Background: Management of high-grade pancreatic injures in children remains controversial. As in adults, AAST grades I and II injuries are generally managed nonoperatively and the very rare grade IV and V injuries that involve the pancreatic head are managed on an individual basis. Grade III injuries, involving pancreatic duct transection within the pancreatic body, are commonly seen in children due to handlebar trauma. These are universally managed with distal pancreatectomy in adults; however, some pediatric surgeons prefer to manage them non-operatively. There have been multiple retrospective studies comparing outcomes between operative management (OM) and non-operative management (NOM), with mixed results. We performed a systematic review to determine whether the current literature supports one management strategy over the other. Methods: A systematic review of all published English literature was performed. Meta-analysis was performed for fistula and pseudocyst formation as these were the only outcomes for which complete data was attainable. Other outcomes studied were: days on total parenteral nutrition (TPN), days to full enteral feeds, and hospital length of stay (LOS). Results: Twenty-five multicenter studies were included. Of 1014 pancreatic injuries, 732 (72.2%) were managed with NOM and 267 (26.3%) by OM. Given the heterogeneity of the data, metanalysis could only be performed for the outcomes of pseudocyst and fistula formation. Pseudocyst formation was higher following NOM than OM (pooled odds ratio 2.05, 95% CI 1.04 to 4.07; p<0.001), and fistula rates were similar among the groups (pooled odds ratio 0.60, 95% CI 0.18 to 2.01; p=0.3115). Metanalysis could not be performed on the other outcomes, and mixed results were demonstrated for every outcome. Conclusion: In children with high-grade pancreatic trauma, NOM leads to higher pseudocyst formation than OM, which is expected. While fistula rates are similar, there is not enough good quality evidence to make definite conclusions about other outcomes or to determine a superior management strategy. A prospective trial is needed to determine the best approach to managing these injuries.
Adesola C Akinkuotu, Fariha Sheikh, Wei Zhang, David E Wesson, Bindi Naik
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