Transcript Duodenal Injuries - The American Association for the Surgery of

Taichiro Tsunoyama
• Duodenal injuries are uncommon
• Incidence of blunt duodenal injury;0.2%
• Penetrating(78%) wounds are more common than
blunt(22%)
• Duodenal injuries are both difficult to diagnose and
repair due to its retroperitoneal location
• First portion of the small intestine
• From the plyoric ring to the Treitz ligament
• 25-30 cm in length, Latin word duodeni (twelve each)
• Divided into 4 portions
1st: Superior
Pass backword and upward toword the neck of the gallbladder
Most of portion is intraperitoneal
2nd: Descending
Contain the bile and panceatic duct(Ampulaa of Vater)
Entirely retroperitoneal
3rd: Transverse
SMA runs downward over the 3rd portion
4th: Ascending
Short distance(2-3cm), suspensory ligament of Treitz
Derived from the pancreatioduodenal artery
Superior branch; from hepatic artery
Inferior branch; from SMA
Drain into the portal vain and SMV
• Duodenum is the portion of the bowel where the stomach
contents are mixed with biliary and pancreatic secretions for
digestion
Contains food as well as powerful digestive enzymes
• About 5L of fluid passes through the duodenum a day
Massive flow volume
gastric juice
2500ml
bile
1000ml
pancreatic juice 800ml
saliva
800 ml
• Most injuries are penetrating in nature
• Blunt injuries account for approx 25%
Crush
Occur with a direct force applied to the abdominal wall,
transferred to the duodenum which is pushed posteriorly
against the spinal column
Shear
Occur when the mobile and nonfixed portions of the
organ accelerate and decelerate forward and backward
respectively
Burst
Force is applied to a gas and fluid-filled filled
duodenum against a closed pylorus and acutely flexed
duodenojejunal angle
1st
2nd
3rd
4th
Multiple
14.4%
33.0%
19.4%
19.0%
14.2%
Asensio J management of duodenal injuries
Cur-r Probl Surg, November 1993
Organs most commonly injured in association:
Liver
16.9%
Pancreas
11.6%
Small bowel 11.6%
Colon
11.5%
Venous Injuries 9.8%
Stomach
9.1%
Biliary tree and Gallbladder 6.8%
Arterial Injuries 6.6%
Asensio J management of duodenal injuries
Cur-r Probl Surg, November 1993
• Directly attributable duodenal mortality; 2-5%,6-29%
• Morbidity rates;30-63%
• Reason for the variability
mechanism of injury
associated injury
time to initial diagnosis
Early death(particularly with penetrating injury)
