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!