Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) have released duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis.

Diagnostic procedures

• Management of pediatric patients with duodenal-pancreatic trauma requires specific skills; only trauma centers should take care of this cohort of patients. (GoR 1C)


• The choice of diagnostic technique at admission must be based on the hemodynamic status. (GoR 1A)


• E-FAST is rapid, repeatable, and effective for detecting free fluid and solid organ injury. (GoR 1A)


• Ultrasonography is not recommended to routinely diagnose duodeno-pancreatic trauma. Contrast-enhanced ultrasonography may have a diagnostic role in stable trauma patients with suspected pancreatic injury. (GoR 2B)


• Repeated and combined measurement of serum amylase and lipase levels, starting from 3 to 6 h after the initial injury, is a useful tool to support clinical evaluation in suspicion of pancreatic injury. Elevated and/or increasing levels of serum amylase and lipase, in absence of definitive diagnosis, are indications for more accurate investigation. (GoR 1B)


• Serial clinical examination is an important part of follow-up after biliary and pancreatic-duodenal trauma. (GoR 2A)


• CT-scan with intravenous contrast is essential in diagnosing duodeno-pancreatic injuries in hemodynamically stable or stabilized trauma patients. (GoR 1A)


• Administration of oral contrast material does not improve intravenous contrast-enhanced CT-scan sensitivity in detecting duodeno-pancreatic injuries. (GoR 2A)


• A repeat CT-scan within 12–24 h from the initial injury should be considered in hemodynamically stable patients with high clinical suspicion for duodeno-pancreatic injury or pancreatic ductal injury with negative CT-scan or non-specific CT findings on admission imaging, and/or elevated amylase and lipase, or persistent abdominal pain. (GoR 2A)


• Magnetic resonance cholangiopancreatography (MRCP) can be considered a second-line non-invasive diagnostic modality to definitely rule out pancreatic parenchymal and pancreatic ductal injuries. It should be considered for the diagnosis of suspected biliary injuries when performed with hepatobiliary contrast. (GoR 1B)


• In pediatric patients and pregnant women, to detect pancreatic parenchymal or pancreatic duct lesions, MRI is preferred if available in the emergency setting. (GoR 2A)


• In adult and pediatric patients, the risks associated with the radiation burden of CT should be balanced against the potential complications that may occur with a missed injury when alternative diagnostic modalities for pancreaticoduodenal injury are not available. (GoR 1C)


• Abdominal plain films using water-soluble contrast in the early trauma scenario are not recommended. (GoR 2A)


• Hepatobiliary scintigraphy is not recommended for detection of biliary leak in patients with suspected gallbladder and biliary injuries in the trauma setting. (GoR 2B)


• Diagnostic peritoneal lavage does not improve the specificity of diagnosing duodeno-pancreatic injury. It is sensitive but not specific for biliary tract injury. (GoR 2B)


• Exploratory laparotomy is indicated in hemodynamically unstable (WSES class IV) patients with a positive E-FAST. (GoR 1A)


• During surgical exploration of patients with abdominal trauma, the duodeno-pancreatic complex must be exposed and explored. (GoR 1A)


• During exploratory laparotomy, when biliary injury is suspected but not identified, an intraoperative cholangiogram is strongly recommended. (GoR 2A)


• In patients who are clinically suspected of having duodenal-pancreatic injuries, and are deteriorating clinically, if the imaging is equivocal, a diagnostic laparotomy should be performed. (GoR 2A)


• In suspected pancreatic duct and extrahepatic biliary tree injuries in hemodynamically stable or stabilized adults and pediatric patients, endoscopic retrograde cholangiopancreatography (ERCP) can be used for both diagnosis and treatment even in the early phase after trauma. (GoR 1B)

Non-operative management (NOM)

• Hemodynamic stability is the key factor in determining management strategy. (GoR 1C

Duodenum

• Hemodynamically unstable (WSES class IV) patients should not be considered for NOM. (GoR 1C)


• NOM can be considered for hemodynamically stable or stabilized patients with duodenal wall hematomas (WSES class I–II, AAST-OIS grade I–II) in the absence of other abdominal organ injuries requiring surgery. (GoR 2B)


• Patients with progressive symptoms or worsening findings on repeat imaging should be considered failures of NOM. (GoR 2C)


• Hematomas initially treated with NOM should be considered for operative management if duodenal obstruction has not resolved within 14 days. (GoR 2C)

Pancreas, biliary tree

• NOM should be the treatment of choice for all hemodynamically stable or stabilized minor PI WSES class I (AAST grade I and some grade II) and gallbladder hematomas without perforation WSES class I (AAST grade I) in the absence of other abdominal injuries requiring surgery. (GoR 2C)


• Location of WSES class II (AAST grade III) PI is the primary determinant of treatment modality in hemodynamically stable adult patients. (GoR 2C)


• NOM may be considered only in selected hemodynamically stable or stabilized patients with WSES class II (AAST grade III) very proximal pancreatic body injuries in the absence of other abdominal injuries requiring surgery and only in higher level trauma centers; success of NOM may be increased with utilization of endoscopic and percutaneous interventions. (GoR 2C).


