Duodenal Anatomy
Retroperitoneal
- Protective
- Subtle presentations
Central location
- 90% have associated injuries
- Majority of early deaths due to major vascular trauma
By segment
- D1 14%
- D2 33% (most complex repairs due to ampulla, and most common)
- D3-4 20% each
- Multiple sites 13%
Complex Hepatobiliary & Pancreatic Anatomy, hard to repair in D2
Pancreatic Anatomy
80% Functional Reserve - decreased with age, alcoholism, etc.
65% of Gland is to the Left of Mesenteric Vessels
Lies over L2 Vertebral Body - can be injured with lumbar fractures
Retroperitoneum
Zone 1 - midline: great vessels, pancreas, duodenum
Zone 2 - lateral: kidneys, ureters, adrenals
Zone 3 - pelvis
Duodenal Trauma – Associated Injuries (series of 3047 pts)
Liver 16.9%
Pancreas 11.6%
Small bowel 11.6
Colon 11.5
Major veins 9.8
Stomach 9.1
Biliary tree and gallbladder 6.8
Major arteries 6.6
GU 6.6
Spleen 1.2
Duodenal Trauma
80% Penetrating --> Infection from leak
- up to 50% mortality if delay in diagnosis is > 24 hrs
20% Blunt --> obstruction
AAST Duodenal Injury Scoring
Grade 1:
- Hematoma - Involving single portion of duodenum
- Laceration - Partial thickness, no perforation
Grade 2:
- Hematoma - Involving more than one portion
- Laceration - Disruption of <50% of circumference
Grade 3:
- Laceration - Disruption of 50-75% circumference of D2 or disruption of 50-100% circumference of D1, D3, D4
Grade 4:
- Laceration - Disruption of >75% circumference of D2 involving ampulla or distal common bile duct
Grade 5:
- Laceration - Massive disruption of duodenopancreatic complex
- Vascular - Devascularization of the duodenum
(D2 harder to manage which is why it has it's own grade 4)
Gr 1 Duodenal Trauma
Treatment = Primary Closure +/- Decompression
Hematoma can cause GOO:
- evacuate if in OR for some other reason
- Observe with non-op management with nutritional support for up to 3 weeks with evacuation for refractory cases
Gr 2 Duodenal Trauma
Treatment = Primary Closure +/- Decompression (duodenum doesn't always heal well)
Gr 3 Duodenal Trauma
D1 – Billroth 1
D2 - Closure +/- Diversion
D3-4 – Resection + Anast +/- Diversion
Gr 4 Duodenal Trauma
Diversion + Closure
or
Resection & Anastamosis +/- Biliary Diversion
Gr 5 Duodenal Trauma
Trauma Whipple
“Triple Tube” Technique
- Internal Drainage
- Feeding Access
- External Drainage
- G tube for drainage
- J tube directed proximal for drainage (Chambers uses a long NG, a ND tube)
- J tube directed distal for feeding
Diversion of Complex Duodenal Injuries
Pyloric exclusion - staple or suture across pylorus, RNY bypass or B2, eventually pylorus will open back up breaking sutures/staples once duodenum healed
Duodenal diverticulization - not really used
Current Status of Pyloric Exclusion
1970-90s data suggested decreased complications with PE in the setting of severe duodenal injures.
Several reports suggest that a number of severe duodenal injuries can be managed with primary repair & drainage rather than the more complex PE
All retrospective/nonrandomized data
PE used more frequently with concurrent pancreatic injuries
Limited good data
No clear cut benefit
Potentially useful in selected cases - especially w/ concurrent pancreatic injury
Await prospective data
Duodenal Trauma high M&M
?Future use of Bioprosthetics?
Pancreatic Trauma
See in 7% of Abd Trauma
75% occur with penetrating
10-25% Mortality
Dx:
- Clinical
- Radiologic
- Lab
Serum amylase: 10% PPV (delayed levels more sensitive), up to 95% NPV (but others observe up to 35% false negative rate with complete transection MPD)
Pancreatic Organ Injury Scale per the AAST
Grade 1
- Hematoma - Mild contusion without duct injury
- Laceration - Superficial laceration without duct injury
Grade 2
- Hematoma - Major contusion without duct injury
- Laceration - Major laceration without duct injury or tissue loss
Grade 3
- Laceration - Distal transection or parenchymal injury with duct injury
Grade 4
- Laceration - Proximal transection or parenchymal injury involving ampulla
Grade 5
- Laceration - Massive disruption of pancreatic head
IT'S ALL ABOUT THE MAIN DUCT
Diagnosis of Duct Involvement
Intraop Observation +/- secretin 1 unit/kg IV
Intraop Ductogram
CT
MRCP
ERCP
CT in Pancreatic Trauma
Sensitivity ~50% for determining whether the duct is involved
IE: flip a coin
False positive ~10%
MRI & ERCP in Pancreatic Trauma
? Evolving role
But what trauma patient can go to MRI?
ERCP in Trauma
Gold Standard for definition of ductal involvement
Stenting = Treatment Option
- Anectdotal evidence of up to 90% success rate with stenting and/or sphincterotomy
- ?adjunct to open or laparoscopic surgery
Pancreatic Trauma
Gr 1 – Contusion
Observe
Gr 2 – Parenchymal Injury
Drain +/- J-tube if in OR for some other reason
Reasonable to observe these patients
Gr 3 – Body/Distal Duct Involvement
Distal pancreatectomy +/- J-tube
Drain only for damage control in unstable patient
Gr 4 – Proximal Duct Involvement
Drain (if isolated injury)
J-tube
Gr 5 – Ampullary Injury &/or Disruption of Head
Something big
G 1-2
Closed suction drains favored over penrose or sump drains to lower infection rates and mortality
Drain for at least 7 to 10 days
G 3-4
Decreased complications with distal resection vs. drainage
80% functional reserve
Beware of Added Complexity
Keep it simple, no fancy pancreatic anastamoses
Blunt PDI
(Hilarious cartoon)
Data: review of 11 NE Trauma Centers experience with BPDI between 1996-2007
Non-Op Management of BPDI
Candidates = Gr 1 Duodenal & Gr 1-3 Pancreatic
Gr 1 D & Gr 1-2 P --> 90% Success rate
Gr 3 P (main duct involvement) --> 50% Success rate
BPDI Algorithm
Blunt pancreatic injury, HDS, CT scan --> AAST-OIS Grade
HGBPI Grade III, IV, V --> surgical intervention
LGBPI Grade I, II --> ERCP or MRCP --> Ductal injury -->
yes --> surgical intervention
no --> NOM
Complications of Pancreatic Trauma
23% mortality
53% infectious complications
Pancreatitis – 10%
Fistula – 20%
Pseudocyst – 5%
Abscess – 32%
Summary
Operative management of pancreatic trauma is based on grade of injury
For most injuries less is better
– Drainage is the mainstay of treatment
– Definitive repair can be safely delayed
These are high morbidity procedures