Tratamiento no quirúrgico versus quirúrgico para el traumatismo pancreático contuso en niños
Resumen
Antecedentes
El traumatismo pancreático en niños es una enfermedad grave con morbilidad alta. Las lesiones traumáticas pancreáticas contusas en niños se pueden tratar de forma quirúrgica o no quirúrgica. Para el traumatismo pancreático contuso menos grave, grado I y II, generalmente se emplea un enfoque no quirúrgico o conservador. Actualmente, no está claro el tratamiento óptimo de la lesión pancreática contusa grave de grado III o V en niños; entre realizar un tratamiento no quirúrgico o quirúrgico.
Objetivos
Evaluar los efectos beneficiosos y perjudiciales del tratamiento no quirúrgico versus quirúrgico del traumatismo pancreático contuso en niños.
Métodos de búsqueda
Se realizaron búsquedas en el registro especializado del Grupo Cochrane de Lesiones (Cochrane Injuries Group), el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, número 5, 2013), MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI‐EXPANDED y CPCI‐S) y ZETOC. Además, se realizaron búsquedas en las bibliografías de los artículos pertinentes, resúmenes de actas de conferencias y registros de ensayos clínicos. La búsqueda se realizó el 21 de junio de 2013.
Criterios de selección
Se seleccionaron todos los ensayos clínicos aleatorios que investigaron el tratamiento no quirúrgico versus quirúrgico del traumatismo pancreático contuso en niños, independientemente del cegamiento, el estado de publicación o el idioma.
Obtención y análisis de los datos
Se utilizaron estrategias de búsqueda relevantes para obtener los títulos y resúmenes de los estudios que fueron pertinentes para la revisión. Dos autores de la revisión evaluaron la elegibilidad de los ensayos de forma independiente.
Resultados principales
La búsqueda encontró 83 referencias relevantes. Se excluyeron todas las referencias y no se encontraron ensayos clínicos controlados aleatorios que investigaran el tratamiento del traumatismo pancreático contuso en niños.
Conclusiones de los autores
Esta revisión muestra que las estrategias con respecto al tratamiento no quirúrgico versus quirúrgico del traumatismo pancreático contuso grave en niños no se basan en ensayos clínicos aleatorios. Se recomiendan ensayos multicéntricos que evalúen el tratamiento no quirúrgico versus quirúrgico del traumatismo pancreático pediátrico para establecer pruebas firmes en este campo de la medicina.
PICOs
Resumen en términos sencillos
Tratamiento de las lesiones pancreáticas contusas graves en niños
Antecedentes
El tratamiento óptimo del traumatismo pancreático contuso grave en niños se ha debatido por mucho tiempo, algunos médicos recomiendan la cirugía mientras que otros prefieren un enfoque conservador sin cirugía como tratamiento primario. Esta revisión sistemática se realizó para evaluar qué estrategia sería preferible. El traumatismo pancreático contuso habitualmente ocurre después de accidentes que incluyen el manubrio de la bicicleta, accidentes de tránsito u otros tipos de lesiones que causan un golpe en el abdomen superior.
Características de los estudios
Se efectuaron búsquedas en las bases de datos médicas de ensayos clínicos aleatorios (en los que dos grupos de niños se asignaron al azar a tratamiento o a ningún tratamiento) de niños tratados por traumatismo pancreático contuso mediante cirugía o ninguna cirugía. Los niños tenían 17 años de edad o menos. La búsqueda se actualizó hasta junio de 2013.
Resultados clave
No se encontraron ensayos clínicos aleatorios que investigaran el tratamiento quirúrgico en comparación con el tratamiento no quirúrgico de la lesión pancreática grave en niños, por lo tanto, no existen pruebas firmes para apoyar el tratamiento no quirúrgico o quirúrgico de las lesiones pancreáticas graves en niños. Aunque es difícil debido a la poca frecuencia y a la naturaleza aguda de estas lesiones, se recomienda realizar ensayos clínicos aleatorios multicéntricos de buena calidad.
Authors' conclusions
Background
Description of the condition
Pancreatic trauma in children is a serious condition that is associated with high morbidity (Kao 2003). Pancreatic pseudocyst formation, pancreatitis and pancreatic fistula formation are common complications of pancreatic trauma, and 19% to 55% of people experience pancreas‐related complications after pancreatic trauma (Wales 2001; Stringer 2005; Haugaard 2012). Furthermore, morbidity, including pneumonia and pleural fluid collections, frequently occurs in people with traumatic lesions of the pancreas (Haugaard 2012). Mortality in people with pancreatic trauma is estimated to be 3% to 8% (Bosboom 2006; Haugaard 2012). Isolated pancreatic trauma is seldom lethal, but pancreatic trauma in children can be life threatening in association with other organ injuries, cranial injuries or injuries of major blood vessels in the peripancreatic area (Kao 2003).
