Transcript Duodenal Injuries - The American Association for the Surgery of

Duodenal Injuries
Niqui Kiffin, M.D.
Operative Skills Conference
17 November 2009
Introduction
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Duodenal injuries are both difficult to diagnose and
repair due to its retroperitoneal location, close
association with the biliary tract and pancreas, as
well as its marginal blood supply
Injuries are fairly uncommon – approx 3-5%
incidence
Almost always occur with associated injuries to
vascular structures or nearby organs
Injury must be suspected and acted upon early due
to significantly increased morbidity and mortality
with delayed diagnosis
Duodenal Anatomy
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Small, thin-walled
organ
Constitutes the
beginning of the SB
Approx 21cm
Starts just distal to
the pylorus
Duodenal Anatomy
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Divided into 4 portions:
– 1st: Superior – Ranges from the pyloric vein of Mayo to the CBD
– 2nd: Descending – Extends from the CBD and the GDA to the
Ampulla of Vater
– 3rd: Transverse – Extends from the Ampulla of Vater to the
mesenteric vessels
– 4th: Ascending – Extends from the mesenteric vessels to the
ligament of Treitz
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Entry is closed by the pyloric sphincter
Exit is suspended by the ligament of Treitz
Organ is almost entirely retroperitoneal
– With the exception of the 1st portion and the convergence of the
3rd to the 4th portion
Blood Supply
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Shares the blood supply
with the pancreas
Arterial supply includes the
GDA, retroduodenal artery,
supraduodenal artery, the
superior
pancreaticoduodenal artery,
the SMA and the inferior
pancreaticoduodenal artery
Multiple variations are
common in this region
Surrounding Anatomy
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Portions of the duodenum
lie directly over the spine
(1st,distal 3rd, and 4th)
Psoas muscles, aorta, IVC,
and R kidney form the
posterior boundaries
Anterior organs include
liver, hepatic flexure of
colon, R transverse colon,
mesocolon, and stomach
Gallbladder is located
laterally and the pancreas is
found medially
Additional Anatomy
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CBD enters the posterior aspect of the
pancreas after it passes underneath
the duodenum (83%).
It enters the gland, courses within the
pancreatic tissue, and enters the
duodenal lumen at the junction
between the 2nd and 3rd portion.
Physiology
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Duodenum is the portion of the bowel
where the stomach contents are mixed with
biliary and pancreatic secretions for
digestion, therefore it contains food as well
as powerful digestive enzymes
Approx 10L of fluid passes through the
duodenum a day
The high volume, as well as the caustic
nature of the secretions, combine to cause
the disastrous complications associated with
duodenal injury.
Mechanism of Injury
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Most injuries are penetrating in nature
– GSW
– SW
– Shotgun
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Blunt injuries account for approx 25%
– MVC
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Steering wheel
– Bicycle handlebars (pediatrics)
– Fall
Mechanism of Injury
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Blunt Injury (con’t)
– Crush
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Occur with a direct force applied to the abdominal wall,
transferred to the duodenum which is pushed posteriorly
against the spinal column
– Shear
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Occur when the mobile and nonfixed portions of the organ
accelerate and decelerate forward and backward respectively
– Burst
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Force is applied to a gas and fluid-filled filled duodenum
against a closed pylorus and acutely flexed duodenojejunal
angle
– “Closed-loop” effect is established periodically throughout the
day as the pylorus is closed approximately 1/3 of the day
Associated Injuries
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Organs most commonly injured in
association:
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Liver
Pancreas
SB
Colon
Venous Injuries
Stomach
Arterial Injuries
Diagnosis
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Requires a high index of suspicion
– Accurate H&P
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More difficult to diagnose in blunt trauma than
penetrating
– As penetrating injuries tend to necessitate an operative
exploration
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No specific diagnostic test found to be accurate all
of the time
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Abdominal X-rays
UGI
Endoscopy
CT Scan
Diagnosis
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History & Physical
– History
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Mechanism of injury
– Deceleration injury (fall, head-on MVC, right-sided impact)
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Details from the field
– Vital signs
– Crushed steering wheel
– Impact to the epigastrium
– Physical
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Peritoneal signs usually not present unless retroperitoneum
violated
May be characterized by minimal findings
– Unless diagnosis delayed
Abdominal X-Ray
