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Case Presentation #1
68 yof MVC, unrestrained driver PMH: DM, LLL resection Initially awake/alert, mild distress HR 110, BP 120/P, RR 22, sats 100% PE:
Chest – mild tenderness over sternum, WHSS Abd – soft but slightly distended, minimally tender
LABS: 7.41/38/349/23 Hgb 8.6 Na 140, K 4.9, Cl 101, BUN 78, Cr 3.3, Glu 409 Amylase 419, Tbil 0.2, GGT 102, Alk Phos 225, AST 354
Case Presentation #1
IV access via CVL Xrays performed
CXR Cspine Pelvis
Decompensated in ER Less awake, confused HR 120’s, SBP 90 ABG 7.38/33/611/19 Intubated Blood transfused
CT Thorax
CT Abdomen/Pelvis
Case Presentation #1
Injuries Head
SDH, R frontal contusion Chest
Aortic pseudoaneurysm Mediastinal hematoma
Abdomen Duodenal perforation Hemoperitoneum & retroperitoneal hematoma Laceration R kidney
Case Presentation #1
OR Ex Lap
Massive hemoperitoneum Blowout of 2nd portion duodenum Bleeding from mesentery and retroperitoneum Procedure: Repaired duodenum, attempted
ligation of mesentery bleeding, packed abdomen
Attempted L thoracotomy for aortic pseudoaneurysm but unable to enter chest
Case Presentation #1
Continued to blood (coagulopathy) PRBC 19, FFP 10, Plts 6
Acidosis 7.31/31/535/15 7.11/43/101/13.5 7.1/24.5/95/7.8
Cardiac arrest and death
Case Presentation #2
29 y.o. m jet ski accident, transferred from outside hospital with L renal artery thrombosis
ER Bay Awake/alert, mild distress HR 110, BP 120/75, RR 24, Sats 97% PE
Obese (wt 150 kg) Mild abdominal tenderness > LLQ
Repeated CT
CT Abdomen/Pelvis
Case Presentation #2
Admitted to ICU Labs:
7.35/41/74/22 Hgb 12/1 Urine 2-4 RBC Na 137, K 5.4, Cl 103, BUN 22, Cr 1.4
Overnight, increased abd pain and tachypnea 7.37/38/95/21, Hgb 12.9 Amylase 880, Lipase 951
Case Presentation #2
OR Findings
Ischemic L colon at splenic flexure Mod laceration spleen (not bleeding) Severely laceration/contused distal pancreas Non-perfused L kidney
Procedure Splenectomy, distal pancreatectomy, L colectomy
with colostomy, L nephrectomy, long nasojejunal feeding tube, large bore drains x 2
Case Presentation #2
Postoperative recovery Extubated Complicated
Self-removal of feeding tube and pancreatic drains Developed infected fluid collection Required multiple percutaneous drainages Readmission to hospital Pneumonias / Vent / Trach’d
Reversal of colostomy 5 months later
Management of Pancreatic and Duodenal Injuries
Bradley J. Phillips, MD
Trauma-Burns-ICUAdults & Pediatrics
Anatomy and Injury Implications
Retroperitoneal organs Exception: 1st portion of duodenum
Injury requires forceful blunt or penetrating trauma
Duodenum Lacks complete serosal covering
Repairs have a tendency to leak
Pancreas Limited tensile strength
Sutures tend to cut through tissue Close proximity to ductal structures
Physiology and Injury Implications
Duodenum Receives virtually all of GI secretions
Saliva: 500 -1,000 ml Gastric: 500 -1,500 ml Bile: 600 – 1,000 ml Pancreatic: 800 – 1,500 ml
Fistula can cause serious fluid/electrolyte problems
Dehiscence of duodenal suture line dangerous secondary to activated enzymes
Mechanisms of Injury
Pancreas Blunt - 6%
Laceration of head or body Rupture over the spine at the neck
Penetrating GSW - 10% SW – 5%
Associated Injuries with Pancreas
Blunt Liver – 36% Spleen – 30% Kidney – 18% Colon – 18% Major vessel – 9%
Penetrating Stomach – 54% Liver – 49% Major vessel – 45% Kidney – 44%
Mechanism of Injury
Duodenum Blunt
Crushing the duodenum against the spine “blow-out” of the duodenal loop
Partially closed at pylorus and ligament of Treitz
Locations 2nd portion most common site 25% occur in the 4th portion near ligament
MUST BE EXAMINED CAREFULLY BY INCISING THE PERITONEUM AND DISSECTING UNDER THE LOWER BORDER OF THE PANCREAS
Associated Injuries with Duodenal
Blunt Pancreas – 40-50%
Penetrating Liver – 54% Major vessels – 52% Small bowel – 50% Colon 49%
Diagnosis
Signs and symptoms Vast majority initially produce only mild tenderness
Clinical changes in isolated pancreatic and duodenal injury may be extremely
subtle until severe, life-threatening peritonitis develops!!
