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Traumatic Injury of the Duodenum and Pancreas: How to Approach a Rare Injury

  • Maria Tsachiridi
  • Alexandros Bougkas
  • Ioannis Stavrakis
Surgery
  • 12 Downloads
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  1. Topical Collection on Surgery

Abstract

In this article, we present our experience of trauma of the upper abdomen, mainly the duodenum and pancreas, and the challenges that we faced during pre-, intra-, and postoperative management of these patients. We also discuss the implementation of the techniques described in literature in the everyday practice. Four cases of trauma of the upper abdomen presented to our hospital and treated by our team are discussed. We present the technique implemented, the postoperative management, as well as dealing with complications. A brief review of literature is conducted to identify the best approach to diagnosis, imaging, and operating techniques. Abdominal blunt and penetrating injury poses a challenge to every trauma surgeon. These injuries are distinguished by their severity and unpredictability of intraoperative findings, as well as the difficulty of their management. The extent of the operation is dictated by the severity of the injury and the complexity of the technique should be proportionate to the experience of the surgeon. The most complicated cases might require additional techniques, procedures, or referral to a specialized center.

Keywords

Duodenal injury Pancreatic injury Abdominal trauma Trauma surgery 

Introduction

Injury to the duodenum and pancreas is a relatively rare condition, and it has been described that such injuries occur in 0.5–6% in the setting of abdominal trauma [1, 2, 3, 4]. They present a significant challenge for a trauma surgeon firstly due to the retroperitoneal location of these organs that make the clinical presentation difficult to interpret and result in delay in diagnosis and treatment that exacerbate high morbidity. Secondly, the very rare nature of these injuries has resulted in the lack of experience among the trauma surgeons. And finally, the anatomical and physiological characteristics of the area contribute to a very high incidence of complications [5].

All four cases discussed were treated in a large trauma center in Athens, Greece, at a span of 5 years. Despite high volume of trauma patients that the hospital receives on daily basis, our experience in the field of pancreatoduodenal trauma was limited.

The aim of this article is to share our experience in the management of upper abdominal trauma. We believe that given the infrequent occurrence of this type of injuries and the lack of comprehensive randomized studies, the presentation of series of patients however small it is helps contribute to collective knowledge and improve our management by learning from each other’s mistakes.

Cases

We discuss four cases of abdominal injury that presented to the Emergency Department of our hospital. All four cases are distinguished by the presence of pancreatoduodenal trauma. We describe our approach to their management, the intraoperative findings, postoperative course, and outcome.

Patient 1

A 47-year-old female presented to the Emergency Department with a gunshot wound. She was shot at by a person suffering from acute psychosis while walking on the street. The entry wound was identified in the right upper quadrant and the exit wound in the left flank.

The patient was taken to operating theaters after typical workup and underwent exploratory laparotomy. The laparotomy findings included hemoperitoneum; fecal peritonitis; hepatic injury to segments V, VI, and VII; perforation of the second part of the duodenum, with two defects; perforation of the jejunum 10 cm from the ligament of Treitz, with two defects; and perforation of the splenic flexure of the large intestine, descending colon, and sigmoid colon, with three defects.

Hemostasis of liver injuries was performed with liver sutures and packing. The duodenum was extensively Kocherized and the duodenal perforation was externalized as controlled fistula with Pezzer’s tube fixed with purse string suture after adequate debridement of the duodenal wall. The affected jejunum, approximately 10 cm of the small bowel, was excised and handsewn end to end anastomosis fashioned. Left hemicolectomy was performed with side to side anastomosis with a stapler.

Finally, drains were placed bilateral subdiaphragmatic, subhepatic (Morrison’s space), at the Douglas’ pouch, and at the left paracolic gutter.

Postoperatively, the patient received total parenteral nutrition (TPN), intravenous fluids, and antibiotics. She remained hemodynamically stable, with good fluid and electrolyte balance and good urine output, nonetheless slightly alkalotic. Due to persistent pyrexia, she underwent imaging with CT scan which showed a collection in the left upper quadrant which was drained percutaneously.

The patient did not improve and became clinically septic, with low blood pressure, tachycardia, and tachypnea; thus, she was taken back to the operating room for second look laparotomy on the 16th postoperative day (POD).

Intraoperative findings this time were of fecal peritonitis, leak of duodenal contents around Pezzer’s tube, defect of the duodenal wall involving ¾ of the perimeter of the duodenum, small leak from jejunojejunal anastomosis, and leak from colonic anastomosis.

A more aggressive approach was adopted this time. We performed antrectomy, duodenal stump closure with stapler, and second layer of serosal sutures and omega loop gastroenteroanastomosis with side to side Brown jejunojejunostomy. The leaking jejunojejunostomy was drained with a tube to form a controlled fistula and a double-barrel large bowel stoma was fashioned. Drains were again placed to subdiaphragmatic spaces bilaterally, in the proximity but not in contact with the duodenal stump, to the left paracolic gutter, and the Douglas’ pouch. Abdominal wall closure was done with full thickness sutures to prevent wound dehiscence.