• Optimal management of hemodynamically stable or stabilized patients with WSES class III (AAST grade IV) PI is controversial. NOM management augmented by endoscopic or percutaneous interventions may be used in selected patients. (GoR 2C)


• NOM of WSES class III (AAST grade IV) injuries should be considered only in an environment that provides around the clock capability for patient intensive monitoring, an immediately available endoscopy and interventional radiology suite, OR, and only in patients with stable or stabilized hemodynamic and absence of other abdominal injuries requiring surgery (GoR 2A).


• Sequelae of PI such as pancreatic fistulae and pseudocysts can frequently be addressed with image-guided percutaneous drain placement, endoscopic stenting, internal drainage, and endoscopic cyst-gastrostomy or cyst-jejunostomy. (GoR 2C)

Operative management (OM)

• Hemodynamically unstable (WSES class IV) patients and those with peritonitis or bowel evisceration or impalement should undergo immediate operative intervention. (GoR 1C)

Duodenum

• Damage control techniques should be considered in hemodynamically unstable patients with DI, particularly those with associated injuries and physiologic derangement. (GoR 2B)


• Primary repair of DI should be considered whenever technically possible regardless of grade of injury. (GoR 2B)


• Ancillary procedures such as pyloric exclusion with and without gastrojejunostomy and biliary diversion may be considered in WSES class III or higher DI (AAST grades III, IV, and V). (GoR 2C)


• Lesions requiring pancreaticoduodenectomy (Whipple procedure) are often accompanied by severe associated injuries and shock. Damage control techniques and staged reconstruction in subsequent phases performed by experienced surgeons should be considered. (GoR 2c)

Pancreas, biliary tree

• In WSES class I (AAST grade I and some grade II) PI found during exploratory laparotomy, drainage may be considered (GoR 2B).


• Patients with distal WSES class II (AAST grade III) PI should undergo OM. (GoR 2C)


• Distal pancreatectomy (with or without splenectomy) is the procedure of choice for distal WSES class II (AAST grade III) PI. (GoR 2C)


• Pancreatoduodenectomy may be needed in patients with destructive injuries of the duodenal-pancreatic complex. In such cases, the operation has better results when performed in a staged fashion. Pancreato-jejunostomy or pancreato-gastrostomy reconstructions are equally effective in selected cases performed by experienced surgeons. (GoR 2C)


• In extrahepatic biliary tree WSES class I injuries (AAST grade I, II, and III) with laceration, perforation, or avulsion of the gallbladder, cholecystectomy is the treatment of choice. (GoR 1C)


• EHBT injuries undergoing an initial damage control procedure may be drained with delayed reconstruction performed as a staged approach. (GoR 2B)


• EHBT WSES class II–III (AAST grades IV and V) injuries should undergo reconstruction with hepaticojejunostomy or choledochojejunostomy if there is no associated vascular injury. (GoR 2C)


• NOM failure of EHBT WSES class II–III (AAST grades IV and V) injuries, hepaticojejunostomy should be considered during reconstruction. (GoR 2C)

Short- and long-term follow-up

• After discharge, the necessity for follow-up imaging should be driven by clinical symptoms (i.e., onset of abdominal distention, tenderness, fever, vomiting, jaundice). (GoR 2B)


• In adults, CT-scan is usually the first-line follow-up imaging tool for new-onset signs and symptoms. (GoR 2A)


• In pregnant females, the MRCP should be considered the diagnostic modality of choice for new-onset signs and symptoms, wherever available. (GoR 2A)


• In pediatric patients, ultrasound or contrast-enhanced US should be the diagnostic modality of choice for follow-up imaging. If cross-sectional imaging is required, MRI is preferred. (GoR 2A)


• Given the complexity and variability of traumatic injuries, the need for and choice of follow-up imaging should be made using a multidisciplinary approach. (GoR 2B)