Pancreatic and Duodenal Injuries Flashcards
(107 cards)
1
Q
What blunt trauma mechanisms are commonly associated with duodenal injury?
A
Significant direct force to the epigastrium, such as from bicycle handlebars in children, steering wheel impacts, and seatbelt injuries
2
Q
What are the indications for surgery in a patient with a suspected duodenal injury?
A
Surgery is indicated if the patient has evidence of peritonitis, hemodynamic compromise with concern for hemorrhage, or CT evidence of free air
3
Q
What is the management approach for a stable patient with periduodenal air and inflammatory changes?
A
Surgical exploration is recommended, either with laparoscopy or laparotomy
4
Q
What characterizes a grade I duodenal injury?
A
A hematoma involving one portion of the duodenum or a partial-thickness laceration without transmural perforation.
5
Q
What is the recommended nonoperative management for a grade I duodenal injury identified on CT without indications for surgery?
A
Nasogastric decompression for up to 2 weeks
6
Q
When should operative intervention be considered in a grade I duodenal injury?
A
If there is progressive obstruction or if the injury fails to resolve after nonoperative management
7
Q
What management is recommended for duodenal hematomas < 50% circumferential involvement?
A
No further intervention, but consider nasogastric decompression and distal feeding tube placement
8
Q
How should a duodenal hematoma > 50% circumferential involvement be managed?
A
Hematoma evacuation with care to avoid mucosal disruption and simple closure. For larger injuries (e.g., 75%), consider reconstruction with gastrojejunostomy
9
Q
What characterizes a grade II duodenal injury?
A
A hematoma involving more than one portion of the duodenum or a full-thickness laceration involving < 50% of the circumference, without duct disruption or ampulla involvement.
10
Q
How are grade II duodenal injuries managed if identified early?
A
Most can be managed with simple, tension-free repair.
11
Q
What are the surgical options for mobilization or narrowing issues in grade II duodenal injuries?
A
Debridement with duodenoduodenostomy or laceration repair with gastrojejunostomy are viable options.
12
Q
What is the recommended management for delayed repair or significant contamination in grade II duodenal injuries?
A
The safest option is often debridement to healthy edges followed by a Roux-en-Y duodenojejunostomy.
13
Q
What characterizes a grade III duodenal injury?
A
A laceration involving 50% to 75% of the circumference of D2 (without duct or ampulla involvement) or 50% to 100% of D1, D3, or D4
14
Q
What is a potential treatment for grade III duodenal injuries?
A
Simple closure can be attempted if possible.
15
Q
What are alternative options for managing grade III duodenal injuries?
A
Duodenoduodenostomy or Roux-en-Y duodenojejunostomy after debridement to healthy tissue.
16
Q
What surgical option may be considered for a D1 injury proximal to the ampulla?
A
An antrectomy with gastrojejunostomy (Billroth II) may be viable
17
Q
What characterizes a grade IV duodenal injury?
A
A laceration involving 75% to 100% of D2 with an intact ampulla/bile duct, or laceration involving ampulla/distal cbd
18
Q
How are most grade IV and grade V duodenal injuries managed?
A
They are typically managed similarly, often requiring more complex interventions
19
Q
What characterizes a grade V duodenal injury?
A
Complete destruction of the duodenum and pancreatic head complex
20
Q
What complex reconstructions are typically required for grade IV and grade V duodenal injuries?
A
Either a Roux-en-Y duodenojejunostomy or a pancreatoduodectomy (Whipple procedure).
21
Q
What is the management focus for clinically unstable patients with grade IV or V duodenal injuries?
A
Focus on hemorrhage control followed by contamination control.
22
Q
Why is vascular control critical in the management of grade IV and V injuries?
A
Due to the proximity to major abdominal vessels such as the portal vein, IVC, SMA, and SMV
23
Q
What is the typical damage control strategy for grade IV and V injuries?
A
Temporary control of holes in the gastrointestinal tract, wide drainage, temporary abdominal closure, and resuscitation in the ICU.
24
Q
How can the common bile duct (CBD) be managed in a grade IV injury when duodenal reconstruction is possible?
A
The CBD can be reimplanted into the duodenum or reconstructed with a Roux-en-Y loop.
25
When might a Whipple procedure be necessary in grade IV or V injuries?
If the injury is irreparable or involves the pancreatic head
26
What temporary measures can be taken for the CBD and pancreatic duct in unstable patients?
Cannulation and externalization to assist with reconstruction at the follow-up operation after resuscitation.
27
What vascular structures are contained in the deep layer during trauma surgery?
The inferior vena cava (IVC) and right renal pedicle
28
How do deep layer injuries typically present?
As contained retroperitoneal hematomas, sometimes with active bleeding from the renal hilum
29
What is the initial management for deep layer injuries?
