversy in managing penetrating pancreatic trauma [7–9]. All grade I and most grade II injuries in this series were managed with operative drainage only; two patients developed pseudocysts. Two patients with grade II injuries underwent operative drainage with pancreatorrhaphy; one patient developed a biloma and the other developed postoperative pancreatitis. Two patients underwent distal pancreatectomy for main duct injury, however, two other patients with grade III injuries were managed with drainage only and these numbers are too small for a valid comparison to draw any definitive conclusions. We would favor drainage in instances where the main pancreatic duct is not involved and favor resection when the main duct is involved extrapolating from what is known about blunt pancreatic injuries, although the data remain mixed and controversial in the setting of penetrating pancreatic injuries [7–9]. The caveats to this are the damage control situation and grade IV and V injuries. In the damage control situation, attempting to definitively manage the pancreas could be life-threatening. However, after stabilization more definitive management could still be offered if indicated. We had no grade IV injuries and a single grade V injury was managed with pancreaticoduodenectomy. These numbers prohibit any conclusion about optimal management for grade IV and V injuries; the surgeon should individualize the management strategy based on the overall status of the patient and extent of the injury. Morbidity with this injury pattern is high. We observed a morbidity rate of 69 %—predominately infectious, which is similar to morbidity rates of 16–52 % described in the adult literature [7–9]. This high morbidity cannot be attributed solely to pancreatic injury given the breadth of associated injuries these patients had, specifically hollow viscous injury which likely contributed most to the
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infectious complications. Moreover, pancreatic injury is likely a surrogate for the extent of intra-abdominal injuries and therefore portends a more complicated post-operative course. Therefore, it is not surprising that all patients necessitated intensive care and that the mean duration of stay was around 1 month. Despite the high morbidity in our series and the high mortality rate (of up to 57 %) reported in adult series of penetrating pancreatic injuries, there were no deaths in this series [6–9]. Given the high association with other injuries, it is not entirely clear why children have better survival with this type of injury compared to adults other than the tendency to have less pre-existing comorbid conditions—albeit, this series is also limited in numbers which may account for the survival difference. Similarly, adult literature reports a pancreatic fistulae rate of 5–8 % after penetrating pancreatic injury managed with drainage or resection [7, 8], however, we observed no pancreatic fistulae formation in our study population. The limited numbers in this series may account for the lack of this known complication after penetrating pancreatic injury, and a standard definition of pancreatic fistula was not used so only clinically significant pancreatic leaks would have been captured by the retrospective analysis. In conclusion, penetrating pancreatic injuries in children are exceedingly rare and account for less than 10 % of all pancreatic injuries. There is a high association with other injuries that results in a high need for intensive care and prolonged hospitalization. Operative exploration is necessary to assess and manage associated injuries. Drainage is probably adequate when the main pancreatic duct is not involved. Management of more extensive pancreatic injuries due to penetrating trauma is less clear. Conflict of interest interest to disclose.
The authors declare they have no conflict of
References 1. Arkovitz MS, Johnson N, Garcia VF (1997) Pancreatic trauma in children: mechanisms of injury. J Trauma 42:49–53
123
