PANCREATIC AND DUODENAL

INJURIES UPDATE

07-08
Warko Karnadihardja

WHY IS IT IMPORTANCE ?
Preoperative diagnosis of these

injuries is often difficult

Operative management can be
complex
The pancreas and duodenum share
blood supply and incidence of
concomitant injury is common

INCIDENCE
Relatively uncommon
70% to 75%, due to penetrating injury
< 10% of abdominal trauma but

represent a major diagnostic challenge

Blunt injury is most common in children
Generally occurs from crushing injury
of the pancreas between the spine and
another objects (e.g. steering wheel,
handle bar, or blunt weapon)

ASSOCIATED INTRA
ABDOMINAL INJURY-1
> 90% of pancreatic injuries
> 50% morbidity and immediate

death associated with vascular

injury
50% to 75% major vascular injury
(Ao, CV, LVC, PV) caused by
penetrating pancreatic injuries, and
12% of blunt pancreatic injuries

ASSOCIATED INTRA
ABDOMINAL INJURY-2
Intra abdominal organs most

commonly injured in conjunction

with pancreatic injury, whether
blunt or penetrating, include: liver,
spleen, duodenum, and small
intestine
Early death from hemorrhage, and
Late death from infection

DIAGNOSIS
Should be suspected based on MIST
Physical examination & assessment
Serum amylase levels
FAST
DPL
CT-Scan
ERCP
MRCP
Isolated pancreatic injury is

uncommon

CRITIQUE ON
ASSESSMENT
Serum amylase levels are neither

sensitive nor specific

DPL is not realible
CT may identify peripancreatic
hematomas but may not identify
pancreatic lacerations or even
complete transections early in the
post injury period
ERCP and MRCP can be used to
diagnose pancreatic ductal injury in
hemodynamically stable pts

Foto abdomen : udara retroperitoneal,

perforasi duodenum

Foto abdomen : udara retroperitoneal,

perforasi duodenum

Ruptur duodenum

Kasus
Pria 17 th, KLL terlempar dari

sepeda motor, perut kena stang. 6

jam datang ke RSHS
Tanda2 peritonitis (+), tidak shock
Sempat dibuat foto polos toraks,
abdomen datar dan tegak
Sito operasi

INTRAOPERATIVE
DIAGNOSIS
Depends on visual inspection and

bimanual palpation of the pancreas by

Opening gastrocolic ligament
Entering lesser sac
Performing a Kocher maneuver
Mobilization of spleen
Opening retroperitoneum to facilitate
palpation : contusion or transection?
Intraoperative
cholangiopancreatography with iodine
contrast or with methylene blue

IMPORTANT POINT
SUSPECTED PANCREATIC INJURIES
SHOULD BE SURGICALLY EXPLORED

IMPORTANT POINT
IDENTIFICATION OF INJURY TO THE
MAJOR DUCT IS THE CRITICAL ISSUE
IN INTRA OPERATIVE MANAGEMENT
OF PANCREATIC INJURY

BLUNT PANCREATIC
INJURY
High index of suspicion
Minimal findings or

equivocal exam
Serial enzymes
Normal CT-Scan
Repeat CT-Scan
Ductal integrity
ERCP
MRCP

NORMAL DUCT ON MRCP

EXTRAVASATION ON MRCP

MRCP ON TRAUMA
A reliable noninvasive diagnostic

tool to determine the status of the

main pancreatic duct
However, MRCP is applicable only to
those pts who are hemodinamically
stable and have minimal or no other
serious injuries