Direct compression with packing until other areas of concern are addressed
30
What vascular structures are contained in the middle layer?
The superior mesenteric artery (SMA), superior mesenteric vein (SMV), and portal vein
31
How is exposure of the middle layer achieved in trauma surgery?
Using the Kocher maneuver, which involves dissecting the lateral peritoneal attachments and rotating the duodenal C-loop and pancreatic head from right to left
32
What are the steps for hemorrhage control in trauma surgery?
Manual compression is followed by proximal and distal vascular control, and then ligation, repair, or more complex vascular reconstruction
33
What is the superficial layer of vascular structures in trauma surgery, and how is bleeding managed?
The superficial layer includes the pancreaticoduodenal vessels, managed initially with Kocherization and manual compression.
34
What should raise concern for duodenal injury during exploratory laparotomy?
The presence of retroperitoneal bile staining, hematoma, or bubbles.
35
What is the purpose of the Kocher maneuver in trauma surgery?
To expose the retroperitoneum by identifying the C-loop of the duodenum, dissecting the lateral attachments, and retracting the duodenum and head of the pancreas superomedially
36
What are the dissection margins for the Kocher maneuver?
The common bile duct (CBD) cranially and the superior mesenteric vein (SMV) caudally
37
Why is the Kocher maneuver often performed in conjunction with mobilization of the right colon?
To expose the lower part of the duodenum, which is covered by the hepatic flexure of the colon
38
What is the Cattell-Braasch maneuver, and what does it achieve?
It is the final extension of the right medial visceral rotation, allowing complete mobilization of the small bowel and exposure of the third and fourth portions of the duodenum, underside of the pancreas, infrarenal IVC, aorta, and bilateral iliac and renal vessels.
39
How is the Cattell-Braasch maneuver performed?
After the white line of Toldt is incised and the right colon is reflected medially, the cecum is elevated and the small bowel is retracted to the patient's left and cranially.
40
What should be exposed during the Cattell-Braasch maneuver?
The small bowel mesentery attachment to the posterior abdomen, which is incised from the cecum to the ligament of Treitz.
41
What risk is associated with improper retraction during the Cattell-Braasch maneuver?
Avulsion of the right colic vein of the superior mesenteric vein (SMV) due to the right colon being affixed by its mesentery alone.
42
What is the goal of primary repair in duodenal injuries?
To create a tension-free and widely patent closure or anastomosis, best accomplished by transverse closure
43
What are the suture options for primary repair of duodenal injuries?
A two-layer closure with full-thickness running absorbable suture (e.g., 3-0 PDS) followed by interrupted silk Lembert sutures, or a single-layer closure
44
What is the alternative to transverse primary closure if the injury is too significant?
The duodenum can be mobilized to allow for circumferential resection and primary duodenoduodenostomy
45
How is the end-to-end anastomosis performed after circumferential resection of the duodenum?
With a two-layer closure: a posterior wall of permanent silk Lembert sutures, followed by a running absorbable layer (e.g., 3-0 PDS), and Lembert sutures on the anterior wall.
46
What can be done if mobilization is an issue and a two-layer closure is not possible?
A single-layer full-thickness running closure can be performed, starting along the pancreas side and working circumferentially
47
How was pyloric exclusion typically performed?
By using either a purse-string closure inside the stomach or a noncutting transverse stapler, along with the creation of a gastrojejunostomy
48
What is the long-term concern associated with the creation of a gastrojejunostomy?
There is debate about whether gastrojejunostomy is ulcerogenic, and some surgeons place patients on lifelong acid suppression
49
What is the surgical option for D1 injuries that are not amenable to primary repair or duodenoduodenostomy?
An antrectomy or proximal duodenal resection with the creation of a gastrojejunostomy
50
How can the gastrojejunostomy anastomosis be performed?
It can be done with a stapler or a two-layer, hand-sewn side-to-side anastomosis
51
What approach is preferred for gastrojejunostomy in these cases?
A retrocolic approach, bringing the small bowel through the colonic mesentery to the left of the middle colic artery
52
What is the safest and simplest reconstructive technique for severe duodenal injuries without ampulla or CBD involvement that are not amenable to primary repair?
A Roux-en-Y duodenojejunostomy.
53
What must be identified before reconstruction if a destructive injury occurs near D2?
The ampulla must be identified to prevent obstruction.
54
What type of anastomosis is recommended in severe duodenal injuries near D2?
A two-layer, end-to-side duodenojejunostomy, with closure of the distal duodenum
55
What is an alternative reconstruction method if the injury is not complete?
A side-to-side anastomosis can be performed
56
When should a Roux-en-Y duodenojejunostomy be attempted?