Diagnosis
Laboratory Amylase elevation
25 % of penetrating trauma 80% in blunt trauma any perforation of the duodenum or upper GI tract
A consistently increased or increasing serum amylase should make one suspect a pancreatic injury.
Diagnosis
Radiographic Plain films Contrast swallow CT scan
Plain film (Historical)
KUB or upright Lucas, Surg Clin N Amer, 1977
Obliteration of R psoas shadow in 18/20 (90%) patients with duodenal rupture
Retroperitoneal air bubbles along R psoas or R kidney in 50% of patients
Contrast Swallow
Useful to diagnosis perforation or hematoma 50% of perforations using water-soluble
contrast (Gastrograffin) Barium probably more accurate Hematoma = “coiled-spring” appearance or
complete obstruction
CT Abdomen
Highly positive predictive value Duodenal injury (Kunin et al, Am J Roent, 1993)
7/7 CT positive for leak (3) or hematoma (4) Findings – leak of contrast, narrowing, or extraluminal air Must be given po contrast
Pancreatic injury (Lane et al, Am J Roent, 1994) 10/10 CT positive proven by OR or autopsy Findings – heterogeneous pancreatic tissue,
peripancreatic fluid Must be given IV contrast
Relative little negative predictive value
Diagnosis
Diagnostic Peritoneal Lavage (DPL) DPL – low sensitivity for duodenal perforation and no utility in
pancreatic injuries
Endoscopic Retrograde Cholangiopancreatography (ERCP) Demonstrates injury to main pancreatic duct Provides “road map” for operation Possible intervention with stent placement However, used in relatively few cases with largest series 9 patients
(Jordan, Trauma , 1991) Probably most useful in blunt trauma patients with remote
pancreatic injury
Diagnosis Intraoperative evaluation
Careful evaluation of pancreas/duodenum Particularly if hematoma overlying
Maneuvers Kocher – expose 1st, 2nd, 3rd portions of duodenum and
head of pancreas
Cattell – exposing root of mesentery of R colon if inadequate exposure from Kocher
Open lesser sac – visualize pancreatic body and tail
Retroperitoneal hematomas may need to be explored to rule out underlying duodenal, pancreatic, or major vessel injuries!
Diagnosis - Intraoperative
No obvious injury, but suspicious Duodenum
Cause must be sought if bile staining found even if minimal
Consider needle cholecystocholangiogram Instillation of methylene blue via NGT
Pancreas Consider pancreatography via ampulla of Vater
through a duodenotomy
Severe edema, crepitance, or bile staining or periduodenal tissues implies a duodenal injury until proven otherwise.
Grading Pancreatic/Duodenal Injuries
PancreasI Simple contusion
II Major contusion/laceration
III Ductal transection or parenchymal injury L of SMA
IV Ductal transection or parenchymal injury R of SMA
V Massive disruption of head
DuodenumI Serosal tears or hematoma of a
single portion
II Injuries > 1 portion or laceration < 50% or circumference
III Lacerations of 50-75% of the 2nd portion or 50-100% or any other part
IV Laceration > 75% of 2nd portion or distal CBD
V Massive disruption of both duodenum/pancreas
Organ Injury Scaling Committee of the American Association for Surgery of Trauma (1994)
Treatment – Pancreatic Injuries
Pancreatic duct / pancreatic tail
Head of the pancreas
SIMPLE
vs.
