Pancreatic Trauma: March 1 Lessons Learned · •AAST Grade III-V managed with NOM •86 patients •Median age 9 •73% grade III, 27% grade IV/V Naik-Mathuria et al, Proposed clinical

Pancreatic Trauma:Lessons Learned

Bindi Naik-Mathuria, MD, MPH

Associate Professor of Surgery and Pediatrics

Trauma Medical Director

Texas Children’s Hospital

Baylor College of Medicine

Houston, TX, USA

March 1st, 20192019

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xxx00.#####.ppt 12/26/2019 10:45:31 AMSurgical ServicesTrauma Services

• I have no disclosures

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Acute grade III pancreatic injury

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• Which management strategy do you prefer for this injury?

- Operative (distal pancreatectomy)

- Non-operative (observation)

- ERCP and stent placement

- Undecided

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Serum Lipase Level

Post-injury Day 1: 121

Post-injury Day 2: 5,800

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Post-Injury Day 3

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Background

• Pancreatic injury in children is relatively rare

• Blunt epigastric force causes the pancreas

to fracture, most commonly in the body overlying the spine

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AAST CT Grading Scale for Pancreatic TraumaGrade Type of Injury Description of Injury

I Hematoma Minor contusion without duct injury

Laceration Superficial laceration without duct injury

II Hematoma 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 involvingampulla

V Laceration Massive disruption of pancreatic head

Observation? Distal Pancreatectomy?

Observation vs. Complex Operative Management

Observation

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Controversy Regarding Management

• Adult recommendations*:

• Grade III/IV injuries should be managed with resection and drainage as non-operative management leads to morbidity

• Pediatric recommendations: UNCLEAR

• Lack of high-quality evidence

• Retrospective

• Lack of standardization

* EAST PMG J Trauma Jan 2017 82(1):185-99.

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Most Common Reported Outcomes

• % Pseudocyst

• % Fistula

• % Other complications

• Hospital Length of Stay

• ICU Length of Stay

• Use of TPN

• Time to oral feeds

• Number of additional interventionsVARIABILITY

When to feed?How to feed?

How long to observe in hospital?

Pseudocyst management?Role of ERCP?

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• 19 pediatric trauma centers

• 12/19 (63%) used both approaches

• Lack of standardization in NOM clinical management51%

OM

49% NOM

21% were laparoscopic

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#GOALS

1. We need to standardize NOM management

2. We need a prospective trial to compare outcomes of OM vs NOM

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Creating a Standard NOM Clinical Pathway

• 20 Pediatric Trauma Centers

• Retrospective study of children ≤ 18

• AAST Grade III-V managed with NOM

• 86 patients

• Median age 9

• 73% grade III, 27% grade IV/V

Naik-Mathuria et al, Proposed clinical pathway for NOM of high-grade pediatric pancreatic injuries, multicenter. J Trauma Acute Care Surg 2017 83(4):589-596

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Pancreatic Enzymes

100

200

300

400

500

Am

yla

se

0 2 4 6 8Day

200

400

600

800

1000

1200

Lip

ase

0 2 4 6 8Day

Amylase Lipase

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Are Serial Pancreatic Enzymes Useful?

Pseudocyst No Pseudocyst p

Amylase at Presentation (median)

421 (n=38) 423 (n=28) 0.97

Lipase at Presentation(median)

1163 (n=38) 778 (n=27) 0.29

Peak Amylase (median) 697 (n=15) 715 (n=12) 0.73

Peak Lipase (median) 3177 (n=39) 1685 (n=27) 0.23

Grade III Grade IV/V p

Amylase at Presentation (median)

399 (n=55) 392 (n=20) 0.95

Lipase at Presentation(median)

1050 (n=55) 713.5 (n=22) 0.70

Peak Amylase (median) 538 (n=23) 1325 (n=7) 0.29

Peak Lipase (median) 2130 (n=55) 1755 (n=21) 0.65

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Feeding Practices

• Diet advancement• 46 (66%) advanced diet based on

symptom improvement• 24 (34%) advanced diet based on

symptom improvement + down-trending labs

• Jejunal feeds 31%• TPN 68%

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Feeding Practices

020

40

60

80

10

0

Days

Feeding Management

Days on TPN Days to Clear Liquids

Days to Regular Diet

020

40

60

80

10

0

Days

Feeding Management for Grade III (Pancreatic Body Inj)


Days to Regular Diet0

20

40

60

80

10

0

Days

Feeding Management for Grade IV/V (Pancreatic Head Inj)


Days to Regular Diet

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Hospital LOS

020

40

60

Days

Hospital LOS for Grades III & IV/V

Grade III Grade IV/V

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Development of a Standard Clinical Pathway