Only when the patient is hemodynamically stable, as it is a time-consuming procedure
57
Which patients are at high risk for a duodenal leak?
Patients with high-grade injuries, shock on presentation, or associated vascular or pancreatic injuries.
58
What is the classic intraluminal drainage technique for duodenal repair?
The triple-tube technique, which includes a gastric tube for proximal drainage, a retrograde jejunostomy tube, and a distal jejunostomy tube for feeding.
59
What is an alternative drainage technique derived from diverticulization techniques?
A lateral duodenostomy tube placed through or adjacent to the suture line
60
What are other options for intraluminal drainage?
A gastrojejunostomy tube placed percutaneously or advancing a nasogastric tube into the duodenum for temporary decompression.
61
What is crucial for recovery after duodenal repair, regardless of the repair type?
Nutrition, ideally enteral nutrition, is of utmost importance for recovery
62
Why might patients struggle to tolerate oral enteral nutrition after duodenal repair?
Due to edema at the repair site, partial obstruction, or ileus
63
What is a common temporary solution for providing enteral nutrition in patients after duodenal repair?
A nasojejunal tube or a distal jejunostomy tube
64
What is a Moss gastrojejunostomy tube, and what are its benefits?
It is a tube with multiple lumens that allows for simultaneous gastric/duodenal decompression and distal feeding, beneficial for managing duodenal repair leaks
65
Why is the Moss gastrojejunostomy tube preferred for patients at high risk of duodenal leak?
It provides internal drainage and allows for enteral nutrition without the risks of multiple enterostomies, and can be easily removed when oral intake becomes possible
66
What is a safe option for identifying injury in the trauma setting, though rarely used? for ampulla
Magnetic Resonance Cholangiopancreatography (MRCP) is a safe option, but it is rarely used in the acute trauma setting
67
What is the recommended method if preoperative imaging is not available before reconstruction?
Perform a cholecystectomy, cannulate the cystic duct, and pass a Fogarty balloon through the cystic duct into the CBD and down into the duodenum
68
What is another method for identifying the ampulla during surgery?
Perform intraoperative cholangiography via a similar method to passing a Fogarty balloon
69
What are some subtle findings on CT that may indicate trauma-related injuries to the pancreas
fluid in the lesser sac, retroperitoneal fluid, intrapancreatic or peripancreatic hematoma, pancreatic disruption, and injuries to nearby structures like the duodenum, jejunum, thoracic spine, or vascular injuries near the celiac or SMA
70
When is surgical management recommended for pancreatic trauma patients with parenchymal laceration?
Surgical management is reserved for patients with evidence of ductal injury on MRCP.
71
How are Grade I and II pancreatic injuries defined?
defined as contusions or lacerations of the pancreatic parenchyma without evidence of ductal injury or tissue loss
Nonoperative management is recommended for Grade I and II injuries identified on CT scan.
72
What is the suggested management approach for capsular tears of the pancreas during surgery?
Capsular tears should not be repaired due to the increased risk of pseudocyst formation. Instead, wide external drainage is preferred
73
How are Grade III pancreatic injuries defined?
involve distal pancreatic ductal transection or injury
74
What is the procedure of choice for Grade III pancreatic injuries
A distal pancreatectomy combined with wide drainage
75
How are Grade IV pancreatic injuries defined?
proximal pancreatic transection or parenchymal injury involving the ampulla, often with combined injury to the duodenum.
76
What management approach may be considered for Grade IV pancreatic injuries?
An attempt at wide drainage may be considered for Grade IV injuries
77
How are Grade V pancreatic injuries defined, and what is the recommended procedure in these cases?
involve massive disruption of the pancreatic head, and a Whipple procedure should be considered as a last resort.
78
What nonoperative management strategies have been used for isolated proximal main duct injuries, and how successful are they?
Transpapillary stenting (via ERCP) or nasopancreatic drain insertion can bridge the disruption or reduce leakage, allowing for successful nonoperative management, but they are less successful in cases of complete ductal transection
79
How can the superior mesenteric vein (SMV) be identified during surgery for pancreatic exposure?
The SMV can be identified by following the venous tributaries as it crosses over the third portion of the duodenum.
80
Anterior Exposure of pancreas
-elevating the stomach and retracting the transverse colon caudally.
-On the left side of the omentum, an avascular plane can be entered bluntly to gain access to the lesser sac.
-gastrocolic ligament can be divided using an energy device
-transverse colon and omentum are retracted inferiorly, and the stomach is retracted superiorly.
-right colon can be mobilized inferiorly, and the transverse mesocolon can be dissected free from the head of the pancreas.
