Management of Pancreatic and Duodenal Injuries
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Transcript Management of Pancreatic and Duodenal Injuries
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
Chest
SDH, R frontal contusion
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-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
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
st
nd
rd portions of duodenum and
Kocher – expose 1 , 2 , 3
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
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
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
Thank-you!
Bradley J. Phillips, MD
Trauma-Burns-ICU
Adults & Pediatrics