About 75 – 85 % of children with pancreatic injuries receive non-surgical treatment, based on the grade of injury (6, 16, 21, 37). Almost all grade I injuries are treated conservatively without surgical interventions. As the grade of injury increases, reports vary regarding the success of conservative treatment, but conservative treatment is attempted and performed successfully at all injury grades.
Non-surgical treatment consists of close monitoring of the patient's vital signs, adequate pain relief and observation (21, 25, 31), and possibly treatment with total parenteral nutrition if the patient is unable to eat or must fast for other reasons. Initial monitoring of s-amylase and lipase levels, as well as repeated radiological examinations such as ultrasound, CT and MRCP, are performed as indicated.
ERCP involving insertion of a stent is regarded as a non-surgical treatment method (9, 20, 28, 35, 36), although this is an intervention which, among other things, is associated with an increased risk of pancreatitis. Stent treatment may reduce leakage of pancreatic secretions into the pancreatic cavity (in cases of pseudocyst or pancreatic fistula). Sequelae following ERCP may occur, e.g. strictures in the pancreatic duct, pancreatic fistula and fluid collection requiring drainage, and subsequent development of pseudocysts (20, 35). There are no relevant studies on whether somatostatin analogues (such as sandostatin) have a role in conservative treatment to reduce pancreatic secretions. These must therefore be assessed on an individual basis.
Percutaneous drainage of fluid collections may be appropriate if fluid collection is confirmed. Then it is important to investigate and exclude injury to the pancreatic duct if fluids collect during the clinical pathway. Several studies report that even more severe grades of injury can be managed conservatively, possibly with ERCP and insertion of a stent, but then a greater risk of complications and a longer hospitalisation can be expected.
In a study from Boston involving 131 children, 43 patients had a grade II or grade III injury. Among these, no difference was found between surgical and non-surgical treatment with regard to length of hospitalisation, complications and co-morbidity (27), but children who underwent surgery were more seriously injured and had trauma to multiple organ systems. However, another study found that grade III injuries in the distal pancreas were best served with surgery, resulting in shorter hospitalisations and fewer complications (22). In up to half of the patients, grade III and IV injuries can be treated with early drainage, with or without ERCP and stent insertion. The risk of further interventions is greater with these measures, and future surgery will nonetheless often be necessary (7, 16, 22). Up to half of the children treated with observation alone will develop pseudocysts. Almost half of these can be treated with observation, and the pseudocyst will usually recede spontaneously (14, 38).