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Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative

Naik-Mathuria, Bindi J. MD; Rosenfeld, Eric H. MD; Gosain, Ankush MD, PhD; Burd, Randall MD, PhD; Falcone, Richard A. Jr. MD; Thakkar, Rajan MD; Gaines, Barbara MD; Mooney, David MD; Escobar, Mauricio MD; Jafri, Mubeen MD; Stallion, Anthony; Klinkner, Denise B. MD; Russell, Robert MD; Campbell, Brendan MD; Burke, Rita V. PhD; Upperman, Jeffrey MD; Juang, David MD; St. Peter, Shawn MD; Fenton, Stephon J. MD; Beaudin, Marianne MD; Wills, Hale MD; Vogel, Adam MD; Polites, Stephanie; Pattyn, Adam MD; Leeper, Christine MD; Veras, Laura V. MD; Maizlin, Ilan MD; Thaker, Shefali MD; Smith, Alexis MD; Waddell, Megan MD; Drews, Joseph MD; Gilmore, James MD; Armstrong, Lindsey MD; Sandler, Alexis MD; Moody, Suzanne; Behrens, Brandon MD; Carmant, Laurenceand the Pancreatic Trauma Study Group (PTSG) Collaborators:

Journal of Trauma and Acute Care Surgery: October 2017 - Volume 83 - Issue 4 - p 589–596
doi: 10.1097/TA.0000000000001576
Original Articles
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CME

BACKGROUND Guidelines for nonoperative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers to develop a consensus-based standard clinical pathway.

METHODS A multicenter, retrospective review was conducted of children with high-grade (American Association of Surgeons for Trauma grade III-V) pancreatic injuries treated with NOM between 2010 and 2015. Data were collected on demographics, clinical management, and outcomes.

RESULTS Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range, 1–18 years). The majority (73%) of injuries were American Association of Surgeons for Trauma grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range, 4–66). All patients had computed tomography scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. 3Endoscopic retrograde cholangiopancreatogram was obtained in 25%. An organized peripancreatic fluid collection present for at least 7 days after injury was identified in 59% (42 of 71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at a median of 6 days (IQR, 3–13 days) and regular diet at a median of 8 days (IQR 4–20 days). Median hospitalization length was 13 days (IQR, 7–24 days). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences.

CONCLUSION High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed.

LEVEL OF EVIDENCE Therapeutic/care management, level V (case series).

From the Texas Children’s Hospital (B.J.N-M., E.H.R.); and the Michael E DeBakey Department of Surgery (B.J.N-M., E.H.R.), Houston, TX; Mayo Clinic (D.B.K., S.P.), Rochester, MN; MultiCare Mary Bridge Children's Hospital & Health Center, Tacoma, WA; Children’s Hospital of Pittsburgh (B.G., C.L.), Pittsburgh, PA; Le Bonheur Children's Hospital (A.G., L.V.V.), Memphis, TN; Children's Hospital of Alabama (R.R., I.M.), Birmingham, AL; Connecticut Children's Medical Center (B.C., S.T.), Hartford, CT; Hasbro Children’s Hospital (H.W., A.S.), Providence, RI; Carolinas HealthCare System (A.S., M.W.), Charlotte, NC; Children’s Mercy Hospital (D.J., S.S.P.), Kansas City, MO; Nationwide Children’s Hospital (R.T., J.D.), Columbus, OH; Saint Louis Children’s Hospital (A.V.), St. Louis, MO; Children’s Hospital of Los Angeles (R.V.B., J.U.), Los Angeles, CA; Randall Children's Hospital at Legacy Emanuel (M.J., J.G.), Portland, OR; Boston Children’s Hospital (D.M., L.A.), Boston, MA; Children’s National Medical Center (R.B.), Washington, DC; University of Utah (S.J.F.), Salt Lake City, UT; Cincinnati Children's (R.A.F.J., S.M.), Cincinnati, OH; Doernbecher Children's Hospital, Oregon Health and Science University (M.J., B.B.), Portland, OR; and Centre Hospitalier Universitaire Sainte-Justine (M.B., L.C.), Montreal, QC, Canada.

Submitted: November 21, 2016, Revised: April 21, 2017, Accepted: April 23, 2017, Published online: June 5, 2017.

This is a Pediatric Trauma Society related manuscript and was presented at the 13th annual meeting of the pediatric trauma society November 11, 2016 in Nashville, TN.

Address for reprints: Bindi J. Naik-Mathuria, MD, Texas Children’s Hospital, 6701 Fannin Drive, Suite 1210, Houston, TX 77030; email: bnaik@texaschildrens.org.

© 2017 Lippincott Williams & Wilkins, Inc.