COMPLEX…
Pancreatic Duct Injuries
Laceration not involving main duct Successfully managed by external drainage
Laceration of major duct Distal body or tail = distal pancreatectomy +/-
splenectomy Drainage Omental patch
Roux-en-Y loop to injury to preserve body/tail
80-90% of the normal pancreas can be resected without significant endocrine or exocrine deficiency
Treatment – Pancreatic Head No duct injury
No different than management of body/tail
Ductal injury Drainage only, if fistula and manage as a chronic fistula Roux-en-Y loop of jejunum over injury site Duodenal diverticulization or pyloric exclusion Whipple
Irreparable duodenal injury or CBD injury Two step procedure – resection then reconstruction
Access of enteral feeding at definitive duodenal or pancreatic repair either via jejunostomy or long nasojejunal feeding tube
Complications of Pancreatic Injuries
Fistula Pancreatic abscess Posttraumatic pancreatitis Pseudocysts Delayed postoperative hemorrhage Malabsorption
Pancreatic Fistula
Most common complication Develops in 1/3 of pancreatic wounds More common with injuries to head of pancreas Amylase concentration > 50,000 U/ml
Levels 5 -10 K usually small close quickly
Treatment Adequate drainage (leave until eating full diet) Prevention of infection Protection of skin Maintain nutrition via JT or TPN +/- Somatostatin - can significantly reduce output Operative (> 6 weeks) – Roux-en-Y jejunal loop
Complications
Abscesses 5% of pancreatic injury Mostly caused associated GI injuries Antibiotics (GPC and GNR coverage) Attempt percutaneous drainage No improvement – laparatomy
Pancreatitis Usually resolves within 1-2 weeks with symptomatic
therapy Feed only via TPN or JT
Complications
Pseudocysts Uncommon unless major duct injury Incidence 1.5-5% Locations
Distal – usually resolve with percutaneous aspiration or drainage
Proximal – generally require surgical intervention ? ERCP stent placement and percutaneous drainage
Ok, now what about the duodenum?
4 basic principles in managing duodenal trauma:
Restore intestinal continuity
Decompress the duodenal lumen
Provide wide, external drainage
Provide nutritional support
Treatment – Duodenal Injuries
Duodenal hematoma Usually 2nd or 3rd portion Partial or even complete obstruction Symptoms of pain and bilious emesis not impressive initially Treatment with NGT suction and TPN allows resolution
within 1-3 weeks
Duodenal laceration Debridement – particularly with GSW Repair primarily and buttress with omentum
Primary closure possible but significant concern about wound closure consider duodenal catheter drainage, pyloric exclusion, or duodenal diverticulization
Treatment – Duodenal Injuries
Duodenal wall loss Attempt transverse primary repair Too much tension
Duodenojejunostomy End-end duodeno-Roux-en-Y-jejunostomy
Duodenal transection Primary end to end anastomosis Extensive loss of tissue
Distal to ampulla of vater – Roux-en-Y jejunostomy Proximal to ampulla – Billroth II gastrojejunostomy or
Whipple
Duodenal Diverticulization
Pyloric Exclusion
Complications - Duodenum
Fistulas Worse complication Incidence 3-12% Difficult fluid and electrolyte management If drains, usually duodenocutaneous fistula
NPO, NGT, TPN, +/- somatostatin Usually takes 3-4 weeks for closure
Outcomes
Mortality Pancreatic
Majority secondary to associated injuries None or one associated injury only 4%
Penetrating trauma mortality = 25% Highest mortality with great vessel injuries = 9%
Duodenal Blunt trauma = 30% Majority secondary to associated injuries
All secondary to => 4 associated injuries Associated pancreatic injury = 40%
Frequent Errors
Reliance on isolated serum amylase to diagnosis or rule-out pancreatic injury
Assuming normal DPL or CT scan completely rules out pancreatic/duodenal injuries
Failure to open upper retroperitoneal hematomas over pancreas/duodenum
Failure to completely expose pancreas if any suspicion of injury
Failure to adequately search for cause of bile staining near duodenum or head of the pancreas
Attempting complex reconstruction of a transected pancreas in patients with other high-risk injuries
Summary Points… Part I: duodenum
The trauma by organ system notes…
Duodenum 4 principles of trauma management Level of injury Simple vs. Complex
Basic Approaches Other Options…
The Duodenal Hematoma
Duodenal Diverticulization
Pyloric Exclusion
Summary Points… Part II: pancreas
The trauma by organ system notes…
Pancreas Anatomy & Exposure Associated Injuries
Simple Injury… Complex Injury…
* Body and/or Tail* Head
Questions…?
Pancreatic and Duodenal Injuries
Bradley J. Phillips, MD
Trauma-Burns-ICUAdults & Pediatrics
Thank-you!