The patient received TPN and antibiotic treatment, and despite infections, her nutritional status improved significantly, and she was discharged on POD 69.

She had a third operation after discharge for colostomy reversal and repair of incisional hernia (Picture 1).
Picture 1

Postoperative appearance with gastroenteroanastomosis

Patient 2

A 35-year-old male was transferred to our Emergency Department after a road traffic accident (RTA) with a motorbike on a remote island.

The imaging (CT scan) revealed bilateral lung contusions, intimal tear of the left renal artery, splenic hematoma, pancreatic laceration, and hemoperitoneum (Picture 2).
Picture 2

Pancreatic laceration (arrow) and perisplenic hematoma

Clinically, acute abdomen and hemodynamic instability were present and the necessity for laparotomy was established.

During the laparotomy, we found a laceration of the upper pole of the spleen, rupture of the left triangular ligament of the liver, hematoma of the lesser omentum, steatonecrosis and pancreatic laceration (grade I) at the body-tail margin, without confirmed pancreatic duct injury, and hematoma of the descending colon and in the area of the ligament of Treitz.

Rigorous washout of the abdominal cavity was performed. Hemostasis and preservation of spleen were attempted successfully. The gastrocolic ligament was incised and two drains were inserted into the lesser sac. The pancreatic laceration was simply drained. Two more drains were placed in subdiaphragmatic spaces and the pouch of Douglas. The injury of the renal artery was treated conservatively after consultation with vascular surgeons.

The patient had long-term TPN treatment and developed high-output pancreatic fistula that was managed conservatively. He received intensive physiotherapy and was discharged on POD 64.

Patient 3

A 42-year-old male who sustained injuries after explosion of a “letter bomb” (explosive device). He presented with three entry wounds to the left thorax, acute abdomen, multiple pelvic and limb soft tissue injuries, and fracture of the left femur. He developed hemodynamical instability and was led urgently to operating theaters for laparotomy.

The CT scan revealed extensive intraabdominal injuries (Picture 3).
Picture 3

Liver injury with a shrapnel, another small foreign body in the lineorenal ligament, pancreatic laceration with possible pancreatic duct injury (arrow), free intraperitoneal gas, and thickening of the gastric wall

The laparotomy findings included hemoperitoneum; peritonitis due to gastric rupture, with two defects on the gastric wall; rupture of the transverse colon, with three defects; hematoma of the transverse mesentery; small splenic laceration; hematoma of the lienorenal ligament; laceration of the right lobe of the liver; retroperitoneal and lesser sac hematoma; and pancreatic laceration with possible rupture of the pancreatic duct at the tail of the pancreas (grade II injury).

Washout of the peritoneal cavity was performed, and the lesser sac was entered and washed out. The gastric defects were debrided and primarily closed. Segmental colectomy and side to side anastomosis with a stapling device for colonic injury were performed. The hepatic laceration was re-approximated with liver sutures and splenic hemostasis was performed with hemostatic agents. Drains were inserted in bilateral subdiaphragmatic spaces, Morrison’s space, lesser sac, and Douglas’ pouch. Mass closure of the abdominal wall was performed. The femur fracture was addressed by orthopedic surgeons.

Postoperatively, the patient was transferred to the Intensive Therapy Unit (ITU). He developed pancreatic fistula that was treated conservatively, received parenteral nutrition, and was discharged after 60 days in hospital.

Patient 4

A 37-year-old male suffered blunt abdominal injury after being compressed against the wall by a tow truck. He walked into the Emergency Department but soon developed acute surgical abdomen, with profuse vomiting; thus, decision to operate was made.

The imaging showed large periduodenal hematoma (Picture 4).
Picture 4

Periduodenal hematoma (arrow)

The laparotomy revealed hemocholeperitoneum (intraperitoneal bleeding and bile leak), tear in the transverse mesocolon, laceration of the pancreatic head, and rupture of the second and third part of the duodenum.

During the operation, the duodenum was fully Kocherized to reveal initially occult duodenal injuries of the posterior duodenal wall. We performed pyloric diversion by placing absorbable purse string suture to the pylorus via gastrotomy, retrocolic gastrojejunal anastomosis (omega loop), segmental resection, and end-to-end anastomosis of the duodenum, duodenostomy with Pezzer’s tube to form controlled fistula and feeding jejunostomy. Drains were placed to the right subdiaphragmatic space, paracolic gutter, Morrison’s space, and Douglas’ pouch.

His recovery was uneventful, he received TPN and enteral jejunal feeding, and the duodenostomy was initially clamped and then removed after 6 weeks. He was discharged after 31 days.