Trauma of the pancreas is divided into blunt and penetrating injuries. Blunt pancreatic trauma is by far the most common type of trauma mechanism in children, and it is typically seen after crashes involving a bicycle handlebar, road traffic crashes or other types of crashes that cause a blow to the upper abdomen (de Blaauw 2008). Penetrating injuries of the pancreas are much more seldom in children, and may be a result of gunshot or stabbing injuries (Akhrass 1997).
Pancreatic trauma is the fourth most common type of internal organ trauma in children. It has been reported to occur in 3% to 12% of blunt injuries and in 1.1% of penetrating injuries in children (Juric 2009). Pancreatic injury is normally graded in five categories according to the organ injury scale of the American Association for the Surgery of Trauma (AAST), with pancreatic duct status being the most important factor (Moore 1990). These categories are summarised in Table 1.
| Grade | Injury | Description |
| I | Haematoma | Minor contusion without duct injury |
|
| Laceration | Superficial laceration without duct injury |
| II | Haematoma | Major contusion without duct injury or tissue loss |
|
| Laceration | Major laceration without duct injury or tissue loss |
| III | Laceration | Distal transection or parenchymal injury with duct injury |
| IV | Laceration | Proximal transection or parenchymal injury involving ampulla |
| V | Laceration | Massive disruption of pancreatic head |
Diagnosing pancreatic trauma is difficult. The abdominal symptoms such as pain, nausea and vomiting are often unspecific, and are not correlated to the seriousness of the trauma (Bosboom 2006; Haugaard 2012). Serum amylase is increased in 55% to 91% of people with pancreatic lesions (Bass 1988; Graham 2000). Typically, serum amylase raises 2 to 12 hours after injury, and is elevated for up to two to five days after injury (Bass 1988). Grade III to IV pancreatic lesions have a higher initial and maximum amylase value when compared with grade I to II lesions (Haugaard 2012). Elevation of amylase beyond 10 to 30 days after trauma is associated with an increased risk of pseudocyst formation (Bass 1988; Bosboom 2006).
Radiological investigations are important for the diagnosis of pancreatic trauma. Ultrasound examination is often performed in the emergency department and supplies information on free peritoneal fluid and co‐existing damage of other organs such as the liver and spleen (Bosboom 2006). Due to its retroperitoneal localisation, the pancreas is usually difficult to visualise with ultrasound. Computer tomography (CT) is used to detect pancreatic damage; however, it is not always possible to detect pancreatic lesions when CT is performed shortly after the accident. Therefore, CT might be repeated after 24 hours when suspicion of pancreatic lesions persist (Bosboom 2006; Haugaard 2012). Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are considered valuable diagnostic tools for detecting pancreatic duct lesions (Hall 1986). MRCP is non‐invasive, while ERCP is invasive and may cause iatrogenic pancreatitis (Bosboom 2006; Haugaard 2012). ERCP gives the possibility of immediate intervention of the pancreatic duct lesion by inserting a stent (Bosboom 2006; Houben 2007).
Description of the intervention
Pancreatic trauma in children can be treated non‐operatively or operatively (Paul 2011; Penninga 2011). The non‐operative approach often consists of close monitoring of the child's clinical condition; repeated radiological investigations such as CT, ultrasound and MRCP; monitoring of the child's amylase and lipase levels and, optionally, parenteral nutrition (Haugaard 2012). In addition, ERCP with placement of a stent in the damaged pancreatic duct is used in some centres as part of the non‐operative approach (Bosboom 2006; Houben 2007). Experience with placement of a stent using ERCP is very limited, and only described in very few cases (Houben 2007; Canty 2001). In adults a fracture of the pancreas involving the pancreatic duct or the common bile duct can be treated with a papillotomy in some cases (Jaik 2008).
Ultrasound‐guided drainage of abdominal and peripancreatic fluid collections, and pancreatic pseudocysts, is frequently applied (Bass 1988; Wales 2001).