0

10

20

30

40

50

60

70

80

90

100

% P

atie

nts

50%

Naik-Mathuria et al, Proposed clinical pathway for NOM of high-grade pediatric pancreatic injuries, multicenter. J Trauma Acute Care Surg 2017 83(4):589-596

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Peri-Pancreatic Fluid Collection Management

• 42/100 (42%) patients• APFC (1-4 wk): 27%• Pseudocyst (4 wk): 15%

• 11/42 (27%) needed CG/resection

• Cysts > 7cm had longer recoveryObservation

64%ERCP/stent10%

Percutaneous Drain

Placement, 24%

Needle Aspiration2%

75

25

79

27

TPN USE NEED FOR DEFINITIVE

PROCEDURE

Intervention Observation

11

25

1215

TIME TO REGULAR DIET

HOSPITAL LOS Rosenfeld EH, Naik-Mathuria B et al. Pediatr Surg Int 2019 Aug 35(8):861-7

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ERCP Use

• ERCP was used at 14/22 (64%) centers

• 20 patients with NOM, 6 with OM

0

1

2

3

4

5

6

7

8

9

1 2 3 4 5 6 7 8 9 10 11 12 13+

Days from Injury to ERCP

Rosenfeld EH, Naik-Mathuria B et al. J Pediatr Surg 2018;53(1):146-151

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Did ERCP Alter Management or Improve Outcome?

• 4/4 (100%) YES

• 3/3 (100%) YES

• 2/3 (67%) YES

• 3/11 (37%) YES

• 0/3 (0%) NO

• 2/2 UNCLEAR if outcome altered

• Evaluation of duct integrity (diagnostic only)

• Stricture

• Fistula control

• Early attempt at duct leak control

• Symptomatic pseudocyst

• Delayed attempt at duct leak control

82

1211

1714

DAYS TO REGULAR DIET DAYS ON TPN* LENGTH OF STAY

Observation Interventional ERCP

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Is MRCP Superior to CT?Rosenfeld EH, Naik-Mathuria B et al. Ped Surg Int 2018 Sept 34(9):961-6

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Avoid serial labs

Early oral feeding Avoid re-imaging until at least one

week

Initial observation

of pseudocyst

Discharge based on

symptoms, not labs

Naik-Mathuria et al. J Trauma Acute Care Surg 2017 83(4):589-596

“LESS IS MORE”

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Prospective, Multicenter Trial OM vs NOM

• Observational longitudinal cohort study

• 25 PTS pediatric trauma centers

• Acute grade III injuries

• Surgeon chooses OM vs NOM

• Standard clinical pathways

• Outcomes:

• Early and delayed complications

• Return to school

• Quality of life

• Readmissions

• Hospital costs

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PRELIMINARY DATA

• 18 patients: 7 OM, 11 NOM

• Avg Time to Oral diet 2.4 days

• 1 day OM vs 3 days NOM

• Avg Length of Stay 8.8 days

• 7 days OM vs 10 days NOM

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MRCP performed

Mechanism ERCP performed

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Jejunal Feeds UseTPN Use

Peripancreatic fluid collection > 7 days after injury

Fistula development

NOYES

2 OM (28%) 2 NOM (18%)

1 PT WITH NOM HAD PANCREATIC INSUFFICIENCY 10 MONTHS AFTER INJURY

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Guideline for Non-Operative Management of Blunt Pediatric Pancreatic Injuries

Retrospective review of 86 children with grade III/IV pancreatic injury managed non-operatively

Pancreatic enzymes peaked 2

days after injury then fell. No correlation with outcomes

Practice variability in

feeding strategy

Most common complication was organized fluid collection (42%). Observation worked well for most. >7cm longer recovery

ERCP/stent

did not lead to faster recovery

Expert consensus panel

GUIDELINE DEVELOPMENT

Baseline pancreatic enzymes then avoid serial labs

Initiate early oral diet when tenderness improves

Avoid re-imaging for symptoms sooner than 1 week if clinically stable

Observe organized fluid collection (NPO, TPN); drain only if does not resolve or very large

Discharge based on symptoms, not labs or imagingFollow-up imaging only if symptomatic

GUIDELINE

Naik-Mathuria B et al. J Trauma Acute Care Surg 2017; 83(4):589-596

Rosenfeld EH et al. J Pediatr Surg 2018; 53(1): 146-151 Rosenfeld EH et al. Pediatr Surg Int 2019; 35(8): 861-867

PANCREATIC TRAUMA STUDY GROUP

Rosenfeld EH et al. Pediatr Surg Int 2018; 34(9): 961-966

Addition of MRCP

to CT did not add much value

@[email protected]

Documents

Pancreatic Trauma: March 1 Lessons Learned · •AAST Grade III-V managed with NOM •86 patients •Median age 9 •73% grade III, 27% grade IV/V Naik-Mathuria et al, Proposed clinical