2. Shilyansky J, Sena LM, Kreller M et al (1998) Nonoperative management of pancreatic injuries in children. J Pediatr Surg 33:343–349 3. Keller MS, Stafford PW, Vane DW (1997) Conservative management of pancreatic trauma in children. J Trauma 42:1097–1100 4. Stawicki SP, Schwab CW (2008) Pancreatic trauma: demographics, diagnosis, and management. Am Surg 74:1133–1145 5. Schroeppel TJ, Croce MA (2007) Diagnosis and management of blunt abdominal solid organ injury. Curr Opin Crit Care 13:399–404 6. Vasquez JC, Coimbra R, Hoyt DB, Fortlage D (2001) Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center. Injury Int J Care Inj 32:753–759 7. Young PR Jr, Meredith JW, Baker CC, Thomason MH, Chang MC (1998) Pancreatic injuries resulting from penetrating trauma: a multi-institution review. Am Surg 64:838–843 8. Ivatury RR, Nallathambi M, Rao P, Stahl WM (1990) Penetrating pancreatic injuries. Analysis of 103 consecutive cases. Am Surg 56:90–95 9. Sorensen VJ, Obeid FN, Horst HM, Bivins BA (1986) Penetrating pancreatic injuries, 1978–1983. Am Surg 52:354–358 10. Moore EE, Cogbill TH, Malangoni MA et al (1990) Organ injury scaling II: pancreas, duodenum, small bowel, colon, and rectum. J Trauma 30:1427–1429 11. Nadler EP, Gardner M, Schall LC, Lynch JM, Ford HR (1999) Management of blunt pancreatic injury in children. J Trauma 47:1098–1103 12. Wales PW, Shuckett B, Kim PCW (2001) Long-term outcome after non-operative management of complete pancreatic transection in children. J Pediatr Surg 36:823–827 13. Bass J, Di Lorenzo M, Desjardins JG et al (1988) Blunt pancreatic injuries in children: the role of percutaneous external drainage in the treatment of pancreatic pseudocysts. J Pediatr Surg 23:721–724 14. Wood JH, Partrick DA, Bruny JL et al (2010) Operative vs nonoperative management of blunt pancreatic trauma in children. J Pediatr Surg 45:401–406 15. Paul MD, Mooney DP (2011) The management of pancreatic injuries in children: operate or observe. J Pediatr Surg 46:1140–1143 16. Iqbal CW, St. Peter SD, Tsao K et al (2014) Operative versus non-operative management for blunt pancreatic transection in children: multi-institutional outcomes. J Am Coll Surg 218: 157–162
ORIGINAL ARTICLE
Multi-institutional experience with penetrating pancreatic injuries in children Hanna Alemayehu • Kuojen Tsao • Mark L. Wulkan • Saleem Islam • Robert T. Russell • Todd A. Ponsky • Daniel C. Cullinane • Adam Alder Shawn D. St. Peter • Corey W. Iqbal
•
Accepted: 9 September 2014 / Published online: 21 September 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Penetrating pancreatic injuries in children are uncommon and are not well described in the literature. We report a multi-institutional experience with penetrating pancreatic injuries in children. Methods A retrospective review of children sustaining penetrating pancreatic injuries was performed at eight pediatric trauma centers. Results Sixteen patients were identified. Eleven patients were male; (mean ± SE) age was 11.7 ± 1.2 years. The mechanism of injury was gun-shot wound in 14 patients and mean injury-severity score was 18 ± 3. All patients
H. Alemayehu S. D. St. Peter C. W. Iqbal (&) Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA e-mail: [email protected] K. Tsao University of Texas Health Science Center at Houston and Children’s Memorial Hermann Hospital, Houston, TX, USA M. L. Wulkan Children’s Healthcare of Atlanta at Egleston, Atlanta, GA, USA S. Islam University of Florida, Gainesville, FL, USA R. T. Russell University of Alabama Birmingham, Birmingham, AL, USA T. A. Ponsky Akron Children’s Hospital, Akron, OH, USA D. C. Cullinane Marshfield Clinic, Marshfield, WI, USA A. Alder Children’s Medical Center, Dallas, TX, USA
had associated injuries, most frequently small bowel injuries (n = 9). Patients had either grade I (n = 4), grade II (n = 7), or grade III (n = 4) injuries; there was a single grade V injury. All patients underwent exploratory celiotomy. Drainage of the injured pancreas was performed in 11 patients, and 2 patients underwent pancreatorrhaphy in addition to drainage; 3 underwent resection for grade III (n = 2) and grade V (n = 1) injuries. Thirteen patients required other intra-abdominal procedures. All patients required intensive care over a mean 11.0 ± 3.0 days. Mean duration of stay was 30.1 ± 5.6 days. Post-operative morbidity was 62.5 % with no mortalities. Conclusions Penetrating pancreatic injuries in children are uncommon and most often due to firearms. There is a high association with other injuries particularly hollow viscous perforation. Keywords Pediatric trauma Pancreatic trauma Penetrating trauma Children
Introduction The incidence of pancreatic injury in the setting of abdominal trauma ranges from 3 to 12 % [1–3]. In children, blunt force injury is the most common mechanism for pancreatic injury, whereas in adults up to 70–75 % of traumatic pancreatic injuries are due to penetrating trauma [4, 5]. Consequently, penetrating pancreatic injuries have been well described in the adult trauma literature [6–9]. However, a similar description of penetrating pancreatic injuries in the pediatric population where penetrating injuries are much less frequently encountered is lacking. We report a multi-institutional review of penetrating pancreatic injuries in children.
