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Duodenal injuries

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Duodenal injures - Diagnosis and management

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Duodenal injuries

  1. 1. Duodenal injuries Dr. Joe M Das
  2. 2. • Duodenum - Do-deka-dactulos (Gk) - duodenum digitorum (Latin) = - breadth of 12 fingers • 12 inches (24-26 cm) • Herophilus (300 B.C.) • 3.7 – 5 % of laparotomies for trauma
  3. 3. Part Length From To Level 1st (Superior) 5 cm Pyloric V of Mayo Sup: CBD Inf: GDA L1 2nd (Descending) 8-10 cm Sup: CBD Inf: GDA Ampulla L1 3rd (Horizontal) 10 cm Ampulla SMA L3 4th (Ascending) 2.5 cm SMA Lig of Treitz L2 First 2 cm of superior part is mobile
  4. 4. Relations • Medial : HOP • Superior : Quadrate lobe and GB • Posterior : (R) kidney & psoas, IVC & portal V, L1-L3 • Anterior : liver that overlies D1 & D2; the hepatic flexure of the colon, right transverse colon, mesocolon and stomach that overlies D4.
  5. 5. Arterial supply • Superior anterior pancreatico duodenal • Superior posterior pancreatico duodenal GDA from Hepatic A • Inferior anterior pancreatico duodenal • Inferior posterior pancreatico duodenal SMA
  6. 6. • Others: – (R) gastric – Gastroepiploic – Supraduodenal artery (Wilkie) – Retroduodenal artery • Venous drainage: – SMV → Portal V
  7. 7. Physiology • Mixing point for the partially digested chyle and the proteolytic and lipolytic secretions of the biliary tract and pancreas • Powerful activated digestive enzymes including lipase, trypsin, amylase, elastase, and peptidases • Approximately 6 L of fluid from the stomach, bile duct, and pancreas passes through the duodenum in a 24-hour period • Escape of duodenal contents into the free peritoneal cavity or retroperitoneum → destructive process that is compounded by the inflammatory response that it provokes.
  8. 8. History • The earliest recorded cases of successful outcomes from penetrating duodenal injuries is credited to Larrey (Fr.) • The first successful repair of a duodenal injury after blunt trauma was reported by Herczel in 1896 • Moynihan repaired a penetrating duodenal injury; he performed a gastrojejunostomy in a patient who lived for 104 days. (1901)
  9. 9. • Penetrating trauma accounts for 78% of all duodenal injuries, whereas blunt trauma accounts for 22%. • D2 is most commonly injured • ‘The epitome of an organ poorly designed to withstand the ravages of trauma.’ • Asso: with injuries to liver, pancreas, small bowel, colon
  10. 10. • Blunt trauma from: – Crushing of duodenum b/w spine and steering wheel – Flexion-distraction fracture of L1-L2 (Chance fracture) – Stomping and striking in midepigastrium – Sudden deceleration
  11. 11. Clinical features • Abdominal pain especially when the right upper quadrant is injured – – Intensified with apparent peritoneal stimulation and – Radiation pain to the back • Retching or vomiting with blood in the vomitus • Abdominal distension especially in the upper quadrant with infrequent or muted borborygmus • Detection of fluid like bile or intestinal juice by diagnostic paracentesis.
  12. 12. When to suspect intra-operatively? • Free gas or fluid looking like bile with undetermined origin • Extraction of intestinal juice or fluid like bile from retro-peritoneal hematoma and • Edema, hematoma, ecchymosis or crepitus in the periduodenal retroperitoneum or root of mesentery and mesocolon. • Instillation of methylene blue via NG tube (Brotman et al) A test to help diagnosis of rupture in the injured duodenum. Injury 1981; 12:464-5
  13. 13. Severe duodenal injury (Snyder) • Missile or blunt injury • Injury of the first or second portion of the duodenum • Adjacent common bile duct injury. Snyder WH 3rd, et al. The surgical management of duodenal trauma. Precepts based on a review of 247 cases. Arch Surg 1980;115(4):422-429.
  14. 14. Problems in management • The retroperitoneal location • Proximity to important abdominal structures • Marginal blood supply • Biliary, pancreatic and gastro-intestinal secretions in it • Delay in the diagnosis
  15. 15. Plain X-ray findings in Duodenal injury • Gas bubbles in retroperitoneum adjacent to (R) psoas, around (R) kidney, ant to upper lumbar spine • Free intraperitoneal gas • Gas in biliary tree • Obliteration of (R) psoas shadow • # transverse processes of lumbar vertebrae
  16. 16. Upper GI series • Water soluble contrast (Meglumine – Gastrografin) – via NG tube ↓ fluoroscopy • (R) lat → Supine → (L) lat • If neg → Barium contrast • Complete obstruction by hematoma → “Coiled spring appearance” or “Stacked coin appearance”
