A. C. Akinkuotu1,2, F. Sheikh1,2, A. Olsen1,2, B. J. Naik-Mathuria1,2 1Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA
Introduction:
Pancreatic injuries represent the fourth most common solid organ injury in children. Although non-operative management (NOM) is the standard of care for minor pancreatic injuries that do not involve the main pancreatic duct, management of major pancreatic injures in children remains controversial, and varies widely among institutions. Since the literature is limited to case reports and series, we sought to perform a systematic review and meta-analysis to determine which management strategy for blunt pancreatic injuries in children had better outcomes.
Methods:
A systematic review of all published literature (PUBMED, SCOPUS and EMBASE) was performed according to the PRISMA guidelines. Case reports and series were excluded. Outcomes of interest for this review were rates of fistula and pseudocyst formation, days on total parenteral nutrition (TPN), days to full enteral feeds and hospital length of stay (LOS).
Results:
Twenty-five studies were included in this review (age range 2 months to 17 years). There were a total of 1014 pancreatic injuries of which 732 (72.2%) were managed with non-operative management (NOM), 267 (26.3%) by operative management (OM) and 15 with drain placement only. Of the studies in which pancreatic injury grades were reported (n=8), there were 190 injuries with AAST grade ≥ 3; 146 were managed with NOM compared to 44 with OM. In the studies in which fistula rates were evaluated (n=6), there was no difference in fistula formation rates between NOM (11/269 (4.09%)) and OM (5/124 (4.03%)) (pooled odds ratio 0.60, 95% CI 0.18 to 2.01; p-0.311). Incidence of pseudocyst formation was recorded in 24 studies and a meta-analysis demonstrated a higher risk of pseudocyst formation with NOM compared to OM (pooled odds ratio 2.05, 95% CI 1.04 to 4.07; p<0.001). Meta-analysis could not be performed on the other outcomes of interest due to heterogeneity of data; however, both duration of TPN and days to full enteral diet trended towards longer times in patients with NOM. In the 10 studies analyzing LOS, 4 showed no difference in hospital LOS between NOM and OM, whereas 2 showed that NOM had a longer length of stay. Other complications noted in these studies included central line infection, pancreatic abscess, small bowel obstruction and wound dehiscence. There were more complications in NOM (n=14) compared to the OM group (n=8) however these complications were not listed in sufficient numbers to analyze.
Conclusion:
Although non-operative management of major pancreatic injury in children is associated with higher rates of pseudocyst formation, current data suggests that there is no difference in outcomes of fistula formation, hospital length of stay or TPN use. Pseudocyst formation alone may not be reason enough to warrant operation for this injury. A multicenter, randomized prospective clinical trial is needed to establish guidelines regarding the ideal management of these patients.