PANCREATIC & DUODENAL

TRAUMA
Morbidity

Mortality

Early hemorrhage

Early

Late hemorrhage
Pancreatic pseudocyst

Hemorrhage
Late

Pancreatic fistula

Hemorrhage

Duodenal fistula

Duodenal fistula

Intraabdominal abscess

Pancreatitis

Obstruction

Uncontrolled sepsis

Malabsorption

MOF

Diabetes

PRINCIPLES OF TRATMENT
OF PANCREATIC INJURIES
1. Control hemorrhage
2. Debride devitalized pancreas, which

can require resection

3. Preserve maximal amount of viable
pancreatic tissue
4. Wide drainage of pancreatic
resections with closed suction drains
5. Feeding jejunostomy for postoperative
care with significant lesions

SURGICAL
EXPOSURES

Opening lesser sac

Opening retroperitoneal
Elevating the body of the pancreas

Divide the gastrohepatic omentum

SURGICAL EXPOSURES
Transection of Ligamentum Treitz
Exposure of the 4th portion of the

duodenum and duodenujejunal

junction

SURGICAL EXPOSURES
Kocher Maneuver
Medial rotation of
Duodenum
Pancreatic head
Distal CBD

SURGICAL EXPOSURES
Cattel Braasch Maneuver
Right abdominal visceral rotation
Technique of exposure of 3rd and

4th portions of duodenum

SURGICAL EXPOSURES
Aird Maneuver
Medial rotation of spleen and tail

of the pancreas

INTRA OPERATIVE DIAGNOSIS

OF PANCREATIC DUCTAL
INJURY
What to do
What not to do
Correlate injury
location
and ductal anatomy
Fluoroscopic
cholecysto
cholangiography
IV opiates
Optional

Open the
duodenum
Transect the tail
to
cannulate the
duct

Secretin stimulation
Intra operative ERCP

COMPLETE TRANSECTION
Debride to viable tissue
Primary repair with spatulation
Interrupted absorbable suture

CHOLECYSTOCHOLANGIOGRAPHY
Lesser sac is open to visualize the

pancreas
Radiographic contrast material and
methylene blue is injected into gall
bladder or the CBD
X-ray is taken looking for extravasation
Pancreas inspected for extra vasation of
methylene blue
Methylene blue pancreatography
I.V. fentanyl causes spasm of the
Sphincter Oddi
Methylene blue cholangiography
precisely identifies the site of injury

TREATING PANCREATIC DUCTAL

INJURY

A Balancing Act of
Parenchymal preservation

Parenchymal resection

Risky anastomosis

Pancreatic insufficiency

Activated fistula

Malabsorption

Secondary hemorrhage

Diabetes mellitus

Wound complications

> 80% resection

WHAT IS TREATMENT
OPTIONS FOR
1. Pancreatic contusion or capsular

laceration without ductal injury?

2. Pancreatic transection distal to the
SMA?
3. Pancreatic transection to the right of
the SMA ? (not involving the ampula)
4. Severe injury to the both the head of
the pancreas and the duodenum ?

Pancreaticoduodenectomy

Caput Pankreas dipotong

dekat tempat trauma
Distal pankreas didrainase secara
Roux-en-Y

Vaskularisasi saluran empedu ekstrahepatik

COROSION CAST OF ADULT LIVER

BLOOD SUPPLY TO CBD

Van Damme and Bonte J : Vascular Anatomy of in

Abdominal Surg. Thieme 1990

Surgical Clin N. Am,1994

TRAUMA TO THE
DUODENUM
Complete transection
Stop hemorrhage
Exposure
Location of injury
Primary repair
Protection of repair

ANATOMY OF THE
DUODENUM
The duodenum shares its blood supply with

the pancreas
There are 4 parts
1st portion duodenum = superior portion
intra peritoneal
2nd Portion duodenum = descending
portion, contains ampula Vateri
3rd Portion duodenum = transverse
portion-extends from the ampula Vateri to
SMA anteriorly, and the ureter, IVC, and Ao
posteriorly
4th Portion duodenum = ascending portion,
begins at SMA and ends at the jejunum

