pancreatic trauma: march 1 lessons learned · •aast grade iii-v managed with nom •86 patients...
TRANSCRIPT
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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• 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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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 on TPN Days to Clear Liquids
Days to Regular Diet0
20
40
60
80
10
0
Days
Feeding Management for Grade IV/V (Pancreatic Head Inj)
Days on TPN Days to Clear Liquids
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