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Management of Adult Pancreatic Injuries: a Practice Management Guideline from the Eastern Association for the Surgery of Trauma

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Management of Adult Pancreatic Injuries: a Practice Management Guideline from the Eastern Association for the Surgery of Trauma EAST 2016 GUIDELINES Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma Vanessa Phillis Ho, MD, MPH, Nimitt J. Patel, MD, Faran Bokhari, MD, Firas G. Madbak, MD, Jana E. Hambley, MD, James R. Yon, MD, Bryce R.H. Robinson, MD, Kimberly Nagy, MD, Scott B. Armen, MD, Samuel Kingsley, MD, Sameer Gupta, MD, Frederic L. Starr, MD, Henry R. Moore, III, MD, Uretz J. Oliphant, MD, Elliott R. Haut, MD, PhD, and John J. Como, MD, MPH, Cleveland, Ohio AAST Continuing Medical Education Article Accreditation Statement Disclosure Information In accordance with the ACCME Accreditation Criteria, the American College of This activity has been planned and implemented in accordance with the Es- Surgeons, as the accredited provider of this journal activity, must ensure that anyone sential Areas and Policies of the Accreditation Council for Continuing Medical in a position to control the content of JTraumaAcuteCareSurgarticles selected for Education through the joint providership of the American College of Surgeons CME credit has disclosed all relevant financial relationships with any commercial and the American Association for the Surgery of Trauma. The American interest. Disclosure forms are completed by the editorial staff, associate editors, College Surgeons is accredited by the ACCME to provide continuing medical reviewers, and all authors. The ACCME defines a `commercial interest' as “any education for physicians. entity producing, marketing, re-selling, or distributing health care goods or services AMA PRA Category 1 Credits™ consumed by, or used on, patients.”“Relevant” financial relationships are those (in The American College of Surgeons designates this journal-based CME activity for any amount) that may create a conflict of interest and occur within the 12’months a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the preceding and during the time that the individual is engaged in writing the article. All credit commensurate with the extent of their participation in the activity. reported conflicts are thoroughly managed in order to ensure any potential bias Of the AMA PRA Category 1 Credit™ listed above, a maximum of 1 credit within the content is eliminated. However, if you’perceive a bias within the article, meets the requirements for self-assessment. please report the circumstances on the evaluation form. Please note we have advised the authors that it is their responsibility to disclose within the Credits can only be claimed online article if they are describing the use of a device, product, or drug that is not FDA approved or the off-label use of an approved device, product, or drug or unapproved usage. Disclosures of Significant Relationships with Relevant Commercial Companies/Organizations by the Editorial Staff Ernest E. Moore, Editor: PI, research support and shared U.S. patents Haemonetics; PI, research support, TEM Systems, Inc. Ronald V. Maier, Associate editor: con- sultant, consulting fee, LFB Biotechnologies. Associate editors: David Hoyt and Steven Shackford have nothing to disclose. Editorial staff: Jennifer Crebs, Jo Fields, Objectives and Angela Sauaia have nothing to disclose.“ After reading the featured articles published in the Journal of Trauma and Acute Author Disclosures Care Surgery, participants should be able to demonstrate increased understanding Faran Bokhari: payment, Abbot Point of Care; consulting fee, Pfizer. Elliott Haut: royalties, of the material specific to the article. Objectives for each article are featured at Lippincott, Williams & Wilkins; consultant payment, Vizient. The remaining authors have the beginning of each article and online. Test questions are at the end of the article, nothing to disclose. with a critique and specific location in the article referencing the question topic. Reviewer Disclosures Claiming Credit The reviewers have nothing to disclose. To claim credit, please visit the AAST website at http://www.aast.org/ and click on Cost the “e-Learning/MOC” tab. You must read the article, successfully complete the For AAST members and Journal of Trauma and Acute Care Surgery subscribers post-test and evaluation. Your CME certificate will be available immediately upon there is no charge to participate in this activity. For those who are not a member receiving a passing score of 75% or higher on the post-test. Post-tests receiving a or subscriber, the cost for each credit is $25. score of below 75% will require a retake of the test to receive credit. System Requirements The system requirements are as