The operative approach to pancreatic trauma can consist of laparotomy with drainage of the peripancreatic area, distal pancreatectomy with or without preservation of the spleen, Roux‐en‐Y pancreaticojejunostomy, and, more seldom, pancreaticoduodenectomy (Whipple's procedure). The type of operation depends on the grade and localisation of the pancreatic lesion (Meier 2001). Spleen‐preserving surgery should be attempted to avoid the lifelong increased risk of infections after splenectomy (Kertai 2010). In case of trauma where multiple organs are involved and an acute laparotomy is performed, the damage control resuscitation concept must be applied and the pancreatic resection done as part of a staged surgery in a center with extensive hepato‐pancreato‐biliary (HPB) experience (Seamon 2009; Sutton 2006).
Grade I and II blunt pancreatic injuries in children are treated non‐operatively. The optimal treatment of blunt AAST grade III and IV injuries is unclear (Mattix 2007). There might be a trend towards non‐operative treatment of blunt severe paediatric pancreatic lesions (de Blaauw 2008). In adults, blunt grade III and IV pancreatic injuries are generally treated operatively. However, in adults the preference for operative treatment is not based on randomised trials.
Differences in morbidity and hospital stay between operative and non‐operative treatment have been reported for children with blunt pancreatic lesions (Meier 2001; Wales 2001; Haugaard 2012). Patients who initially are treated non‐operatively might require an operation when the clinical condition of the patient worsens (Stringer 2005). When worsening of the clinical condition of the patient occurs, it is frequently due to infection or sepsis (Stringer 2005). It is currently unclear what consequences the delay of surgery has in patients where initially a non‐operative approach has been chosen, but who eventually receive an operation due to worsening of the condition (Vane 2009). It has been suggested that surgery is technically more difficult in patients who initially have been treated non‐operatively due to intraabdominal adhesions and leakage of pancreatic enzymes in the surgical field (Meier 2001).
Why it is important to do this review
Pancreatic trauma in children is a serious condition. Currently, the optimal treatment of serious paediatric pancreatic injury (AAST grade III to V) is unclear (Penninga 2011). A Cochrane review is warranted to summarise the available evidence and the benefits and harms of non‐operative versus operative treatment in children with serious blunt (AAST grade III to V) pancreatic injury. We have not been able to identify any existing systematic reviews evaluating the benefits and harms of non‐operative versus operative treatment for serious pancreatic trauma in children or adults.
Objectives
To assess the benefits and harms of operative versus non‐operative treatment of blunt pancreatic trauma in children.
Methods
Criteria for considering studies for this review
Types of studies
We planned to include randomised clinical trials, irrespective of blinding, language and publication status.
Types of participants
Children with blunt pancreatic trauma grade I to V, who were 17 years of age or younger.
Types of interventions
Operative treatment versus non‐operative interventions or no intervention for pancreatic trauma.
Types of outcome measures
All outcome measures were planned to be assessed at final follow‐up.
Primary outcomes
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Mortality.
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Pancreatic complications (pancreatic pseudocysts, fistulas, pancreatitis, abscesses).
Secondary outcomes
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Other complications (infections, wound problems).
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Diabetes mellitus.
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Other adverse events. Serious complications/adverse events were defined as any untoward medical occurrence that was life threatening; resulted in death, or persistent or significant disability; or any medical event that might have jeopardised the child, or required further intervention to prevent harm (ICH‐GCP 1996).
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Hospital length of stay among children who survived until hospital discharge.
Search methods for identification of studies
We placed no restrictions on date, language or publication status.
Electronic searches
The Cochrane Injuries Group Trials Search Co‐ordinator searched the following:
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Cochrane Injuries Group Specialised Register (21 June 2013);
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Cochrane Central Register of Controlled Trials (CENTRAL, Issue 5 of 12, 2013);
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MEDLINE (OvidSP) (1946 to June week 2 2013);
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Embase (OvidSP) (1974 to 20 June 2013);
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ISI Web of Science: Science Citation Index Expanded (SCI‐EXPANDED) (1970 to June 2013);
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ISI Web of Science: Conference Proceedings Citation Index‐Science (CPCI‐S) (1990 to June 2013);
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ZETOC (1993 to June 2013).
Searching other resources
We searched bibliographies of relevant articles. We searched relevant conference proceeding abstracts and the following online trials registers through 5 December 2013:
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Current Controlled Trials (www.controlled‐trials.com);
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Clinicaltrials.gov (www.clinicaltrials.gov);
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The World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp).
Data collection and analysis
The Injuries Group's Trials Search Co‐ordinator performed the electronic database searches. She collated results using bibliographic software and then forwarded titles and abstracts to the review authors for screening. The review authors carried out searches of all other resources.