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Air collections outlining R kidney
Presence of gas around the R psoas
muscle
Usually do not present with free
intraperitoneal air
Diagnosis
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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
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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
Diagnosis
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CT Scan
– Best method for visualizing retroperitoneal
structures without an operation
– Also very helpful in evaluating the remaining
intra-abdominal cavity in stable patients
– Not always very sensitive
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Extravasation of oral contrast from the duodenum with
a retroperitoneal hematoma – OR
Extraluminal gas/fluid around the duodenum/focal
bowel wall thickening/interruption of progress of the
bowel contrast medium –May be inconclusive
– May be combined with UGI, endoscopy, or OR for
conclusive diagnosis
CT Abdomen/Pelvis
Exploratory Laparotomy
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Midline incision
Immediate control of life-threatening
hemorrhage
Control of GI contamination
Thorough exploration of the abdominal
cavity and retroperitoneum
Operative Exposure of
Duodenal Injuries
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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
Operative Exposure of
Duodenal Injuries
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Thorough exploration requires
evaluation of all 4 portions
– Kocher Maneuver
– Transection of the ligament of Treitz
– Cattell and Braasch maneuver
Kocher Maneuver
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Incise the lateral peritoneal
attachments of the duodenum
Sweep the 2nd and 3rd portions
medially using blunt and sharp
dissection
– Use gentle traction
– Be mindful not to cause iatrogenic injury
to the duodenum
Kocher Maneuver
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Surgeon should be able to palpate the head
of the pancreas to the level of the
mesenteric vessels
Surgeon will 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
– Be mindful of the R gonad vessel
Kocher Maneuver
Transection of the
Ligament of Treitz
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Transect the ligament
of Treitz to visualize
the 4th portion of the
duodenum
– Use sharp dissection
– ID and preserve the
inferior mesenteric vein
– Rotate the duodenum
laterally from right to
left
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Can visualize the 3rd
(anteriorly) and 4th
portion
Can palpate the 3rd
portion posteriorly
Cattell & Braasch
Maneuver
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Incise the avascular line of Toldt
Mobilize the R colon and the hepatic flexure
Sharply incise the retroperitoneal
attachments of the SB from the RLQ to the
duodenojejunal junction
Reflect the SB out of the abdominal cavity
Gives excellent exposure, however it is a
somewhat complex maneuver that may not
be required
Cattell & Braasch
Maneuver
Duodenum Organ Injury
Scale
Duodenal Repair Options
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Duodenorrhaphy
Duodenorrhaphy with
external drainage
Duodenorrhaphy with
tube duodenostomy
– Primary
– Antegrade
– Retrograde
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Triple ostomy
technique
Jejunal serosal patch
Pedicled Graft
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Duodenal Resection
Duodenal
Diverticulization
Pyloric exclusion
Whipple procedure
Duodenorrhaphy
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Used to repair approximately 75-85% of all injuries
Debride nonviable tissue
Meticulous double layer closure
– Closely reapproximate the mucosal layer with absorbable suture
– Interrupted seromuscular layer with nonabsorbable suture –
Lembert sutures
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Close longitudinal injuries transversely if less than 50% of the
duodenal circumference to avoid duodenal narrowing
Consider placing omentum over your repair
External drainage is surgeon’s prerogative
– Do not place directly over the repair
Duodenorrhaphy
Duodenorrhaphy with
Tube Duodenostomy
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With more complex injuries, some surgeons have
advocated “protecting the repair” with
decompression maneuvers
Primary
– Tube is placed through a separate stab incision in the
duodenum
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Antegrade
– Duodenum is decompressed by passage of a tube through
the pylorus
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Retrograde
– Tube is passed retrograde from insertion in the jejunum
Duodenorrhaphy with
Tube Duodenostomy
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The use of tube duodenostomy is very
controversial
– Studies have shown conflicting results
– Some advocate decompression of
duodenum, however many surgeons are
not comfortable placing additional holes
in the GI tract
Duodenorrhaphy with
Tube Duodenostomy
Jejunal Serosal Patch
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Described by Kobbold and Thal
Resected areas of duodenal wall in dogs (1.5 x
3cm)
Injuries were repaired by sewing the serosa of a
loop of jejunum to the edges of the duodenal
defect
After the animals were sacrificed, a histologic study
showed mucosal resurfacing of the jejunal serosa
Since then, this technique has been used on human
patients using a patch from a Roux-en-Y limb.