follows: Adobe® Reader 7.0 or above installed; Internet Explorer® 7 and above; Firefox® 3.0 and above, Chrome® 8.0 and above, or Safari™ 4.0 and above. Questions If you have any questions, please contact AAST at 800-789-4006. Paper test and evaluations will not be accepted. J Trauma Acute Care Surg Volume 82, Number 1 185 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. J Trauma Acute Care Surg Ho et al. Volume 82, Number 1 BACKGROUND: Traumatic injury to the pancreas is rare but is associated with significant morbidity and mortality, including fistula, sepsis, and death. There are currently no practice management guidelines for the medical and surgical management of traumatic pancreatic injuries. The overall objective of this article is to provide evidence-based recommendations for the physician who is presented with traumatic injury to the pancreas. METHODS: The MEDLINE database using PubMed was searched to identify English language articles published from January 1965 to December 2014 regarding adult patients with pancreatic injuries. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to formulate evidence-based recommendations. RESULTS: Three hundred nineteen articles were identified. Of these, 52 articles underwent full text review, and 37 were selected for guideline construction. CONCLUSION: Patients with grade I/II injuries tend to have fewer complications; for these, we conditionally recommend nonoperative or nonresectional management. For grade III/IV injuries identified on computed tomography or at operation, we conditionally recom- mend pancreatic resection. We conditionally recommend against the routine use of octreotide for postoperative pancreatic fistula prophylaxis. No recommendations could be made regarding the following two topics: optimal surgical management of grade V injuries, and the need for routine splenectomy with distal pancreatectomy. (J Trauma Acute Care Surg. 2017;82: 185–199. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Systematic review, level III. KEY WORDS: Pancreas; pancreatic injury; pancreatic trauma; practice management guideline. raumatic injuries to the pancreas are infrequent but can be patients to diagnose pancreatic injury. The sensitivities for detect- T associated with major morbidity and mortality, including ing pancreatic injury are highly variable ranging from 47% to acute hemorrhage, pancreatic leaks, abscesses, fistulae, and 79%, with newer-generation scanners being more sensitive.13,14 pancreatitis.1 Estimates for the incidence of pancreatic injury Identification of pancreatic duct injury using CT imaging also range from 0.2% to 12% of abdominal traumas.2–6 Many varied, with sensitivities ranging from 52% to 54% with specific- factors, such as patient stability, the acuity of concomitant ities between 90% and 95%.13 Others have reported sensitivities life-threatening injuries, and the need for damage control from 91% to 95% with specificities of 91% to 100% pancre- procedures, must therefore be balanced when considering atic duct injury using multidetector CT scans.15,16 Use of the proper approach to pancreatic injury management. magnetic resonance cholangiopancreatography (MRCP) and Historically, injuries to the pancreas were described by endoscopic retrograde cholangiopancreatography (ERCP) injury location as involving the head, body, and/or tail of the for diagnostic tools for pancreatic injury are limited to case pancreas.7–9 Early taxonomy for pancreatic injury did not re- reports. However, the use of magnetic resonance imaging is quire determination of involvement of the pancreatic duct, even believed to increase the diagnostic confidence of pancreatic though surgeons have long believed that ductal injury is the injury according to Panda et al.16 Areviewofthecaseseries principal cause of pancreatic-specific morbidity and mortal- also showed that MRCP can be a useful tool for diagnostic ity.10,11 The American Association for the Surgery of Trauma purposes, whereas ERCP may provide diagnostic as well as grading system, published in 1990, is a practical and prognostic therapeutic intervention but is limited due to the logistics of way to describe pancreatic injury. With this system, typically, performing ERCP in general and the technical challenges of higher-grade injuries correlate with higher mortality and com- performing it in a multiple trauma patient with the risk of ex- plications.2,12 Grades I and II include minor pancreatic contu- acerbating the issue with pancreatitis.17 sions and lacerations that spare the pancreatic duct. Grade III Therapeutic operative interventions for pancreatic injury injuries include pancreatic duct injuries at the body and tail, are typically treated by drainage or suture repair for minor inju- and grade IV injuries include ductal injuries at the pancreatic
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