Early Evaluation Of The Pts Clinical Pathway For Non-operative Management Of High-grade Pancreatic Trauma In Children
*Bindi Naik-Mathuria1, *Robert Russell2, *Richard Falcone3, *Brendan Campbell4, *Shawn St Peter5, Bethany Slater6, *Nathaniel Kreykes7, *Mubeen Jafri8, *Tony Escobar9, *Marianne Beaudin10, *Peter Ehrlich11, *Chad Hamner12, *David Notrica13, *Elizabeth Renaud14, *Steven Teich15, *Thomas Rouse16, *Rajan Thakar17, *Bret Engbrecht18, *Barbara Gaines19, *Hari Thangarajah20, *Ankush Gosain21, *Kuojen Tsao22, *Katie Russell23, *David Gourlay24
1Texas Children's Hospital, Houston, TX;2Children's Hospital of Alabama, Birmingham, AL;3Cincinnati Children's Hospital, Cincinnati, OH;4Connecticut Children's Hospital, Hasbro, CT;5Mercy Children's Hospital, Kansas City, TX;6Comer Children's Hospital, Chicago, IL;7Minnesota Children's Hospital, Minnesota, MN;8Oregon Children's Hospital, Portlant, OR;9Marybridge Children's Hospital, Tacoma, WA;10St Justine Children's Hospital, Montreal, BC;11Michigan Children's Hospital, Michigan, MI;12Cook Children's Hospital, Dallas, TX;13Phoenix Children's Hospital, Phoenix, AZ;14Hasbro Children's Hospital, Providence, RI;15Carolina HS University Medical Center, Charlotte, NC;16Riley Children's Hospital, Indianapolis, IN;17Nationwide Children's Hospital, Columbus, OH;18Pen State Children's Hospital, Hershey, PA;19Pittsburgh Children's Hospital, Pittsburgh, PA;20Riley Children's Hospital, San Diego, CA;21Le Bonheur Children's Hospital, Memphis, TN;22Memorial Hermann Children's Hospital, Houston, TX;23Primary Children's Hospital, Salt Lake City, UT;24Children's Hospital of Wisconsin, Milwaukee, WI
Background (issue):Background: Non-operative management (NOM) for pancreatic trauma with duct disruption is variable. We previously proposed a standardized clinical pathway promoting early oral feeding and limited imaging and labs. The purpose of this study was to assess outcomes.Method: Sub-analysis of a prospective, multicenter study of 28 pediatric trauma centers (2018-2021). Children with blunt pancreatic injury with suspected duct disruption were managed per the NOM clinical pathway and outcomes were compared to a historical cohort.Findings: Of 20 patients, median age was 4 years. Clear liquid diet was tolerated by median 2 days and low-fat by 4. TPN was used in 26%. Median length of stay (LOS) was 8 days (range 2-41). An organized peripancreatic fluid collection (PFC) developed in 7 patients (37%), which required readmission in 71%. Pelvic fluid on initial imaging was associated with PFC development in 83% of cases vs 20% (p=.01). One patient failed NOM and required surgery and one developed early exocrine pancreatic insufficiency. There was no fistula formation. At 2 week follow up, 88% had no pain. Compared to the historical cohort (32 patients), TPN use was significantly lower (pre-protocol 56% vs post 26%, p=0.03), PFC was lower (pre-protocol 81% vs post 37%, p=0.003), and time to diet was shorter (pre-protocol 7 vs post 4 days; p=0.05), but LOS was similar.Conclusion (Implications for Practice): The PTS NOM clinical pathway appears to be safe and can lead to rapid recovery, especially when no PFC develops. Pelvic ascites at presentation may predict PFC and prompt operative or endoscopic intervention. Further study is needed.
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