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 2 nd 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/ /43/101/ /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: 1 st 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: ,000 ml Gastric: ,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  2 nd portion most common site  25% occur in the 4 th 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 1 st, 2 nd, 3 rd 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 Pancreas I Simple contusion IIMajor contusion/laceration IIIDuctal transection or parenchymal injury L of SMA IV Ductal transection or parenchymal injury R of SMA VMassive disruption of head Duodenum ISerosal tears or hematoma of a single portion IIInjuries > 1 portion or laceration < 50% or circumference IIILacerations of 50-75% of the 2 nd portion or % or any other part IVLaceration > 75% of 2 nd portion or distal CBD VMassive 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 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 2 nd or 3 rd 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-ICU Adults & Pediatrics Thank-you!