  17. 17. CT findings in Duodenal injury • Retroperitoneal collection of contrast • Extraluminal gas • Lack of continuity of the duodenal wall. • Duodenal contusion is suspected with – Edema or hematoma of the duodenal wall – Intramural gas accumulations – Focal duodenal wall thickening (>4 mm) as findings of small bowel injury. • Fluid or a hematoma in the retroperitoneum, stranding of retroperitoneal fatty tissue, or pancreatic transection can be present in both conditions
  18. 18. Grade 1,2 & 3 duodenal injuries
  19. 19. Cattell and Braasch maneuver
  20. 20. • 1st part • 2nd part • 3rd part • 4th part Upper portion Lower portion Cholangiogram Visual inspection Complex repair Debridement Closure Resection - Anastomosis
  21. 21. Intramural hematoma • Most common in children • Submucosa / subserosa → Obstruction • GOO in 48 hrs • “Coiled spring appearance” or “Stacked coin appearance” • Conservative ℞ (NGA + TPN)  3 weeks No improvement Laparotomy (To r/o duo perforation / injury to HOP)
  22. 22. Intramural hematoma • If detected intra-operatively, – Open serosa, evacuate hematoma, repair the wall ( May convert partial tear to a full thickness one) – Explore to exclude perforation, leaving hematoma intact with post-op NGA
  23. 23. Principles in the management 4 basic principles in managing duodenal trauma: – Restore intestinal continuity – Decompress the duodenal lumen – Provide wide, external drainage – Provide nutritional support
  24. 24. Duodenorrhaphy (>½ of circumference of duodenum)
  25. 25. Duodenorrhaphy (<½ of circumference of duodenum)
  26. 26. Tube duodenostomy
  27. 27. Suck-me, feed-me jejunostomy
  28. 28. Addition of gastrostomy
  29. 29. Serosal patch technique
  30. 30. Jejunal mucosal patch / pedicled graft
  31. 31. Duodenal perforation • High risk injuries: – Associated pancreatic injury – Blunt / Missile injury – Involvement of >75% of duodenal wall – Injury to D1 / D2 – Time interval between injury & repair > 24 hrs – Associated CBD injury • Repair / Diversion / Pancreaticoduodenectomy
  32. 32. Repair • Most injuries – primary closure in one or two layers • Longitudinal duodenotomies closed transversely if length of duo injury < 50% of circumference • If chance of lumen compromise: – Pedicled mucosal graft (segment of jejunum / gastric island flap) – Jejunal serosal patch – Buttress of duo repair by jejunal loop
  33. 33. Repair of complete transection • First part: – Antrectomy + Closure of duodenal stump + Billroth II GJ • Third / Fourth parts (Distal to ampulla): – Closure of distal duodenum + Roux-en-Y DJ • Second part: – Direct E-S duodenal defect to Roux-en-Y loop • Soft silicone rubber closed system drainage
  34. 34. Debridement, segmental resection, EEA
  35. 35. Vaughan / Jordan pyloric exclusion technique
  36. 36. Duodenal Diversion • In high risk duodenal injury • Earliest technique – Tube decompression • Stone & Garoni “triple ostomy” – Gastrostomy tube to decompress stomach – Retrograde jejunostomy to decompress duo – Antegrade jejunostomy for feeding • Duodenal diverticulation – Distal Billroth II gastrectomy + Closure of duodenal wound + Placement of decompressive catheter into duodenum (± Truncal vagotomy + Biliary drainage)
  37. 37. Triple ostomy
  38. 38. Duodenal diverticulisation Primary duodenorrhaphy + Truncal vagotomy + Antrectomy with GJ + Tube choledochostomy + External drainage
  39. 39. Pacreaticoduodenectomy
  40. 40. Indications for Whipple’s procedure • Massive and uncontrollable bleeding from the head of the pancreas, adjacent vascular structures, or both. • Massive and unreconstructable ductal injury in the head of the pancreas. • Combined unreconstructable injuries of the following: – Duodenum and head of the pancreas – Duodenum, head of the pancreas, and common bile duct
  41. 41. Complications • Duodenal fistula • Intra-abdominal abscess • Pancreatitis • Duodenal obstruction • Bile duct fistula • Mortality ≈ 17%
  42. 42. Bibliography • Complex duodenal injuries - Rao R. Ivatury, MD et al • Diagnosis and Classification of Pancreatic and Duodenal Injuries in Emergency Radiology - Ulrich Linsenmaier, MD, PhD et al -Radiographics • Management of duodenal trauma - CHEN Guo- qing and YANG Hua - Chinese Journal of Traumatology 2011; 14(1):61-64 • Duodenal injuries – E Degiannis – BJS 2000, 87, 1473-79

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