Similar outcomes for operative, nonoperative care of blunt pancreatic trauma in kids

Last Updated: 2016-01-08

By Will Boggs MD

NEW YORK (Reuters Health) - Survival, complications, and other outcomes are similar after operative and nonoperative management of pediatric blunt pancreatic trauma, according to a new U.S. study.

"On reviewing our results I was surprised by the variation in the management of these patients across the country," Dr. Maria Carmen Mora from Tufts University School of Medicine in Springfield, Massachusetts, told Reuters Health. "There was almost an even split between the operative and non-operative groups. I think this really emphasizes the fact that there is no true consensus on the best management of a child with a pancreatic injury."

Dr. Mora's team used data from the National Trauma Data Bank to compare outcomes among children with blunt pancreatic injuries who were managed operatively (230 patients) or nonoperatively (194 patients). Twenty-eight children in the operative group had surgery more than 48 hours after admission and were analyzed separately as the "delayed operative" group.

Abbreviated Injury Scale (AIS) scores of 5 (critical) were more common in the operative group (40.6%) than in the nonoperative (28.4%) or delayed operative (35.7%) group. But the average Injury Severity Score (ISS) and associated injuries did not differ among the groups, the researchers report in the Journal of the American College of Surgeons, online December 17.

"While a higher proportion of patients with an AIS of 5 (severe) were treated with operative management, a large number of them were being managed non-operatively," the team notes. "A higher proportion of patients with an AIS of 3 were treated non-operatively, but a significant minority of these patients were also managed with operative intervention. This wide range of treatment differences observed in pediatric pancreatic injuries observed nationwide reflects how the management of pancreatic injuries in children remains controversial."

Death rates were similarly low for the operative (2.5%), nonoperative (3.6%), and delayed operative (3.6%) groups.

In multivariable analysis, the groups did not differ in overall complication rates, but pseudocyst was most common in the nonoperative group and infection was more common in both operative groups than in the nonoperative group.

The hospital stay was shorter for nonoperative and operative groups than for the delayed operative group, and ICU admission was more likely and the ICU stay longer for both operative groups than for the nonoperative group. Patients in the operative groups were also more likely to spend any time on ventilators.

"Children with pancreatic injuries can be managed safely either nonoperatively or operatively," Dr. Mora concluded. "Surgeons with limited pancreatic experience should not be pressured to operate. However, our data does not parse out those patients with pancreatic duct injuries so it is difficult to comment on whether those patients specifically would benefit from either an operative or non-operative approach."

Dr. David Notrica from Level 1 Pediatric Trauma Center, Phoenix Children's Hospital and Mayo Medical School, in Phoenix, Arizona, who recently reviewed the management of pediatric blunt abdominal trauma, said he had "severe methodological reservations about this study."

"Modern management of pancreatic injury is based on the status of the main pancreatic duct. If it is transected, several studies have shown better outcomes with operative management, while non-operative management is better for children when the pancreas is injured, but the duct is not transected. The methodological problem is that AIS >3 includes both types of patients."

"At our pediatric trauma center, we evaluate the integrity of the duct with ERCP or MRCP and let that guide our management," Dr. Notrica said. "If the duct is intact, we recommend non-operative management. If the duct is completely transected, we recommend laparoscopic distal pancreatectomy if <50% of the pancreas will be sacrificed. If the injury is more proximal and >70% and the duct is transected, we recommend reconstruction with a pancreatico-jejunostomy. When the injury is between 50-70%, this is a gray zone, and other factors such as general illness may impact the decision. In a few cases where the main duct was injured, but not completely transected, our endoscopists have successfully stented across the injury, but these are rare and a few have failed anyway."

"I don't think you can draw a conclusion based on this study," Dr. Notrica said. "The question of operative versus nonoperative management of pancreatic injury cannot be answered with NTDB data."

SOURCE: bit.ly/1OfkETl

J Am Coll Surg 2015.