Selection of studies
Two review authors (MH and LP) independently assessed the search results for study eligibility. We obtained full‐text copies of all studies that met the inclusion criteria. We listed studies that were subsequently excluded in the review with the reason for exclusion (Characteristics of excluded studies). We solved disagreements by discussion or in consultation with a third review author (CG). We had planned to contact the authors of the trials if information about methodology or data was unclear or missing.
Data extraction and management
Two review authors (MH and LP) planned to independently extract data using standard data extraction forms (Moher 2009; Higgins 2011). We were to translate studies reported in non‐English language journals before assessment. Where multiple publications from one study existed, we planned to group reports together and mark the publication with the most complete data as the primary reference. Where relevant outcomes were published in other reports, we planned to use these data. We would have resolved disagreements by consultation with all authors. From each trial, we were to extract the following information: first author, country of origin, study design, inclusion and exclusion criteria, number of participants, participant characteristics, injury severity, single‐ or multi‐organ trauma, number of children treated operatively, number of children treated non‐operatively, the intervention administered in the two treatment groups (e.g. type of operation, type of non‐operative intervention), follow‐up period, primary and secondary outcomes, adverse events and participants lost for follow‐up. If information was not available in the published trial, we intended to contact authors of the publications in order to assess the trials correctly. We planned to use 'Summary of findings' tables in which the primary outcome measures would be assessed.
Assessment of risk of bias in included studies
The design and reporting of a randomised clinical trial will restrict bias in the comparison of the intervention with the control (Moher 1998; Gluud 2006). According to empirical evidence (Schulz 1995; Moher 1998; Kjaergard 2001; Wood 2008), we intended to assess the risk of bias in the included trials according to the following criteria:
Sequence generation
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Low risk of bias: sequence generation was achieved using computer random number generation or a random number table. Drawing lots, tossing a coin, shuffling cards and throwing dice are adequate if performed by an independent adjudicator.
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Uncertain risk of bias: the trial was described as randomised, but the method of sequence generation was not specified.
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High risk of bias: the sequence generation method was not, or may not be, random.
Allocation concealment
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Low risk of bias: allocation was controlled by a central and independent randomisation unit, sequentially numbered, opaque and sealed envelopes or similar, so that intervention allocations could not have been foreseen in advance of, or during, enrolment.
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Uncertain risk of bias: the trial was described as randomised but the method used to conceal the allocation was not described, so that intervention allocations may have been foreseen in advance of, or during, enrolment.
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High risk of bias: if the allocation sequence was known to the investigators who assigned participants.
Blinding of participants and personnel
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Low risk of bias: the trial was described as blinded for participants and personnel, and the method of blinding was described, so that knowledge of allocation was adequately prevented during the trial.
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Uncertain risk of bias: the trial was described as blind for participants and personnel, but the method of blinding was not described.
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High risk of bias, the trial was not blinded for participants and personnel, and so group allocation was known during the trial.
Blinding of outcome assessment
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Low risk of bias: the trial was described as blinded for outcome assessors from knowledge of which intervention a participant received, and the method of blinding was described, so that knowledge of allocation was adequately prevented during the trial.
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Uncertain risk of bias: the trial was described as blinded for outcome assessors, but the method of blinding was not described.
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High risk of bias, the trial was not blinded for outcome assessors, and so group allocation was known during the trial.
Incomplete outcome data
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Low risk of bias: the numbers and reasons for dropouts and withdrawals in all intervention groups were described, or it was specified that there were no dropouts or withdrawals.
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Uncertain risk of bias: the report gave the impression that there had been no dropouts or withdrawals, but the number and reasons were not specifically stated.
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High risk of bias: the number and reasons for dropouts and withdrawals were not described.
Selective outcome reporting
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Low risk of bias: predefined, or clinically relevant and reasonably expected outcomes were reported on.
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Uncertain risk of bias: not all predefined, or clinically relevant and reasonably expected outcomes were reported on or were not reported fully, or it is unclear whether data on these outcomes were recorded or not.
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High risk of bias: one or more predefined, clinically relevant, or other reasonably expected outcomes were not reported; data on these outcomes were likely to have been collected.
Other biases
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Low risk of bias (the trial appeared to be free of other sources of bias; e.g. conflict of interest bias).
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Uncertain risk of bias (there was insufficient information to assess whether other sources of bias were present).
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High risk of bias (it is likely that potential sources of bias were related to specific design used, or other bias risks are present).
Review authors' judgements were planned to be based on the definitions of the above listed domains.