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Pediatr Surg Int (2014) 30:1107–1110
Table 1 Patient characteristics N (%) Male sex
11 (69)
Gun-shot wound
14 (88)
Associated Injuries
16 (100)
Preoperative computed tomography scan
7 (44)
Grade of Injurya Grade I
4 (25)
Grade II
7 (44)
Grade III
4 (25)
Grade IV
0 (0)
Grade V
1 (6) Mean ± SE
Mean ISS
17.9 ± 2.9
Mean age (years)
11.7 ± 1.2
Presenting serum amylase (U/L)
118.8 ± 19.2
Presenting serum lipase (U/L)
562.8 ± 156.0
a Grading per the American Association for the Surgery of Trauma Classification
Methods A multi-institutional, retrospective review was conducted at eight pediatric trauma centers (seven level-I, a single level-II) from 1995 through 2012 of all patients B18 years of age who sustained a pancreatic injury as a result of penetrating trauma. IRB approval was obtained at each participating institution. Demographic and pre-hospital data were collected in addition to the initial diagnostic work-up, treatment, and outcomes. Grade of pancreatic injury was classified according to the American Association for the Surgery of Trauma grading system [10]. All continuous data are expressed as the mean ± standard error and all nominal data are expressed as percentages unless otherwise stated.
Results A total of 20 patients were identified with pancreatic trauma resulting from penetrating trauma—this was out of a total of 310 children with pancreatic injury over the same time period for a rate of 7 % of pancreatic trauma attributable to penetrating trauma and 93 % due to blunt injury. Sixteen patients had complete medical records available and data are reported for these patients. Most patients were male (69 %) and the mean age at injury was 11.7 ± 1.2 years. Gun-shot wound (GSW) was the most common mechanism of injury resulting in pancreatic injury in 14 of 16 patients (88 %)—there was one patient whose
123
injury occurred in a boating accident, and one patient who sustained a stab injury (Table 1). The mean injury severity score (ISS) was 18 ± 3 with a median of 17 (range 9–54), and a mode of 9. There was a 100 % rate of associated injuries which are outlined in Table 2. Injury to the small intestine was the most frequently encountered associated injury occurring in more than half of patients. Altogether, hollow viscous injury was seen in 12 patients and solid organ injury in 9. Major vascular injuries were primarily intra-abdominal: inferior vena cava (n = 2), splenic vein (n = 1), and left renal vein (n = 1). A single patient suffered a femoral artery laceration from multiple GSWs. All patients underwent exploratory celiotomy. Most pancreatic injuries were managed with operative drainage (Table 3). Two patients underwent distal pancreatectomy for grade III injuries. Another patient underwent pancreaticoduodenectomy for a grade V pancreatic injury—this was the only patient with a grade V injury. Fourteen patients required other intra-abdominal procedures due to associated injuries. There were no deaths in this series however, post-operative morbidity was 69 % and the mean duration of hospitalization was 30.1 ± 5.6 days. All patients required intensive care over a mean 11.0 ± 3.0 days. The most frequent post-operative complication was infectious (19 %). There were two patients (13 %) who developed pseudocysts after operative drainage of grade II pancreatic injuries. The remainder of the post-operative complications is outlined in Table 3. There were no clinically significant pancreatic fistulae.
Discussion Penetrating pancreatic injuries are exceedingly rare in the injured child accounting for only 6 % of all pancreatic injuries making blunt abdominal trauma, the most common cause of pancreatic injury in children. The rarity of this injury has resulted in a lack of literature regarding penetrating pancreatic trauma in children, although blunt pancreatic injuries in children have been well studied. When this uncommon injury does occur, it is almost always due to firearms and has a 100 % rate of associated injuries. This high rate of associated injuries is not surprising given the anatomic location of the pancreas, the propensity for high velocity projectiles to ricochet causing collateral damage, and the risk for more than one entry site from multiple GSWs or injuries related to ammunition that sprays such as a shotgun blast. Despite this high rate of associated injuries, there were no mortalities in this series, contrary to significant mortality rates in adult patients with penetrating pancreatic injuries [6–9].
