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

Abstract

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. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

Keywords: Adult; Ampulla; Bile duct; Biliary tree; Classification; Conservative; Duodenum; Endoscopic retrograde cholangiopancreatography (ERCP); Endoscopy; Guidelines; Injury; Non-operative; Operative; Pancreas; Pediatric; Surgery; Trauma.

Fig. 1

PRISMA flow chart

Fig. 2

Diagnostic algorithm for duodeno-pancreatic and extrahepatic biliary tree traumatic lesions

Fig. 3

Management algorithm for duodeno-pancreatic and extrahepatic biliary tree traumatic lesions (asterisk indicates NOM should only be attempted in centers capable of a precise diagnosis of the severity of PI/DI/EHBTI and capable of intensive management (close clinical observation and hemodynamic monitoring in a high dependency/intensive care environment, including serial clinical examination and laboratory assay, with immediate access to diagnostics, interventional radiology, endoscopy, and surgery and immediately available access to blood and blood products)