Measures of treatment effect
For dichotomous outcomes, results were planned to be expressed as risk ratios (RR) with 95% confidence intervals (CI). Where continuous scales of measurement were used to assess the outcomes of treatment, we planned to use the mean difference (MD) or the standardised mean difference (SMD) if different scales were used (Thompson 2002).
Dealing with missing data
We intended to handle missing data as follows:
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contact the investigators to request missing data;
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perform sensitivity analyses to assess how sensitive our results are to reasonable changes in the assumptions that were made;
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for incomplete data, to perform 'worst‐worst' case scenario analyses, 'best‐best' case scenario analyses, 'worst‐best' case scenario analyses, and 'best‐worst' case scenario analyses.
Assessment of heterogeneity
We planned to assess heterogeneity using a Chi2 test on N‐1 degrees of freedom, with an alpha of 0.05 used for statistical significance, and with the I2 test (Higgins 2003).
Assessment of reporting biases
We planned to use a funnel plot to explore bias, if there were at least 10 studies included in an analysis (Egger 1997; Macaskill 2001). Asymmetry in the funnel plot was to be used to assess this collective form of bias. We planned to perform linear regression to determine the funnel plot asymmetry (Egger 1997), if we had a minimum number of 10 trials.
Data synthesis
We planned to pool the data using both the random‐effects and the fixed‐effect models to ensure robustness of the result. In case of significant differences of the results from the two models, we planned to provide both results. If the difference in the results was not significant, then we planned to present the results using the random‐effects model (Higgins 2002), as heterogeneity might be expected between studies due to differences in preferred operation type, availability of non‐operative procedures and type of surgeons performing the operations.
Subgroup analysis and investigation of heterogeneity
We planned subgroup analyses for the:
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type of operation performed;
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type of non‐operative intervention performed;
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grade of pancreatic lesion.
We planned to perform a test of interaction to evaluate the differences between the estimates, using the method described in Section 9.6.3 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).
Sensitivity analysis
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Trials with low risk of bias in the domain allocation concealment compared with trials with allocation concealment at high risk of bias;
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to assess how sensitive our results are to reasonable changes in the assumptions that were made, as described in the Dealing with missing data section.
Trial sequential analysis
We planned to apply trial sequential analysis as cumulative meta‐analyses are at risk of producing random errors because of sparse data, and repetitive testing on accumulating data (Wetterslev 2008; Wetterslev 2009). To minimise random errors, we intended to calculate the required information size (i.e. the number of participants needed in a meta‐analysis to detect or reject a certain intervention effect) (Wetterslev 2008). Information size calculation should also account for the diversity present in the meta‐analysis. In our meta‐analysis, we planned information size to be based on the assumption of a plausible relative risk reduction of 20% or on the relative risk reduction observed in the included trials with low risk of bias (Wetterslev 2008). The underlying assumption of trial sequential analysis is that significance testing may be performed each time a new trial is added to the meta‐analysis. We planned to add the trials according to the year of publication and, if more than one trial was published in a year, we planned to add trials alphabetically according to the last name of the first author (TSA manual 2011). On the basis of the outcome proportion in the control group and the mentioned RRs, the risk for type I (5%) and type II (20%) errors, and the diversity, the required information size, and the trial sequential monitoring boundaries were planned to be constructed (Wetterslev 2008). These boundaries should determine the statistical inference one may draw regarding the cumulative meta‐analysis that has not reached the required information size. If a trial sequential monitoring boundary is crossed before the required information size is reached in a cumulative meta‐analysis, firm evidence may have been established and further trials may be superfluous. In contrast, if the boundaries are not surpassed, it is most probably necessary to continue doing trials in order to detect or reject a certain intervention effect. We had planned to use as default a type I error of 5%, type II error of 20%, and to adjust information size for diversity unless otherwise stated (Wetterslev 2008; Wetterslev 2009). We planned to perform analyses using trial sequential analysis software (TSA manual 2011).
Results
Description of studies
Results of the search
The search identified 442 references (Figure 1). After removal of duplicates, 396 references remained. After removal of 313 irrelevant references based on the title or abstract, or both, we retrieved the full‐text of 83 articles reporting on paediatric pancreatic trauma. We decided to study all these 83 articles and their reference lists to get a complete overview of the topic, even though the title or abstract of the articles already reported that the type of study was not a randomised clinical trial. After reading all 83 articles, we excluded them all as there were no randomised clinical trials.
Study flow diagram.
Included studies
We found no randomised clinical trials comparing non‐operative versus operative treatment in children with pancreatic trauma.
Excluded studies
We excluded all retrieved trials, as they were not randomised, or not relevant to the topic of this review.