Some surgeons have criticized the idea of making
an additional suture line
Jejunal Serosal Patch
Pedicled Graft
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First described by Jones and Joergenson, later
modified by DeShazo
Patch is constructed by using a proximal segment
of jejunum, which is carried up in a retrocolic
location on its vascular pedicle.
Antimesenteric border is then split longitudinally
and anastomosed using a double-layer technique to
the duodenal defect.
This technique has also been described using
pedicle flaps from stomach (gastric island flaps) or
the ileum. Blood supply is based on the
gastroepiploic vessels.
Pedicled Graft
Duodenal Resection
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If nearly the entire circumference of the duodenum is
devitalized, a segmental resection with an end-to-end
duodenostomy may be performed
Rate-limiting step may be mobilization of the 2nd portion of
the duodenum
In cases where the injury is adjacent to the ampulla of Vater,
extreme care must be taken
– Consider performing a choledochostomy with passage of a probe
in order to be certain of the exact location of the ampulla
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Cases have been documented where re-implantation of the
ampulla or the CBD were necessary
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
Grade III/IV Injuries
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Certain injuries are severe enough to require an extended
repair
– Grade III or IV duodenal injuries
– Compromised blood supply to the duodenum
– Associated pancreatic injury without injury to the main pancreatic
duct
– Delayed diagnosis
– Injury to 1st or 2nd portion
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The following procedures exclude the duodenum from the
passage of gastric contents to allow time for the duodenum to
heal and to prevent suture line dehiscence
– Duodenal diverticulization
– Pyloric Exclusion
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Should be noted that these procedures can only be performed
if the injury is amenable to primary repair
Duodenal
Diverticulization
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Originally described by Berne in 1968
Concept had first been described in 1907, however
this technique did not include the entire process
Technique was prompted by the unacceptably high
complication rate associated with combined
duodenal/pancreatic injuries
Procedure includes antrectomy, debridement and
repair of the duodenum, tube duodenostomy,
vagotomy, biliary tract drainage, and a feeding
jejunostomy tube
Procedure is very time-consuming and may or may
not require all of the steps
Duodenal
Diverticulization
Pyloric Exclusion
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An alternative to duodenal diverticulization
Secures exclusion of the duodenal suture line and diversion of
the gastric contents
Procedure entails a duodenorrhaphy plus a gastrotomy
Through the gastrotomy the pylorus is closed using
absorbable suture
– Ideally the suture breaks down over a few weeks and the pylorus
opens up
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Then a gastrojejunostomy is performed using the gastrotomy
site
Alternative method includes using a stapler across the pylorus
Pyloric Exclusion
Whipple Procedure
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Whipple Procedure aka Pancreaticoduodenectomy may be
required for severe duodenal injuries that involve the main
pancreatic duct and the CBD or ampulla
Indications include:
– Massive, uncontrollable bleeding from the HOP or adjacent
vascular structures
– Massive and unreconstructable injury to the main pancreatic duct
in the head
– Combined unreconstructable injuries of:
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Duodenum and HOP
Duodenum, HOP, and CBD
Almost never performed during the 1st operation
Approximately 30-40% mortality rate with patients that
require trauma Whipple
Whipple Procedure
Conclusion
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Duodenal injuries are fairly uncommon,
however they may be devastating when
they occur
Average mortality is 17%
– Increases with delayed diagnosis
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Most duodenal injuries can be repaired with
simple repair, however all trauma surgeons
should have a few techniques in their
armamentarium for more severe injuries
References…
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Asensio JA, Demetriades D, Berne JD, et al. A Unified
Approach to the Surgical Exposure of the Pancreatic and
Duodenal Injuries. The American journal of Surgery Vol
174: 1997; 54-59.
Asensio JA, Feliciano DV, Britt LD, et al. Management of
Duodenal Injuries. Current Problems in Surgery Vol 30,
No 11: 1993; 1021-1100.
Britt, LD. Duodenal Primary repair, Diversion, and Exclusion.
Operative Techniques in General Surgery Vol 2, No 3:
2000; 234-39.
Feliciano DV, Mattox KL, Moore EE, et al. Duodenum and
Pancreas. Trauma 6th ed: 2008; CH 35.