Follow-up

The patients were followed up for 1–3 years. All had satisfactory recovery and quality of life except for patient 1 who developed delayed gastric emptying symptoms that eventually improved after dietetic modification and adequate training.

Discussion

The injury to the duodenum and pancreas is rare and is more frequent in children following blunt trauma, and in adults, the commonest cause is penetrating trauma, such as stabbings and gunshot injuries. The duodenal injury rarely presents as an isolated injury due to anatomical proximity to other organs such as the pancreas and liver. Also, due to the retroperitoneal position of the duodenum, these injuries present a diagnostic challenge to a surgeon with the resulting delay in treatment and associated morbidity [6].

Similarly, the pancreatic trauma due to blunt injury is a rare occurrence in major trauma centers, ranging from 0.2 to 12% [7]; penetrating trauma to the pancreas is much more common.

The mechanism of blunt injury to the duodenum and pancreas includes direct blows to the epigastrium, in which case, the pancreas or the duodenum is crushed against the vertebral column [8]. The duodenum that is mobile at the two ends and fixed to the retroperitoneum at its middle part is also prone to shearing forces due to sudden acceleration or deceleration [6]. Another proposed mechanism is a burst of closed loop of the duodenum, when the pylorus and distal duodenum become compressed against the spinal column. The increased pressure of gas inside the closed loop causes the rupture of the duodenum [9].

The suspicion and diagnosis of pancreatic and duodenal injuries can pose a challenge for the surgeon. Due to their retroperitoneal position and lack of peritoneal involvement, the symptoms of such injury are highly nonspecific. Patients having disproportionally severe abdominal symptoms as compared to clinical findings that might include severe abdominal and back pain and high ileus with vomiting and in absence of head trauma should be investigated for retroperitoneal injury.

The mainstay of trauma investigation and management currently in all the major trauma centers worldwide is the trauma scan. The sensitivity of multidetector CT for detecting pancreatic injuries has been reported between 70 and 95%.

The CT findings of pancreatic trauma include direct findings, such as laceration, transection, and focal enlargement or hematoma of the pancreas. Indirect findings such as peripancreatic fluid in the lesser sac, thickening of the left anterior renal fascia, and fluid between the pancreas and spleen are nonspecific but may indicate pancreatic injury. The laceration involving more than 50% of parenchymal tissue or grade III injury on AAST grading suggests pancreatic duct injury and warrants further imaging with magnetic retrograde cholangiopancreatography (MRCP) (Table 1) [7].
Table 1

AAST duodenal injury scale (adapted from www.aast.org)

Duodenum injury scale

Grade*

Type of injury

Description of injury

I

Hematoma

Involving single portion of the duodenum

Laceration

Partial thickness, no perforation

II

Hematoma

Involving more than one portion

Laceration

Disruption < 50% of circumference

III

Laceration

Disruption 50–75% of circumference of D2

Disruption 50–100% of circumference of D1, D3, D4

IV

Laceration

Disruption > 75% of circumference of D2

Involving the ampulla or the distal common bile duct

V

Laceration

Massive disruption of duodenopancreatic complex

Vascular

Devascularization of the duodenum

*Advance one grade for multiple injuries up to grade III. D1, first portion of the duodenum; D2, second portion of the duodenum; D3, third portion of the duodenum; D4, fourth portion of the duodenum

The CT findings suggestive of duodenal injury include wall thickening of > 4 mm, lack of wall continuity, periduodenal fluid, fluid in the right anterior pararenal space, diminished bowel wall enhancement, extraluminal air, or contrast [7].

Good communication between the surgeon and the radiologist, including clear description of the mechanism of trauma and of the suspicion of retroperitoneal injury will help in timely and accurate diagnosis of this rare trauma.

As described in literature, there are several options of surgical treatment for duodenal trauma: starting from the simple primary closure for small defects [10] to more complex procedures such as Roux-en-Y duodenojejunal anastomosis [11], duodenal diverticulization [12], pyloric exclusion [13], triple ostomy, and pancreas sparing duodenectomy [9].

The simple algorithm is that injuries of lesser grade should be treated with simpler surgical techniques and injuries of greater severity should be treated with more complex techniques [14]. It is crucial to identify any possible injury to the biliary tree; therefore, extensive Kocherization along with mobilization of the ligament of Treitz is essential for full assessment of the duodenum, bile ducts, head of the pancreas, and the vessels of the area for perforation, hematoma, contusions, etc.

The grades I and II isolated pancreatic injuries can be treated conservatively [15] and when found during laparotomy can be treated with hemostasis and drainage [16]. Higher grade injuries might require distal pancreatectomy, Whipple’s procedure, or pancreatic stenting [7].