Risk of bias in included studies
We included no trials in this review.
Effects of interventions
We included no trials in this review.
Discussion
Summary of main results
There is currently no consensus whether blunt pancreatic lesions in children should be treated operatively or non‐operatively. There is generally consensus that mild blunt pancreatic trauma without lesion of the pancreatic duct (grade I to II) should be treated non‐operatively (Haugaard 2012). In contrast, treatment of severe blunt pancreatic trauma with lesion of the pancreatic duct (grade III to V) is controversial, and treatment can either be non‐operative or operative.
Quality of the evidence
We found no published or pending randomised clinical trials that compared non‐operative versus operative treatment of pancreatic trauma in children for inclusion in this review. Therefore, all available evidence is based on non‐randomised studies.
We detected a number of non‐randomised studies during the search that reported on non‐operative and operative treatment in children with pancreatic lesions. Most of the studies were retrospective case series. We have summarised the results of these including complications seen in the different studies associated with both non‐operative and operative treatment (Table 2; Table 3; Table 4).
| Primary author | Year, country | Number of children (n), grade | Treatment | Mortality | Pancreas‐related complications | Other complications | Success of NOM |
| 2009, Croatia | 7, grade I‐II | NOM | 0% | 43% (Grade ll, pseudocysts) | 43% (2 sepsis, 1 pleural effusion) | 100% |
NOM: non‐operative management; OM: operative management.
'Success of NOM' was defined as primary NOM where no secondary surgery was needed.
| Primary author | Year, country | Number of children (n), grade | Treatment | Mortality | Pancreas‐related complications | Other complications | Success of NOM |
| 2001, USA | 18, grade III‐IV | 9 OM vs. 7 NOM, 2 deaths | 11% (severe head trauma) | OM 0% NOM 100% | ‐ | 29% | |
| 1997, USA | 154, grade I‐V | Grade I‐II: 26 OM vs. 97 NOM Grade III‐V: 16 OM vs. 15 NOM | 8% | Grade I‐II: 10% Grade III‐V: 32% | ‐ | ‐ | |
| 2001, Canada | 9, grade III‐V | 9 NOM | 0% | 44% | 33% (subphrenical abscess, sepsis occurred twice) | 100% |
'‐' indicates that it was not possible to extract data from the given study.
NOM: non‐operative management; OM: operative management; TPN: total parenteral nutrition.
'Success of NOM' was defined as primary NOM where no secondary surgery was needed.
| Primary author | Year, country | Number of children (n), grade | Treatment | Mortality | Pancreas‐related complications | Other complications | Success of NOM |
| 2010, USA | 44, grade I‐IV | 14 OM vs. 29 NOM, 1 death | 4% (multi‐trauma) | OM 21% vs. NOM 73% | OM 57% vs. NOM 20% | ‐ | |
| 2001, Italy | 9 | 2 OM vs. 7 NOM | 0% | OM 50% vs. NOM 71% | ‐ | 86% | |
| 1991, South Africa | 40 | 8 OM vs. 32 NOM | 0% | NOM 38% | OM 13% (respiratory stop, abscess) | 100% | |
| 1988, Canada | 26 | 11 OM vs. 15 NOM | 0% | OM 18% vs. NOM 53% | ‐ | 93% | |
| 2008, The Netherlands | 34, grade I‐IV | 3 OM vs. 31 NOM | 0% | OM 66% vs. NOM 45% | NOM 13% (sepsis) | 90% | |
| 1999, USA | 12, grade I‐V | 7 OM vs. 5 NOM | 17% (multi‐organ injury) | 42% | ‐ | ‐ | |
| 1987, Canada | 21 | 8 OM vs. 13 NOM | 10% (aorta laceration, head trauma) | OM 25% vs. NOM 77% | ‐ | 77% | |
| 2000, Scotland | 16 | 1 OM vs. 15 NOM | 0% | NOM 67% | ‐ | 80% | |
| 1999, Australia | 14 | 14 NOM | 0% | NOM 57% | ‐ | 79% | |
| 1999, USA | 51 | 27 OM vs. 24 NOM | ‐ | ‐ | ‐ | 79% | |
| 1999, Japan | 20 | 1 OM vs. 19 NOM | 5% (acidosis after TPN) | NOM 50% | ‐ | 84% | |
| 2007, USA | 173, grade I‐V | 43 OM vs. 130 NOM | ‐ | ‐ | ‐ | 74% | |
| 1998, Canada | 28, grade I‐V | 28 NOM | 0% | 36% | 4% (pelvic abscess) | 100% | |
| 2005, UK | 9, grade I‐IV | 1 OM vs. 8 NOM | 0% | OM 0% vs. NOM 100% | OM 100% (sepsis) | 38% | |
| 1996, Japan | 8 | 1 OM vs. 7 NOM | 0% | OM 100% vs. NOM 14.3% | ‐ | 100% |
'‐' indicates that it was not possible to extract data from the given study.
