Practice Variability in the Management of Pediatric Pancreatic Trauma

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Cameron Nelson
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of the Pediatric Trauma Study Group Falcone R Burd R

Gourlay D Jacobs D Vogel A Gibbs D Hamner C Upperman

1 Practice Variability in the Management of Pediatric Pancreatic Trauma Bindi Naik-Mathuria, MD and members of the Pediatric Trauma Study Group Falcone R Burd R Puapong D Mooney D Campbell B Kreyekes N Fenton S Gourlay D Jacobs D Vogel A Gibbs D Hamner C Upperman J Beaudin M Kulp H Burke R Abdelssalam S Russell R Gosain A

2 Background Non-operative management of other blunt solid organ injuries (spleen/liver/kidney) is now considered standard of care in pediatric trauma The pancreas however, remains an organ of debate Page 1 xxx00.#####.ppt 11/12/ :46:17 PM

3 AAST CT Grading Scale for Pancreatic Trauma Grade 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 involving ampulla V Laceration Massive disruption of pancreatic head Page 2 xxx00.#####.ppt 11/12/ :46:18 PM Observation Observation? Distal Pancreatectomy? Observation vs. Complex Operative Management

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5 EAST Trauma Management Guidelines (2009) Level III evidence: Grade I and II injuries can be managed by drainage alone Grade III injuries should be managed with resection and drainage Management of pediatric injuries seems to follow many of the same principles as those for adults, albeit with key exceptions in the potential role for nonoperative management. Page 4 xxx00.#####.ppt 11/12/ :46:18 PM

6 document not have tline. Journal of Pediatric Surgery Volume 22, Issue 12, December 1987, Pages Blunt injury to the pancreas in children: Selective management based on ultrasound 1 1 Arkadi Gorenstein, Dara O'Halpin, David E. Wesson Toronto, Ontario, Canada, Alan Daneman, Robert M. Filler, * Recommended a View more articles Citing articles (32 Available online 13 April 2007 Show less Page 5 xxx00.#####.ppt 11/12/ :46:19 PM

7 NOM had more interventions Page 6 xxx00.#####.ppt 11/12/ :46:19 PM

8 Variable Clinical Management in NOM? When to feed? How to feed? Pseudocyst management? Role of ERCP? Time on TPN Length of hospital stay Number of interventions Page 7 xxx00.#####.ppt 11/12/ :46:19 PM

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10 PTS Pancreatic Trauma Study Group Page 9 xxx00.#####.ppt 11/12/ :46:20 PM

11 Purpose To prove the hypothesis that practice variability exists among pediatric trauma surgeons regarding high-grade pancreatic injuries Preference for OM or NOM Clinical management of NOM To assess feasibility of a prospective, randomized, controlled trial comparing outcomes of OM and NOM Page 10 xxx00.#####.ppt 11/12/ :46:21 PM

12 Method Page 11 xxx00.#####.ppt 11/12/ :46:21 PM

13 Results Data collected from 19 centers 123 injuries (> grade 1) reported over the past 3 years Median 6 per center Range 1-22 per center duct injury/suspected Median 1 per center Range 0-8 per center Grade II Grade III Grade IV Unclear/Unknown Pancreatic Injuries at 20 Pediatric Trauma Centers (3 years) Page 12 xxx00.#####.ppt 11/12/ :46:21 PM

14 Results 41% OM 59% NOM 5 centers used NOM for all cases 2 centers used OM for all cases 21% were laparoscopic 12 centers (63%) used both approaches Page 13 xxx00.#####.ppt 11/12/ :46:22 PM

tenderness improved NPO until labs normal OR tenderness improved NPO until pseudocyst resolved Early jejunal feeds Early ERCP

15 Clinical Management of NOM Cases Which are the primary management strategies for non-operative patients used at your center? Yes No % NPO until amylase/lipase normal NPO until epigastric tenderness improved NPO until labs normal AND tenderness improved NPO until labs normal OR tenderness improved NPO until pseudocyst resolved Early jejunal feeds Early ERCP Percutaneous with.without drain for stent pseudocyst A B C D E F G H I ERCP only if pseudocyst develops Page 14 xxx00.#####.ppt 11/12/ :46:22 PM

16 Results MRCP is available at 89% of centers MRCP is considered standard of care at 68% of centers ERCP is utilized by 73% of centers 63% of centers are willing and 26% may be willing to randomize patients to either NOM or OM strategy Page 15 xxx00.#####.ppt 11/12/ :46:23 PM

17 Conclusions Practice variability exists among pediatric surgeons regarding the management of high-grade pancreatic injuries Most centers surveyed use both the NOM and OM approaches (equipoise) NOM varies too widely to make meaningful retrospective comparisons of outcomes among centers A prospective trial to compare outcomes is feasible Page 16 xxx00.#####.ppt 11/12/ :46:23 PM

18 Limitations Population surveyed had already expressed interest in comparing outcomes of OM and NOM Only pediatric trauma centers were surveyed Page 17 xxx00.#####.ppt 11/12/ :46:23 PM

19 Future Directions Prospective, multicenter, controlled trial to compare outcomes of OM and NOM Develop best practice management guidelines for NOM to limit variability Page 18 xxx00.#####.ppt 11/12/ :46:24 PM

20 Thank You! Surgical Page 19 xxx00.#####.ppt 11/12/ :46:24 PM

Operative or Non-Operative Management for High-Grade Pediatric Pancreatic Trauma? A Systematic Review Still Leaves the Question Unanswered

Research Article imedpub Journals http://www.imedpub.com/ Trauma & Acute Care Vol.1 No.1:8 Operative or Non-Operative Management for High-Grade Pediatric Pancreatic Trauma? A Systematic Review Still Leaves