Exsanguination from associated vascular, liver or spleen
Complication
Anastomotic breakdown
fistula
intra-abdominal abscess
sepsis
MOF
Delay in diagnosis >12hr; 53 % of their patients
Delay in diagnosis >24hr; 28 % of their patients
Mortality
40%; the patients who diagnosed over 24hr
11%; the patients who underwent surgery within 24hr
Lucos C,Ledgerwood A: Factor influencing outcome after blunt duodenal injury. J
Trauma 15(10):839-846,1975
1. Early diagnosis
2. Control of hemorrhage
3. Control of bacterial contamination
• Requires a high index of suspicion
Accurate H&P
• More difficult to diagnose in blunt trauma than penetrating
As penetrating injuries tend to necessitate an operative
exploration
• No specific diagnostic test found to be accurate all of the time
Abdominal X-rays
UGI
Endoscopy
CT Scan
Often quite subtle
Air collections outlining right kidney
Presence of gas around the right psoas muscle
Upper GI Series
Usually with Gastrograffin or thin barium
May see a leak with fluoroscopy
Consider changing position for oblique or lateral views to
get a 3D picture
Endoscopy
May visualize a intra-luminal blood, a perforation or a
hematoma directly
May be considered in conjunction with UGI or CT
Not usually used acutely due to the possibility of worsening
injury with either the scope or the insufflation
•Must be performed with both oral and intravenous
contrast
•Best method for visualizing retroperitoneal structures
without an operation
•Helpful in evaluating the remaining intra-abdominal
cavity in stable patients
•Not always very sensitive
Extravasation of oral contrast from the duodenum with a
retroperitoneal hematoma
Extraluminal gas/fluid around the duodenum
Focal bowel wall thickening
Interruption of progress of the bowel contrast medium
S. Prichayudh et al.
Successful management of large intramural duodenal haematoma causing
obstructive jaundice
10.1016/j.injury.2007.05.025
• Unreliable in detecting isolated duodenal and other
retroperitoneal injuries
• But DPL is often helpful because of 40% of patients
have associated intra-abdominal injuries that will result in
a positive DPL
• The finding of amylase or bile are more specific
indicators of possible duodenal injury
• Midline incision
• Immediate control of life-threatening hemorrhage
• Control of GI contamination
• Thorough exploration of the abdominal cavity and
retroperitoneum
Intra-op findings that require exploration
Crepitus along the duodenal sweep
Bile staining of paraduodenal or adjacent tissues
Documented bile leak
Right-sided retroperitoneal or periduodenal hematoma
Thorough exploration requires evaluation of all 4 portions
Kocher Maneuver
Transection of the ligament of Treitz
Cattell and Braasch maneuver
• Should be able to palpate the head of the pancreas to the
level of the mesenteric vessels
• Be able to visualize the anterior and posterior aspects of
the 2nd and 3rd portions of the duodenum, the head of the
pancreas and the infrarenal IVC
Technique for exposure of 3rd and 4th portion of the duodenum
1. Incise the avascular line of Toldt
2. Mobilize the asending colon and the hepatic flexure
3. Sharply incise the retroperitoneal attachments of the Small
bowel from the RLQ to the duodenojejunal junction
4. Reflect the Small bowel out of the abdominal cavity
Gives excellent exposure, however it is a somewhat complex
maneuver that may not be required
Exposure of the entire fourth portion of the duodenum and
the duodenojejunal junction
Non operative
NG tube
Surgical evacuation and seromuscular repair
Duodenorrhaphy
• Used to repair approximately 75-85% of all injuries
• Debride nonviable tissue
• Double layer closure
• Close longitudinal injuries transversely if less than 50% of
the duodenal circumference to avoid duodenal narrowing
• Consider placing omentum over your repair
Duodenorrhaphy
Primary repair(with Tube Duodenostomy)
Resection anastomosis
Roux-en-Y duodenojejunostomy
Pyloric Exclusion
Mild
Severe
Agent
Stab
Blunt or missile
Size
<75%wall
≥75%wall
Duodenal site
3,4
1,2
Injury repair
interval
<24
≥24
Adjacent injury
No CBD
CBD
No pancreatic injury
Pancreatic injury
Protection of the duodenalrepair is not necessary in the
mild group
“protecting the repair” with decompression maneuvers
1. Primary
Tube is placed through a separate stab incision in the
duodenum
2. Antegrade
Duodenum is decompressed by passage of a tube through
the pylorus
3. Retrograde
Tube is passed retrograde from insertion in the jejunum
Duodenorrhaphy with Tube
Duodenostomy
•
An alternative to duodenal diverticulization
• Secures exclusion of the duodenal suture line and diversion
of the gastric contents
• Through the gastrotomy, the pylorus is closed using
absorbable suture
• Alternative method includes using a stapler across the
pylorus (TA-50)
Pyloric Exclusion
Seamon MJ
A ten-year retrospective review: does pyloric exclusion
improve clinical outcome after penetrating duodenal and
combined pancreaticoduodenal injuries?
J Trauma. 2007 Apr;62(4):829-33.
Barone JE,
Pyloric exclusion leads to a trend toward more
complications, a higher pancreatic fistula rate, and a longer
hospital length of stay.
J Trauma. 2007 Sep;63(3):720
DuBose JJ, Demetriades D
Pyloric exclusion in the treatment of severe duodenal
injuries: results from the National Trauma Data Bank.
Am Surg. 2008 Oct;74(10):925-9
• The serosa of a loop of jejunum is sutured to the edge of
the duodenal defect
• The serosa exposed to the duodenal lumen rapidly
undergoes complete mucosal resurfacing.
Jejunal Serosal Patch
• If nearly the entire circumference of the duodenum is
devitalized, a segmental resection with an end-to-end
duodenostomy may be performed
• If it is not possible to mobilize the duodenum without
tension, a Roux-en-Y duodenojejunostomy can be performed
with the distal duodenum oversewn.
Duodenal Resection
• Originally described by Berne in 1968
• The concept is to completely divert both gastric and
biliary contents
• antrectomy,
debridement and repair of the duodenum
tube duodenostomy
vagotomy
biliary tract drainage(T-tube)
feeding jejunostomy tube
• Procedure is very time-consuming and may or may
not require all of the steps
Duodenal Diverticulization
• Massive disruption of duodeopancreatic complex
• Duodenal devascularization
• Whipple for Trauma
• Performed as a staged procedure
• Control of hemorrhage, resection debridement in the initial
laparotomy
stapler resection of the duodenal sweep and pancreatic head,
ligation of the common bile duct at pancreatic head
• Resuscitation in the ICU
• Gastrointestinal reconstruction with pancreatic remnant
anastomosis and choledochojejunal anastomosis
18 patients (retrospective 126-month study)
17 penetrating (94%) / 1 blunt (6%)
Indications
• massive uncontrollable retropancreatic hemorrhage
13 patients (72%)
• massive unreconstructable injury to
the head of thepancreas/main pancreatic duct intrapancreatic
portion/distal common bile duct
18 patients (100%)
Overall survival was 67% (12 of 18 patients)
• Nonabsorbable interrupted sutures should be used to
sew the mucosa of the jejunum to the pancreatic capsule
• A second layer of nonabsorbable sutures is added