Surgical management of acute pancreatic injuries in children

Abstract

This study was undertaken to review traumatic injuries of the pancreas in children. Fifty-one children from 2 to 16 yr of age underwent 52 operations for pancreatic injuries over a 37-yr period at Jefferson Davis Hospital, Ben Taub General Hospital, and Methodist Hospital in Houston. Nineteen sustained penetrating injuries, and 32 received blunt trauma. Twenty-one of the children with blunt trauma and none of those with penetrating injuries had elevated serum amylase concentrations on admission. Forty-seven patients were operated on acutely, and 1 patient was operated on 10 days following injury. Four patients were operated on for complications of pancreatic injury following previous laparotomy. Immediately following injury 19 children were found to have through-and-through perforation or laceration, 21 were found to have pancreatic contusion, and 11 were found to have complete transection of the pancreas. Findings at operation for complications of pancreatic injury included three pseudocysts and one pancreatic fistula with complete transection of the pancreas. One hundred and fifty-one associated injuries, including 16 vascular injuries, were found; they ranged from 1 to 10 per patient. Seven operative procedures were employed. In 32 children external drainage only was performed; pancreatorrhaphy and external drainage were performed in 6 children; distal pancreatectomy was used in 7 children following complete pancreatic transection. Two patients, one with postoperative fistula formation with transection of the pancreas, required distal pancreatojejunostomy and oversewing of the proximal pancreatic stump. Two patients with severe duodenal injury and transection of the head of the pancreas underwent Whipple procedures. Two patients with pseudocysts had cystogastrostomies, and 1 patient had external drainage. Operative deaths occurred in 4 children and were the result of complications unrelated specifically to pancreatic injury. Fourteen patients developed complications of pancreatic injury: 11 pancreatic fistulas and 3 pseudocysts. Surgical indications, operative technique, and complications are presented in detail. The management of pancreatic injuries in children begins with diagnosis. All patients sustaining penetrating abdominal injuries should be explored, and those with blunt trauma should be evaluated on physical findings, with peritoneal lavage and determinations of serum amylase concentration serving as supportive evidence. The presence of a pancreatic injury always warrants external drainage, preferably with soft Penrose drains. Salvage of the distal gland following transection is preferred if the patient's condition permits, if the spleen is intact, and if the distal gland is not in need of debridgement. Pancreatic fistula is the most common complication of pancreatic trauma, but it rarely presents a management problem and usually is closed by the second postoperative week.