DIAGNOSIS OF DUODENAL
INJURIES
Clinical suspicion is based in MIST
Blunt injury:
Midepigastric or RUQ pain and tenderness
Can have peritoneal signs
The symptoms and findings can be subtle
X-ray study:
Retroperitoneal air
Obliteration of the right psoas margin
Diagnosis is generally made at

laparotomy

DIAGNOSIS OF DUODENAL
INJURIES
With penetrating mechanisms
Duodenal injury is found at

laparotomy, usually for GSW

CT-findings:
Paraduodenal hemorrhage
Air or contrast oral leak
Upper gastro-intestinal study
Adequate intra operative exposure is
vital duodenal injuries are among
the most commonly missed at
laparotomy

DUODENUM INJURY &

OPERATIVE MANAGEMENT
Grade I or II : Hematomas single or

multiple segments
Non operative
NGT for 1 to 2 weeks
Surgical evaluation and
seromuscular repair of grade I or II
lacerations
Primary repair
Stapled, double layer or single
layer

DUODENUM INJURY GRADING

AND OPERATIVE
MANAGEMENT
Grade III or IV laceration
Large
Very large
Injured ampulla
Injured distal CBD
Management
Primary repair
Resection anastomosis
Roux-en-Y duodenojejunostomy

TREATING THE DUODENAL

INJURY
A Balancing Act
Severe

Mild
Secondary to stab wound
< 75% circumference
3rd to 4th portion
Injury to repair interval < 24 hr
No associated pancreatic or

Blunt or gun shot wound

> 75% circumference
1st or 2nd portion
Injury to repair interval > 24 hr
Associated biliary or pancreatic
injury

biliary injury
No

Yes

DECOMPRESSIVE
PROCEDURES
Three tube technique
Gastrostomy or

gastroduodenostomy
Retrograde duodenostomy
Feeding jejunostomy
Tube duodenostomy
External drainage

DIVERSIONARY
PROCEDURES
Duodenal diverticulation
Pyloric exclusion
Temporary GI dysconnection
External drainage

Simple duodenoraphy
Duodenojejunostomy

Jejunal serosal patch

segemental
dengan
end-to-end

Reseksi
anastomosis

Eksklusi pylorus untuk diversi duodenum

WHIPPLE FOR TRAUMA

Grade V pancreatic injury
Massive disruption of pancreatic

head
Grade V duodenal injury
Massive disruption of
duodenopancreatic complex
Duodenal devascularization
Non reconstructable injury to
pancreas, duodenum and distal
CBD

WHIPPLE FOR TRAUMA

Very well suited for staged procedure
1. Control of hemorrhage & resection
debridement
2. Resuscitation in the ICU
3. Gastrointestinal reconstruction
Achiles Heel & pancreatic remnant
anastomosis
Alternatives
Ductal ligation
Pancreaticogastrostomy
Total pancreatectomy
Islet cell auto transplantation

Pancreaticoduodenectomy

SECRETION
Bile
Pancreatic juices

: 1000ml/day
: 800-1000

ml/day
Gastric juices
: 1.500-2.500
ml/day
Mix in the duodenum

TREATMENT OPTIONS
1. Intramural duodenal hematoma
2. Duodenal perforation
Isolated injury to the duodenum
Associated vascular injury
Blunt injury
Missile injury
Associated common bile duct injury
3. > 75% of the wall involved
4. > 24 hours since injury
5. Combined injuries to the duodenum

and the head of pancreas

6. Organ injury scale

OUTCOME-1
Mortality rate 40% if diagnosis is

delayed > 24 hours

Mortality 2% to 11% if surgery
within 24 hours of injury
Duodenal dehiscence with resultant
sepsis accounts for nearly 50% of
the deaths
Complications occur in 64%

OUTCOME-2
Retrograde to be decompression

can be associated with a decreased

mortality rate:
9% with to be decompression vs
19.4% without
Duodenal fistula rate was
2.3% with decompression vs
11.8% without
Pyloric exclusion can also provide
adequate decompression

THANK YOU