NOM: non‐operative management; OM: operative management; TPN: total parenteral nutrition.
'Success of NOM' was defined as primary NOM where no secondary surgery was needed.
Proponents of operative surgical intervention argue that it reduces the risk of secondary complications, especially the formation of pancreatic pseudocysts and that delay in surgical intervention leads to greater morbidity (Smith 1988; McGahren 1995; Meier 2001; Snajdauf 2007). Operative treatment can either be explorative laparotomy with drainage or more extensive surgery. If the distal part of the pancreatic duct is damaged, some surgeons advocate a spleen‐sparing distal pancreatectomy (Jobst 1999; Kolar 2005). A spleen‐removing distal pancreatectomy is performed in adults, but is avoided in children because of the increased risk of infections (Kertai 2010). In trauma involving the proximal pancreatic duct or the pancreatic head (or both), a Roux‐en‐Y pancreaticojejunostomy with preservation of the pancreatic tail is performed (Stringer 2005). If both the pancreatic head and duodenum are severely damaged, a radical pancreaticoduodenectomy, Whipple's operation, can be performed (Meier 2001).
In contrast, other doctors propose a non‐operative approach, arguing to avoid surgery if possible and instead observe the patient closely, and to only perform an operation if the patient's clinical condition deteriorates or the patient shows signs of haemodynamic instability (Kouchi 1999). As a part of the non‐operative treatment, some centres keep the patient fasting, use total parenteral nutrition (TPN) and place a nasogastric tube with suction to alleviate pain and nausea (Alanen 2000). Moreover, these doctors argue that complications seen with non‐operative treatment, such as formation of pancreatic pseudocysts, often are treated successfully by non‐surgical treatment options such as ultrasound‐guided percutaneous external drainage (PED) (Haller 1994; Shilyansky 1998; Lucaya 1998; Holland 1999; Wales 2001), or endoscopic ultrasound‐guided drainage (EUS). Other studies recommend the insertion of a stent by ERCP in cases where the pancreatic duct is completely or partially lacerated thereby avoiding open surgical intervention (Rescorla 1995; Canty 2001). Experience with this procedure is limited, and there might be an increased risk of developing strictures of the pancreatic duct, besides the fact that the child has to undergo general anaesthesia (de Blaauw 2008).
The non‐randomised studies showed that mortality in children with blunt isolated pancreatic trauma is rare. When mortality occurs, it is associated with other complications such as multi‐organ injury, injury of large blood vessels, severe head trauma and sepsis. Pancreas‐related morbidity, especially formation of pancreatic pseudocysts, in patients treated non‐operatively might be higher than in patients treated operatively. In contrast, morbidity outside the pancreas, such as sepsis, pleural effusion and formation of non‐pancreatic abscesses, might be lower when undergoing non‐operative treatment compared with operative treatment (Haugaard 2012). Long‐term complications after both operative and non‐operative treatment occur seldomly, and chronic endocrine and exocrine dysfunction is rarely seen, even in patients with severe pancreatic lesions (Wales 2001).
Penetrating pancreatic lesions are predominantly caused by gunshot wounds, and are associated with a high risk of multiple organ damage and injury of the large blood vessels in the abdominal and thoracic region. Therefore, all penetrating pancreatic lesions are generally treated surgically by an exploratory laparotomy (Firstenberg 1999). However, penetrating pancreatic lesions are not the focus of this review, and consensus exists that penetrating pancreatic lesions are treated surgically.
Operative treatment in all patients with pancreatic trauma is generally indicated if the patient's clinical status worsens, shows signs of peritoneal irritation or becomes haemodynamically unstable.