81
posterior exposure of the pancreatic head
-via the Kocher maneuver
82
posterior aspect of the pancreatic body and tail be exposed?
medial rotation of the spleen
83
mobilizing the spleen for medial rotation?
freeing the white line of Toldt along the left colon at the splenic flexure and dividing the spleen's attachments from its ligaments to the diaphragm, colon, and short gastric arteries.
84
What tools are used for direct cannulation of the pancreatic duct when needed?
A 5Fr catheter with saline or water-soluble contrast, or a lacrimal/blunt probe, can be used for direct cannulation
85
What methods can be used to identify distal pancreatic duct injuries?
Direct visualization of ductal disruption and the use of lacrimal probes may assist, but identification can be difficult in trauma settings.
86
What findings suggest ductal disruption in pancreatic trauma?
complete transection of the pancreas, laceration of more than one-half the diameter of the pancreas, and severe maceration of the gland
87
What is the recommended procedure for distal ductal injury in pancreatic trauma?
Distal pancreatectomy is strongly recommended, as missing the injury can lead to severe morbidity.
88
What should be done if there is suspicion of ductal injury but it cannot be confirmed?
At the least, wide external drainage should be performed
89
What methods are suggested for assessing proximal ductal injuries if the diagnosis is unclear during surgery?
MRCP after temporary closure, water-soluble contrast with fluoroscopy, or methylene blue dye can be used to assess for ductal injury
90
What is an alternative to a Fogarty catheter for assessing the ampulla or ductal injury during surgery?
A cholangiocatheter can be used to inject water-soluble contrast, or a large-bore intravenous line with a butterfly catheter can be inserted into the gallbladder for injection during fluoroscopy
91
What is a safe temporary option if proximal disruption is not obvious but still suspected?
Wide external drainage is a safe temporary option, followed by MRCP to confirm ductal injury.
92
What alternative technique can be used for splenic vessel control if hemodynamic instability is present?
A linear cutting stapler can be fired across the splenic vessels and then across the pancreas if hemodynamic instability prevents isolation and ligation
93
Why should the inferior mesenteric vein be identified before dividing the pancreas?
The inferior mesenteric vein should be identified because it drains into the splenic vein, and its division can complicate the procedure.
94
What technique is used to reduce the risk of pancreatic leak after division of the pancreas?
The transected pancreas is oversewn with overlapping 3-0 absorbable U-stitch sutures, and the pancreatic duct is oversewn if visualized.
95
A Whipple procedure may be warranted in cases of:
-Near-complete destruction of the duodenum or pancreatic head
-Proximal pancreatic main duct injury combined with common bile duct (CBD) and duodenal injury
-Injury to the ampulla of Vater
-Uncontrolled bleeding from vessels of the pancreatic head or retropancreatic portal vein or SMV.
96
What is ideally done to the bile duct during delayed reconstruction in trauma-related Whipple procedures?
The bile duct should be identified and cannulated for direct drainage
97
What dietary management should be followed for a patient with a duodenal leak?
kept NPO , parenteral nutrition
Enteral nutrition is preferred if a tube has been placed during surgery
98
What follow-up should be performed before resuming enteral nutrition in a patient with a duodenal leak?
A contrast study should be performed to evaluate the duodenal leak before resuming enteral nutrition.
99
What is the first step in managing a biliary leak?
-wide drainage > surgical drains or percutaneous drainage by IR
100
How can biliary drainage be managed in the presence of dilated intrahepatic ducts due to stricture or obstruction
Percutaneous transhepatic drainage through the choledochojejunostomy can be performed
101
What is a common complication of pancreatic and pancreatico-duodenal injuries?
Pancreatic fistula is a common complication, with a higher incidence in distal pancreatectomy than in Whipple procedures
102
What is the recommended initial treatment for significant pancreatic leaks?
- NPO and start parenteral nutrition
-somatostatin analogue
103
What is a useful treatment for distal pancreatic leaks if medical management fails?
Endoscopic procedures (ERCP) to stent the main pancreatic duct proximally can be useful if medical management is unsuccessful.
104
How is delayed gastric emptying typically managed?
prokinetic agents, such as erythromycin
Resolution generally occurs within 3 weeks.
If there is no improvement after 3 weeks, placement of a percutaneous gastrojejunostomy should be considered.
105
What usually causes delayed bleeding in the postoperative period
Delayed bleeding is often the result of a pseudoaneurysm, especially in the setting of a pancreatic leak
106
What should be done if a patient's drain appearance changes to sanguineous?
assumed to be a sentinel bleed with arterial spasm > immediate IR consultation for diagnostic angiography and therapeutic angioembolization
107
What are the most common sources of bleeding after Whipple procedures and distal pancreatectomies?
Whipple procedure > gastroduodenal artery stump
distal pancreatectomy > the splenic artery
