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

Duodeno-pancreatic and extrahepatic biliary tree injuries are, by definition, transitional lesions that may involve one or more anatomical structures. Their management is multidisciplinary. The initial phase is best managed by trauma or emergency surgeons but the late reconstructive phase should involve hepatobiliary surgeons. Moreover, endoscopy, interventional radiology, and gastroenterology may be involved to improve success of non-operative management (NOM) and to manage early and late sequelae of injury and complications. Transition of treatment strategies should occur as quickly and seamlessly as possible as morbidity and mortality both increase with delays in treatment.

Adult duodenal trauma has an incidence of 0.2–0.6% of all trauma patients and 1–4.7% of all cases of abdominal trauma [1‐3]. Pediatric duodenal trauma is also rare, occurring in < 1% of all pediatric trauma and 2–10% of children with abdominal trauma [4‐6]. Associated injuries are present in 68–86.5% of patients, with major vascular injury occurring in 23–40% of cases. Presence and type of associated injuries greatly impact the treatment of duodenal trauma [1, 2, 7‐12]. Penetrating trauma is the most common cause of duodenal injury (DI) in adult patients, accounting for 53.6–90% of cases [2, 8‐10, 12, 13]. Pediatric DI is most frequently due to blunt trauma which occurs in 70–78% of cases. Non-accidental trauma, motor vehicle crashes, and bicycle/handle bar injuries are the most common causes of pediatric DI [4‐6]. Male gender is more commonly affected in both adult and pediatric DI.

Adult pancreatic injury (PI) is rare, occurring in less than 1% of all traumas and 3.7–11% of abdominal trauma [1‐7]. Pediatric PI is also rare occurring in < 1% of children [8, 9]. Blunt trauma is the most common cause among both adults and children accounting for 61.1–89% of cases in most series, with motor vehicle and bicycle crashes being the most frequent causes [5, 6, 10‐16]. However, penetrating mechanisms are much more common in studies from South Africa, North America, and the military [2‐4]. Associated injuries are frequent, occurring in 55–100% of cases, and are more common in patients requiring surgery and following penetrating mechanisms of injury [1, 3, 6, 11, 12, 14, 17]. Male gender is more commonly affected, accounting for 63–79% of adults and 57–73% of pediatric PI [3, 5, 6, 8, 10‐12, 14‐16].

Extrahepatic biliary tree injury (EHBTI) is even rarer than pancreatic injury. EHBTI occurs in 0.1% of adult and 0.009% of pediatric trauma. Isolated EHBTI is extremely rare occurring in only 2–3% of cases [18‐21]. The most frequently associated injuries include the liver, pancreas, and duodenum. Blunt trauma is more common than penetrating for all EHBTI except the gallbladder, which is more frequently injured due to penetrating mechanisms [18, 21, 22]. Management of EHBTI in both adults and children is primarily dictated by associated injuries and injury grade. The majority of EHBTI will require surgical or endoscopic management.

A computerized search was done by the bibliographer in different databanks (MEDLINE, Scopus, EMBASE). Citations were included for the period between January 1990 and March 2019 using the primary search strategy: duodenum, pancreas, bile duct, biliary tree, ampulla, trauma, adult, paediatric, classification, guidelines, injury, surgery, diagnosis, follow-up, operative, non-operative, conservative, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic, management, combined with AND/OR. No search restrictions were imposed. The dates were selected to allow comprehensively published abstracts of clinical trials, consensus conference, comparative studies, congresses, guidelines, government publication, multicenter studies, systematic reviews, meta-analysis, large case series, original articles, and randomized controlled trials. Research details are summarized in Fig. 1. The level of evidence (LE) was evaluated using the GRADE system (Table 1) [23]. A group of experts in the field coordinated by a central coordinator was contacted to express their evidence-based opinion on several issues about the pediatric (< 16 years old) and adult duodeno-pancreatic and extrahepatic biliary tree trauma. Through the Delphi process, the different issues were discussed in subsequent rounds. The central coordinator assembled the different answers derived from each round. Each version was then revised and improved. The definitive version was discussed during the World Society of Emergency Surgery (WSES) World Congress held in June 2019 in Njimengen, The Netherlands, by a combined WSES-American Association for the Surgery for Trauma (AAST) expert group. The final version in which the agreement was reached resulted in the present manuscript. Statements are summarized in Table 2.

Non-operative management of bilio-duodeno-pancreatic injuries without ductal involvement with or without endoscopic adjuncts is recommended for hemodynamically stable patients. EHBTI can be managed with cholecystectomy for minor injuries, although more severe injuries require surgical reconstruction. Severe bilio-duodeno-pancreatic injuries are rare, often accompanied by hemodynamic instability and may benefit from DCS techniques. Many initial injuries as well as the sequelae of injury may be addressed with percutaneous or endoscopic drainage, and endoscopic stenting. Despite advances in care, morbidity and mortality following severe bilio-duodeno-pancreatic trauma remain high. The management of duodenal, pancreatic, and extrahepatic biliary tree injuries must be multidisciplinary. The management in the initial phase is best accomplished by the trauma or emergency surgeon, and in the reconstructive phase, hepatobiliary surgeons may be helpful and should be consulted.