Guideline sources The following summarized guidelines for the evaluation and management of pancreatic trauma are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES/AAST 2019). 1 Guidelines 1. Diagnostic investigations Ultrasound: Obtain extended FAST for detecting free fluid and solid organ injury. A Do not obtain routine ultrasound for the diagnosis of duodeno-pancreatic trauma. Consider obtaining contrast-enhanced ultrasound in stable patients with trauma with suspected pancreatic injury. D Abdominal radiography: do not obtain abdominal plain films using water-soluble contrast in the early trauma scenario. D Computed tomography: obtain CT with IV contrast for the diagnosis of duodeno-pancreatic injuries in hemodynamically stable or stabilized patients with trauma. A Show 3 more https://web.pathway.md/diseases/recW22g8rkO6OszA0 1/4 6/29/23, 10:52 PM Pancreatic trauma Pathway Magnetic resonance cholangiopancreatography: consider obtaining MRCP as a second-line noninvasive diagnostic modality to definitely rule out pancreatic parenchymal and pancreatic ductal injuries. Consider obtaining MRCP with hepatobiliary contrast for the diagnosis of suspected biliary injuries. B Hepatobiliary scintigraphy: do not obtain hepatobiliary scintigraphy for detection of biliary leak in patients with suspected gallbladder and biliary injuries in the trauma setting. D Pancreatic enzymes: Consider obtaining repeated and combined measurements of serum amylase and lipase levels starting from 3-6 hours after the initial injury to support the clinical evaluation in patients with suspected pancreatic injury. B Obtain more accurate investigations in patients with elevated and/or increasing levels of serum amylase and lipase in the absence of a definitive diagnosis. B 2. Diagnostic procedures Endoscopic retrograde cholangiopancreatography: consider performing ERCP for both diagnosis and treatment in hemodynamically stable or stabilized adult and pediatric patients with suspected pancreatic duct and extrahepatic biliary tree injuries, even in the early phase after trauma. B Peritoneal lavage: recognize that diagnostic peritoneal lavage does not improve the specificity of diagnosing duodeno-pancreatic injury, and it is sensitive but not specific for biliary tract injury. B 3. Medical management Non-operative management: offer nonoperative management in all hemodynamically stable or stabilized patients with minor pancreatic injury (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. B Show 5 more 4. Surgical interventions Exploratory laparotomy: perform exploratory laparotomy in hemodynamically unstable (WSES class IV) patients with a positive extended FAST. A Show 3 more Indications for surgery: consider performing drainage in patients with WSES class I (AAST grade I and some grade II) pancreatic injury found during exploratory laparotomy. C Show 7 more 5. Specific circumstances https://web.pathway.md/diseases/recW22g8rkO6OszA0 2/4 6/29/23, 10:52 PM Pancreatic trauma Pathway Pediatric patients: prefer MRI if available in the emergency setting to detect pancreatic parenchymal or pancreatic duct lesions in pediatric patients. B Show 2 more Pregnant patients: Prefer MRI if available in the emergency setting to detect pancreatic parenchymal or pancreatic duct lesions in pregnant patients. B Consider obtaining MRCP wherever available as the diagnostic modality of choice for new- onset signs and symptoms in pregnant patients. B Patients with duodenal injury (non-operative management): use hemodynamic stability as the key factor in determining management strategy in patients with duodenal injury. B Show 4 more Patients with duodenal injury (operative management): perform immediate operative intervention in hemodynamically unstable (WSES class IV) patients and in patients with peritonitis, bowel evisceration, or impalement. B Show 4 more 6. Follow-up and surveillance Serial clinical assessment: perform serial clinical examination during follow-up after biliary and pancreatic-duodenal trauma. B Serial imaging assessment: Decide on the need and choice of follow-up imaging after discharge based on clinical symptoms (onset of abdominal distention, tenderness, fever, vomiting, jaundice) and in a multidisciplinary setting given the complexity and variability of traumatic injuries. B Obtain CT as the first-line follow-up imaging for new-onset signs and symptoms in adult patients. B Clinical findings Symptoms Past medical history Abdominal pain Duodenal injury Back pain Traumatic injury Epigastric pain Vital signs Nausea Vomiting Hypotension Signs of shock Past events Abdominal exam Blunt abdominal trauma Motor vehicle accident Abdominal distension Abdominal tenderness Neurological exam Hematological findings Altered mental status https://web.pathway.md/diseases/recW22g8rkO6OszA0 3/4 6/29/23, 10:52 PM Pancreatic trauma Pathway WBC count Lab findings ESR serum CRP serum amylase serum lipase Imaging findings Free intraperitoneal fluid Studies 2023 Antimicrobial prophylaxis in pancreatoduodenectomy In adults undergoing open pancreatoduodenectomy for any indication, piperacillin-tazobactam was superior to cefoxitin with respect to the rate of postoperative surgical site infection within 30 days. Michael I D'Angelica et al. JAMA. 2023 May 9. References 1. Federico Coccolini, Leslie Kobayashi, Yoram Kluger et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 11;14 56. Open 2. Michael I D'Angelica, Ryan J Ellis, Jason B Liu et al. Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy: A Randomized Clinical Trial. JAMA. 2023 May 9;329 18 1579 1588. Open https://web.pathway.md/diseases/recW22g8rkO6OszA0 4/4