Transcript Management of Pancreatic and Duodenal Injuries

Case Presentation #1
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68 yof MVC, unrestrained driver
PMH: DM, LLL resection
Initially awake/alert, mild distress
HR 110, BP 120/P, RR 22, sats 100%
PE:
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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
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Head
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Chest
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SDH, R frontal contusion
Aortic pseudoaneurysm
Mediastinal hematoma
Abdomen
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Duodenal perforation
Hemoperitoneum & retroperitoneal hematoma
Laceration R kidney
Case Presentation #1
 OR
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Ex Lap
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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)
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PRBC 19, FFP 10, Plts 6
 Acidosis
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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:
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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
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7.37/38/95/21, Hgb 12.9
Amylase 880, Lipase 951
Case Presentation #2
 OR
 Findings
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Ischemic L colon at splenic flexure
Mod laceration spleen (not bleeding)
Severely laceration/contused distal pancreas
Non-perfused L kidney
Procedure
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Splenectomy, distal pancreatectomy, L colectomy
with colostomy, L nephrectomy, long nasojejunal
feeding tube, large bore drains x 2
Case Presentation #2
 Postoperative recovery
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Extubated
Complicated
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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-ICU
Adults & 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
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Fistula can cause serious fluid/electrolyte problems
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Dehiscence of duodenal suture line dangerous
secondary to activated enzymes
Mechanisms of Injury
 Pancreas
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Blunt - 6%
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Laceration of head or body
Rupture over the spine at the neck
Penetrating
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GSW - 10%
SW – 5%
Associated Injuries with Pancreas
 Blunt
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Liver – 36%
Spleen – 30%
Kidney – 18%
Colon – 18%
Major vessel – 9%
 Penetrating
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Stomach – 54%
Liver – 49%
Major vessel – 45%
Kidney – 44%
Mechanism of Injury
 Duodenum
 Blunt
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Crushing the duodenum against the spine
“blow-out” of the duodenal loop
 Partially closed at pylorus and ligament of Treitz
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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
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Pancreas – 40-50%
 Penetrating
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Liver – 54%
Major vessels – 52%
Small bowel – 50%
Colon 49%
Diagnosis
 Signs and symptoms
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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
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Amylase elevation
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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
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Plain films
Contrast swallow
CT scan
Plain film (Historical)
 KUB or upright
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Lucas, Surg Clin N Amer, 1977
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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
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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
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Duodenal injury (Kunin et al, Am J Roent, 1993)
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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)
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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)
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DPL – low sensitivity for duodenal perforation and no utility in
pancreatic injuries
 Endoscopic Retrograde Cholangiopancreatography
(ERCP)
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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)
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Probably most useful in blunt trauma patients with remote
pancreatic injury
Diagnosis
 Intraoperative evaluation
 Careful evaluation of pancreas/duodenum
 Particularly if hematoma overlying
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Maneuvers
st
nd
rd portions of duodenum and
 Kocher – expose 1 , 2 , 3
head of pancreas
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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
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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
 Pancreas
 Duodenum
I 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
I
II
III
IV
V
Serosal tears or hematoma of a
single portion
Injuries > 1 portion or laceration <
50% or circumference
Lacerations of 50-75% of the 2nd
portion or 50-100% or any other part
Laceration > 75% of 2nd portion or
distal CBD
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
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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
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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
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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
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Most common complication
Develops in 1/3 of pancreatic wounds
More common with injuries to head of pancreas
Amylase concentration > 50,000 U/ml
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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
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Uncommon unless major duct injury
Incidence 1.5-5%
Locations
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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:
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Restore intestinal continuity
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Decompress the duodenal lumen
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Provide wide, external drainage
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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
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Worse complication
Incidence 3-12%
Difficult fluid and electrolyte management
If drains, usually duodenocutaneous fistula
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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%
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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
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Basic Approaches
Other Options…
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The Duodenal Hematoma
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Duodenal Diverticulization
Pyloric Exclusion
Summary Points… Part II: pancreas
 The trauma by organ system notes…
 Pancreas
 Anatomy & Exposure
 Associated Injuries
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Simple Injury…
Complex Injury…
* Body and/or Tail
* Head
Questions…?
Pancreatic and Duodenal Injuries
Thank-you!
Bradley J. Phillips, MD
Trauma-Burns-ICU
Adults & Pediatrics