Management of pancreatic and duodenal trauma in childhood: a university hospital experience over a 10-year period

Trauma is the most common pediatric mortality cause, with a rate of 49% [1]. Abdominal trauma is children’s second most common trauma site, following isolated head trauma [2, 3]. Duodenal and pancreatic injuries have been reported to occur in 2–12% of children suffering from abdominal injuries [4, 5]. Isolated duodenal and pancreatic injuries have been observed in approximately two-thirds of cases, while combined injuries in both organs have occurred in the remaining third [6]. The most common cause of pancreatic and duodenal injuries in pediatric patients worldwide has been reported as falling from a height [7]. On the contrary, in a 17-year clinical experience of pancreatic trauma published by Ravi Kumar Garg and Jai Kumar Mahajan in 2017, it was reported that the most common cause of pancreatic injury was bicycle handlebar injury [8]. Additionally, motor vehicle accidents, assaults (such as punches and kicks), falls from bicycles, collisions, child abuse, endoscopic biopsy procedures, foreign body ingestions, and penetrating traumas at an ever-increasing rate constitute other causes of pancreatic and duodenal trauma [9‐15].

Because pancreatic and duodenal injuries are rare traumas, the follow-up of these traumas is controversial in the literature. Pediatric pancreatic and duodenal injury management is mainly based on adult data, although there is a steadily growing body of research on this topic. Surgical intervention was not required in most pediatric patients admitted to the hospital with a history of blunt trauma [16]. Many pediatric centers have reported surgery rates of 1% or less; however, postoperative meticulous care and follow-up have become necessary in these patients to achieve a low mortality rate in patients requiring surgery [17, 18].

We aimed to retrospectively review our pediatric patients hospitalized for pancreatic and duodenal trauma regarding their diagnostic characteristics and therapeutic management to improve the outcomes of these rare and complex injuries.

Following approval of the Ethics Committee of Atatürk University Medical Faculty with decision # B.30.2.ATA.0.01.00/147, data from 31 patients admitted to Atatürk University, Faculty of Medicine, Department of Pediatric Surgery for pancreatic and/or duodenal trauma between 2010 and 2019 were retrospectively analyzed. Age, gender, province of origin, duration before admission to the hospital, type of trauma, injured organs, injury severity, diagnostic procedures, treatment modalities, complications, length of hospitalization, blood transfusion requirement, and mortality rate were recorded. Data acquisition and evaluation were performed on a computer using IBM SPSS Statistics software.

The epidemiology of pediatric pancreaticoduodenal trauma has not been well-studied. However, some data suggest that it accounts for less than 1% of all pediatric traumas and 2–12% of abdominal traumas in children [4, 5]. In our study, trauma was more prevalent in male patients. The fact that more than half of the cases were admitted from the province of our hospital may be because the relevant clinics manage lower-grade traumas deemed not to necessitate surgery in the neighboring provinces. While trauma-related admissions within the province occur more rapidly, transportation problems in the surrounding provinces might also have affected this situation. Lack of available trauma centers in the surrounding provinces to follow up multi-trauma, the inadequacy of intensive care units that can provide treatment in cases of need, the fact that specialist physicians working in the surrounding provinces have not seen sufficient cases of duodenal and pancreatic trauma in the institutions where they received training, and even if they have, the scarcity of the number of cases constitute the most important reasons for referral.

It is known that patients with Grade IV and V trauma are exposed to higher-energy traumas, and vital organ injuries are more prevalent in them. Disruptions in the transportation network and problems during patient transport are also associated with these traumas. For these reasons, patients with Grade IV and V pancreatic and/or duodenal traumas, the incidence of which is typically low, could not be followed up and treated in our clinic.

The most common cause of pancreatic and duodenal injuries in pediatric patients has been reported to be falling from a height [7], whereas, in our clinic, it was falling from a bicycle. While the bicycle handlebar was the cause of trauma in 28% of bicycle injuries worldwide, this rate was found to be almost half in our clinic. In our study, falling from a height was the fourth most common cause. Blunt trauma is the most common underlying mechanism of pediatric pancreatic and duodenal injuries [3]. In our clinic also, we observed that most pancreatic and duodenal injuries were due to blunt trauma. While the literature has reported that the coexistence rate of pancreatic and duodenal traumas is approximately 33.3% [6], this rate was low in our study.

In the study published by Adamson WT et al. in 2003, abdominal CT was performed in all trauma patients with an elevated amylase level, and pancreatic laceration was detected in 51% of their abdominal CTs [19]. In our study, 20 of 23 patients with pancreatic trauma had elevated serum amylase levels at initial hospital presentation. Even though Grade I pancreatic injury was encountered in two of eight duodenal trauma patients, amylase elevation was observed in six patients with duodenal trauma. When both of our results were analyzed, we concluded that although elevated serum amylase level is an essential marker for pancreatic trauma, it should be kept in mind that its elevation is also present in duodenal trauma cases.

The diagnosis rate of intestinal perforations developing after abdominal trauma using direct radiography was reported as 52% [20]. Due to the duodenum’s anatomical location, the diagnosis rate by direct radiography at the moment of admission in our clinic was low. This rate increased three-fold on the subsequent contrast-enhanced abdominal radiographs. While serial abdominal CT scans have been recommended to prevent diagnostic delay, we showed in our clinic that serial contrast-enhanced direct abdominal radiographs could also avoid diagnostic delay, and thus, patients were less exposed to radiation.

Regarding speed and radiation exposure, FAST is more advantageous than tomography. It can be performed at the bedside, even in unstable patients. In duodenal and pancreatic injuries, the evaluation of lesions by physicians with insufficient FAST experience raises concerns about the reliability of the FAST among physicians. As found worldwide and in our study, FAST has lower sensitivity and specificity than tomography in pancreatic and duodenal trauma [21].

The fact that abdominal CT is less invasive, more accessible, and more widely applicable than peritoneal lavage has narrowed the scope of diagnostic peritoneal lavage. The difficulty of laparoscopic surgical intervention after diagnostic laparoscopy of the duodenum and pancreas, which are located retroperitoneally and deeply, has prevented diagnostic laparoscopy from being a favored diagnostic method [22].

Englum et al. gathered data from trauma centers in the USA and showed that the proportion of conservative treatment for pancreatic injuries was 76.3% [3]. This percentage was 69.6% in our study, similar to Englum et al.’s result. Moreover, in our study, duodenal traumas were found to be diagnosed later than pancreatic traumas, whereas the mean discharge time of pancreatic trauma patients was longer than that of duodenal trauma patients. This was due to the conservative treatment being preferred to surgical treatment primarily for pancreatic trauma, the waiting time for intervention in pseudocyst developing later, and the fact that surgical indication margins were not as precise as in duodenal trauma.

Because of the anatomical neighborhood of the pancreas, a solid organ, and the duodenum, a luminal organ, the possibility of both organs being affected by a trauma to that region should always be considered. It is important to consider the possibility of duodenal injury when high amylase levels are detected after abdominal trauma. Duodenal injuries (perforation/hematoma) that are not visible on initial abdominal tomography can be detected with less radiation through contrast-enhanced abdominal radiography. Positive physical examination findings, persistent clinical symptoms accompanying radiologic evidence of perforation in duodenal trauma, and an intra-abdominal pancreatic pseudocyst in pancreatic trauma have been recognized as the most critical surgical indications regarding pancreaticoduodenal trauma. A high success rate of conservative treatment in pancreatic and/or duodenal trauma was associated with the absence of duodenal perforation and regression of clinical symptoms of pancreatic pseudocyst with supportive treatment.