Pediatr Surg Int (2014) 30:1107–1110 Table 2 Associated injuries
1109
Site of injury
N (%)
Small intestine
9 (56)
Hepatobiliary
6 (38)
Major vascular injury
5 (31)
Renal
5 (31)
Gastric
5 (31)
Colon
5 (31)
Spleen
4 (25)
Spine
3 (19)
Thoracic
3 (19)
Extremity
3 (19)
Diaphragm
3 (19)
Duodenum
2 (13)
Table 3 Management and outcomes N (%) Operative drainage
11 (69)
Operative drainage with pancreatorraphy
2 (13)
Operative resection
3 (19)
Distal pancreatectomy
2 (13)
Pancreaticoduodenectomy
1 (6)
Mortality
0 (0)
Morbidity
11 (7)
Infection
3 (19)
Pancreatic pseudocyst Pancreatitis
2 (13) 1 (6)
Pancreatic leak (after resection)
1 (6)
Pulmonary embolus
1 (6)
Wound dehiscence
1 (6)
Fasciitis (non-surgical)
1 (6)
Biloma
1 (6)
Need for intensive care
16 (100)
Mean duration of intensive care (days)
11.0 ± 3.0
Mean duration of hospitalization (days)
30.1 ± 5.5
While operative versus non-operative management is controversial for blunt pancreatic injuries, there is little argument against emergent exploration for penetrating abdominal trauma, especially that from a firearm. All patients in this series underwent celiotomy including more than half who were taken directly to the operating room without pre-operative axial imaging. Presenting serum pancreatic enzyme levels were only moderately elevated and may not be a reliable indicator of pancreatic injury. If pre-operative imaging is obtained and a pancreatic injury is recognized, then the surgeon can expect a very high likelihood of encountering injuries to both the hollow viscera and solid organs. Delaying operative exploration to assess for pancreatic injury radiologically is probably not
necessary, even with elevated enzymes, given the low likelihood of pancreatic injury in this population. Furthermore, the indication to explore patients with penetrating abdominal injuries is to treat other, life-threatening injuries. Yet in patients with penetrating injuries who have not undergone pre-operative imaging, the lesser sac should be explored to rule out a pancreatic injury as it has been reported that a missed pancreatic injury can be quite morbid due to the risk for pancreatic fistula and pseudocyst development [11]. Definitive management of pancreatic injuries is highly controversial. It has been shown that non-operative preservation of the pancreas after blunt injury is feasible [12, 13]. However, when the main pancreatic duct is involved, the outcomes for blunt injury have been shown to favor resection with distal pancreatectomy [14–16]. It is not clear if that data are applicable to penetrating trauma where there is such a high association with other intra-abdominal injuries. Adult retrospective reviews have indicated similar controversy in managing penetrating pancreatic trauma [7–9]. All grade I and most grade II injuries in this series were managed with operative drainage only; two patients developed pseudocysts. Two patients with grade II injuries underwent operative drainage with pancreatorrhaphy; one patient developed a biloma and the other developed postoperative pancreatitis. Two patients underwent distal pancreatectomy for main duct injury, however, two other patients with grade III injuries were managed with drainage only and these numbers are too small for a valid comparison to draw any definitive conclusions. We would favor drainage in instances where the main pancreatic duct is not involved and favor resection when the main duct is involved extrapolating from what is known about blunt pancreatic injuries, although the data remain mixed and controversial in the setting of penetrating pancreatic injuries [7–9]. The caveats to this are the damage control situation and grade IV and V injuries. In the damage control situation, attempting to definitively manage the pancreas could be life-threatening. However, after stabilization more definitive management could still be offered if indicated. We had no grade IV injuries and a single grade V injury was managed with pancreaticoduodenectomy. These numbers prohibit any conclusion about optimal management for grade IV and V injuries; the surgeon should individualize the management strategy based on the overall status of the patient and extent of the injury. Morbidity with this injury pattern is high. We observed a morbidity rate of 69 %—predominately infectious, which is similar to morbidity rates of 16–52 % described in the adult literature [7–9]. This high morbidity cannot be attributed solely to pancreatic injury given the breadth of associated injuries these patients had, specifically hollow viscous injury which likely contributed most to the
