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Practice Variability in the Management of Pediatric Pancreatic Trauma
Bindi Naik-Mathuria, MD, Baylor College of Medicine, Houston TX and members of the PTSG (Pancreatic Trauma Study Group): Richard Falcone, MD, David Mooney, MD, Stephen Fenton, MD, Adam Vogel, MD, Randall Burd, MD, David Gourlay, MD, Robert Russell, MD, Jeffrey Upperman, MD, Rita Burke, PhD, Ankush Gosain, MD, Brendan Campbell, MD, David Gibbs, MD, Heather Kulp, MD, Nathaniel Kreykes, MD, Chad Hamner, MD, David Jacobs, MD, Shahab Abdesalaam, MD, Devin Puapong, MD and Marianne Beaudin, MD

Abstract:
Purpose:
To assess volume, practice patterns, resources and preferences in order to evaluate the feasibility of a prospective, multicenter, randomized trial to compare outcomes of operative (OM) and non-operative management (NOM) of high-grade pancreatic injuries in children. Method: A study group of pediatric trauma centers was established through the Pediatric Trauma Society. Each center completed a survey following a query of their institutional database. Results are presented using descriptive statistics. Results: Over the past 3 years, 75 high-grade pancreatic injuries (AAST grade II+) were treated at 19 centers: grade III median: 1 (range 0-6 per center), grade IV median: 0 (range 0-3 per center) and grade unclear/ungraded median: 0 (range 0-11 per center). 59% were managed with NOM. Five centers used NOM for all cases, 2 only used OM, and 12 employed both strategies. 21% of operations were laparoscopic. There was wide variability in clinical management of NOM patients: the most common feeding strategy was reported by only 52% of centers, percutaneous drainage of acute fluid collection/pseudocyst by 42% and ERCP (early/after pseudocyst) by 72%. MRCP is available at 89% of centers and considered standard of care at 68%. Regarding willingness to randomize patients, 63% of centers reported "yes" and 26% reported "maybe". Conclusion: Practice variability exists among pediatric surgeons regarding the initial approach to high-grade blunt pancreatic trauma and the clinical management of NOM patients, which makes comparing multicenter retrospective outcomes challenging. These results highlight the need for a prospective, multicenter trial and demonstrate feasibility within this study group.
Objective:
At the end of this activity, the learner will be able to understand that practice variability does exist in the management of major pancreatic injuries in children in North America.
Objective Content: The management of major pediatric pancreatic trauma remains controversial, and the current evidence is poor as it is based on retrospective, mostly single center studies. Therefore, outcomes have been difficult to evaluate in order to determine whether surgery or observation is better for these patients. The purpose of this study was to assess national practice patterns as well as the resources of centers interested in initiating a prospective trial to study this issue.


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