Traumatic pancreatic lesions in children are rare, and the acute nature of the condition makes it difficult to conduct large randomised trials in this field of medicine. This review found no randomised trials despite searching all relevant databases. This makes it impossible to conclude anything definitive about whether operative or non‐operative treatment should be applied in children with severe blunt pancreatic lesions (grade III to V), because such a conclusion would be associated with high risk of bias.
| Grade | Injury | Description |
| I | Haematoma | Minor contusion without duct injury |
|
| Laceration | Superficial laceration without duct injury |
| II | Haematoma | Major contusion without duct injury or tissue loss |
|
| Laceration | Major laceration without duct injury or tissue loss |
| III | Laceration | Distal transection or parenchymal injury with duct injury |
| IV | Laceration | Proximal transection or parenchymal injury involving ampulla |
| V | Laceration | Massive disruption of pancreatic head |
| Primary author | Year, country | Number of children (n), grade | Treatment | Mortality | Pancreas‐related complications | Other complications | Success of NOM |
| 2009, Croatia | 7, grade I‐II | NOM | 0% | 43% (Grade ll, pseudocysts) | 43% (2 sepsis, 1 pleural effusion) | 100% | |
| NOM: non‐operative management; OM: operative management. 'Success of NOM' was defined as primary NOM where no secondary surgery was needed. | |||||||
| Primary author | Year, country | Number of children (n), grade | Treatment | Mortality | Pancreas‐related complications | Other complications | Success of NOM |
| 2001, USA | 18, grade III‐IV | 9 OM vs. 7 NOM, 2 deaths | 11% (severe head trauma) | OM 0% NOM 100% | ‐ | 29% | |
| 1997, USA | 154, grade I‐V | Grade I‐II: 26 OM vs. 97 NOM Grade III‐V: 16 OM vs. 15 NOM | 8% | Grade I‐II: 10% Grade III‐V: 32% | ‐ | ‐ | |
| 2001, Canada | 9, grade III‐V | 9 NOM | 0% | 44% | 33% (subphrenical abscess, sepsis occurred twice) | 100% | |
| '‐' indicates that it was not possible to extract data from the given study. NOM: non‐operative management; OM: operative management; TPN: total parenteral nutrition. 'Success of NOM' was defined as primary NOM where no secondary surgery was needed. | |||||||
| Primary author | Year, country | Number of children (n), grade | Treatment | Mortality | Pancreas‐related complications | Other complications | Success of NOM |
| 2010, USA | 44, grade I‐IV | 14 OM vs. 29 NOM, 1 death | 4% (multi‐trauma) | OM 21% vs. NOM 73% | OM 57% vs. NOM 20% | ‐ | |
| 2001, Italy | 9 | 2 OM vs. 7 NOM | 0% | OM 50% vs. NOM 71% | ‐ | 86% | |
| 1991, South Africa | 40 | 8 OM vs. 32 NOM | 0% | NOM 38% | OM 13% (respiratory stop, abscess) | 100% | |
| 1988, Canada | 26 | 11 OM vs. 15 NOM | 0% | OM 18% vs. NOM 53% | ‐ | 93% | |
| 2008, The Netherlands | 34, grade I‐IV | 3 OM vs. 31 NOM | 0% | OM 66% vs. NOM 45% | NOM 13% (sepsis) | 90% | |
| 1999, USA | 12, grade I‐V | 7 OM vs. 5 NOM | 17% (multi‐organ injury) | 42% | ‐ | ‐ | |
| 1987, Canada | 21 | 8 OM vs. 13 NOM | 10% (aorta laceration, head trauma) | OM 25% vs. NOM 77% | ‐ | 77% | |
| 2000, Scotland | 16 | 1 OM vs. 15 NOM | 0% | NOM 67% | ‐ | 80% | |
| 1999, Australia | 14 | 14 NOM | 0% | NOM 57% | ‐ | 79% | |
| 1999, USA | 51 | 27 OM vs. 24 NOM | ‐ | ‐ | ‐ | 79% | |
| 1999, Japan | 20 | 1 OM vs. 19 NOM | 5% (acidosis after TPN) | NOM 50% | ‐ | 84% | |
| 2007, USA | 173, grade I‐V | 43 OM vs. 130 NOM | ‐ | ‐ | ‐ | 74% | |
| 1998, Canada | 28, grade I‐V | 28 NOM | 0% | 36% | 4% (pelvic abscess) | 100% | |
| 2005, UK | 9, grade I‐IV | 1 OM vs. 8 NOM | 0% | OM 0% vs. NOM 100% | OM 100% (sepsis) | 38% | |
| 1996, Japan | 8 | 1 OM vs. 7 NOM | 0% | OM 100% vs. NOM 14.3% | ‐ | 100% | |
| '‐' indicates that it was not possible to extract data from the given study. NOM: non‐operative management; OM: operative management; TPN: total parenteral nutrition. 'Success of NOM' was defined as primary NOM where no secondary surgery was needed. | |||||||