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infectious complications. Moreover, pancreatic injury is likely a surrogate for the extent of intra-abdominal injuries and therefore portends a more complicated post-operative course. Therefore, it is not surprising that all patients necessitated intensive care and that the mean duration of stay was around 1 month. Despite the high morbidity in our series and the high mortality rate (of up to 57 %) reported in adult series of penetrating pancreatic injuries, there were no deaths in this series [6–9]. Given the high association with other injuries, it is not entirely clear why children have better survival with this type of injury compared to adults other than the tendency to have less pre-existing comorbid conditions—albeit, this series is also limited in numbers which may account for the survival difference. Similarly, adult literature reports a pancreatic fistulae rate of 5–8 % after penetrating pancreatic injury managed with drainage or resection [7, 8], however, we observed no pancreatic fistulae formation in our study population. The limited numbers in this series may account for the lack of this known complication after penetrating pancreatic injury, and a standard definition of pancreatic fistula was not used so only clinically significant pancreatic leaks would have been captured by the retrospective analysis. In conclusion, penetrating pancreatic injuries in children are exceedingly rare and account for less than 10 % of all pancreatic injuries. There is a high association with other injuries that results in a high need for intensive care and prolonged hospitalization. Operative exploration is necessary to assess and manage associated injuries. Drainage is probably adequate when the main pancreatic duct is not involved. Management of more extensive pancreatic injuries due to penetrating trauma is less clear. Conflict of interest interest to disclose.
The authors declare they have no conflict of
References 1. Arkovitz MS, Johnson N, Garcia VF (1997) Pancreatic trauma in children: mechanisms of injury. J Trauma 42:49–53
123
2. Shilyansky J, Sena LM, Kreller M et al (1998) Nonoperative management of pancreatic injuries in children. J Pediatr Surg 33:343–349 3. Keller MS, Stafford PW, Vane DW (1997) Conservative management of pancreatic trauma in children. J Trauma 42:1097–1100 4. Stawicki SP, Schwab CW (2008) Pancreatic trauma: demographics, diagnosis, and management. Am Surg 74:1133–1145 5. Schroeppel TJ, Croce MA (2007) Diagnosis and management of blunt abdominal solid organ injury. Curr Opin Crit Care 13:399–404 6. Vasquez JC, Coimbra R, Hoyt DB, Fortlage D (2001) Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center. Injury Int J Care Inj 32:753–759 7. Young PR Jr, Meredith JW, Baker CC, Thomason MH, Chang MC (1998) Pancreatic injuries resulting from penetrating trauma: a multi-institution review. Am Surg 64:838–843 8. Ivatury RR, Nallathambi M, Rao P, Stahl WM (1990) Penetrating pancreatic injuries. Analysis of 103 consecutive cases. Am Surg 56:90–95 9. Sorensen VJ, Obeid FN, Horst HM, Bivins BA (1986) Penetrating pancreatic injuries, 1978–1983. Am Surg 52:354–358 10. Moore EE, Cogbill TH, Malangoni MA et al (1990) Organ injury scaling II: pancreas, duodenum, small bowel, colon, and rectum. J Trauma 30:1427–1429 11. Nadler EP, Gardner M, Schall LC, Lynch JM, Ford HR (1999) Management of blunt pancreatic injury in children. J Trauma 47:1098–1103 12. Wales PW, Shuckett B, Kim PCW (2001) Long-term outcome after non-operative management of complete pancreatic transection in children. J Pediatr Surg 36:823–827 13. Bass J, Di Lorenzo M, Desjardins JG et al (1988) Blunt pancreatic injuries in children: the role of percutaneous external drainage in the treatment of pancreatic pseudocysts. J Pediatr Surg 23:721–724 14. Wood JH, Partrick DA, Bruny JL et al (2010) Operative vs nonoperative management of blunt pancreatic trauma in children. J Pediatr Surg 45:401–406 15. Paul MD, Mooney DP (2011) The management of pancreatic injuries in children: operate or observe. J Pediatr Surg 46:1140–1143 16. Iqbal CW, St. Peter SD, Tsao K et al (2014) Operative versus non-operative management for blunt pancreatic transection in children: multi-institutional outcomes. J Am Coll Surg 218: 157–162
