Re: Managing grade V pancreatic injuries—Think smart, act smart, and call in the pancreatic cavalry early

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In Reply:
We would like to thank Dr. Krige for his letter regarding our manuscript entitled “Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma.”
Dr. Krige raises important concerns about the treatment of grade V pancreatic injuries. These injuries carry high mortality and morbidity, and, as mentioned by Dr. Krige, the literature is limited. Our Population, Intervention, Comparator, Outcomes (PICO) question to address this difficult clinical scenario was “For adults with total destruction of the head of the pancreas (grade V) (P), should pancreaticoduodenectomy (I) or surgical treatment other than pancreaticoduodenectomy (C) be performed?” The Grading of Recommendations Assessment, Development and Evaluation methodology format is such that authors must recommend the “Intervention,” the “Comparator,” or give no recommendation. We were not able to give a recommendation about whether or not pancreaticoduodenectomy is the preferred treatment because for these complex cases, there is essentially no high-quality evidence to guide treatment, thus the treatment approach must be individualized. Dr. Krige's article, which is a case series of 19 patients who had pancreaticoduodenectomy, provides an important description of outcomes for this question, but it does not change the overall decision to provide “No recommendation” on this question.
We thank Dr. Krige for his thoughtful comments and guidance regarding these injuries. We apologize for not including his group’s study in our review. We agree with the assessment that an individualized and multidisciplinary approach using modern resuscitation, damage control techniques, and expert consultation when needed is the most prudent treatment paradigm for these patients.
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