According to AAST classification, patients 1 and 4 in our series had grades II–III duodenal injuries (Table 2). During the laparotomy, the lesser sac was accessed, the duodenum was Kocherized, and the ampulla of Vater was carefully identified and assessed; it was found intact in both patients. In both cases, we chose to create a controlled fistula as part of a damage control approach. The subsequent sepsis that our first patient developed can be attributed to the extent of her injuries, multiple anastomoses, contaminated operation due to multiple bowel perforations, and systemic inflammatory response. Also, we did not establish intraluminal feeding access and relied solely on parenteral nutrition with all the known complications. As she was hemodynamically stable on presentation and continued to be throughout the operation, a complex operation was performed creating two bowel anastomoses. Having had this experience, we now suggest adherence to the principles of the damage control surgery and avoidance of complex reconstructions in the setting of trauma. Furthermore, in the first operation, we did not perform any of the suggested by the literature, duodenal drainage or bypass procedures.
Table 2

AAST pancreatic injury scale (adapted from www.aast.org)

Pancreas injury scale

Grade*

Type of injury

Description of injury

I

Hematoma

Minor contusion without duct injury

Laceration

Superficial laceration without duct injury

II

Hematoma

Major contusion without duct injury or tissue loss

Laceration

Major laceration without duct injury or tissue loss

III

Laceration

Distal transection or parenchymal injury with duct injury

IV

Laceration

Proximal transection or parenchymal injury involving the ampulla

V

Laceration

Massive disruption of the pancreatic head

*Advance one grade for multiple injuries up to grade III

At the time of the second operation and due to the damage sustained by the duodenum, we preferred the duodenal diverticulization procedure with antrectomy, stapled duodenectomy, and gastrojejunostomy (Picture 5). The rest of the bowel defects were brought out as a controlled fistula for small bowel and colonic stoma in view of ongoing intraabdominal sepsis and risk of further leak.
Picture 5

Duodenal diverticulization

Our fourth patient presented as well hemodynamically stable and walking. Only later during his stay for observations and investigations, on the basis of the mechanism of the injury, he developed acute surgical abdomen and vomiting. This depicts how high suspicion of duodenal injury should be maintained based on the mechanism of the injury and no abdominal trauma should be disregarded lightheartedly.

During the operation, a duodenal defect was found, but nevertheless, the duodenum was Kocherized to reveal another defect on the posterior wall. There is enough evidence in the literature that broad Kocherization of the duodenum along with the entry to the lesser sac should be performed during laparotomy for upper abdominal trauma even despite normally looking scan, more so if a defect is already found on the anterior wall. In addition to that, many suggest Cattell-Braasch maneuver and division of the ligament of Treitz to assess the third and fourth portion of the duodenum respectively [14, 17].

This time, a pyloric exclusion technique (Picture 6) along with proximal duodenostomy (drainage procedure) and feeding jejunostomy was performed with subsequent good results.
Picture 6

Pyloric exclusion

Two other patients had severe abdominal injuries including pancreatic lacerations (grades I and II). Despite the indication of pancreatic injury on the imaging, the MRCP could not be performed, due to hemodynamic instability, extensive injuries, and need for urgent intervention. Patient two in our study had only grade I laceration; thus, the need for any further imaging was deemed redundant intraoperatively. The third patient had a suspicion of pancreatic duct injury on imaging. Unfortunately, neither ERCP nor intraoperative pancreatogram could be performed in the setting of hemodynamic instability and extensive injuries. The pancreas was examined and found viable; thus, no pancreatectomy was performed, and the site was simply drained.

Both the patients developed pancreatic fistula that was treated conservatively and eventually the output decreased and the fistula healed.

The literature search reveals that the grades I and II isolated pancreatic injuries can be treated conservatively [15] and when found during laparotomy can be treated with hemostasis and drainage [16].

The authors’ opinion is that in the setting of severe abdominal injury and hemodynamic instability, where no imaging is available or possible, the low-grade pancreatic injury can be treated with simple drainage. In any case, our suggestion is that no pancreatectomy rather than for very distal tail injury should be attempted by an inexperienced surgeon without specialist HPB advice. More central injuries should be drained and referred to a specialist center as soon as possible.

Conclusion

The traumatic injury to the pancreas and duodenum is a relatively uncommon type of injury, and even in trauma centers, the experience with this type of trauma is limited. A high level of suspicion should be maintained as these injuries are difficult to diagnose. The imaging of choice remains high-resolution CT scan. The extent of the operation is dictated by the severity of the injury and the complexity of the technique should be proportionate to the experience of the surgeon. The most complicated cases might require additional techniques, procedures, or referral to a specialized center.

Notes

Compliance with Ethical Standards

Informed Consent

Informed consent was obtained from all individual participants included in the study. No patient identifying information is used in this article.

Conflict of Interest

The authors declare that they have no conflict of interest.

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Copyright information

© Springer Nature Switzerland AG 2018 2018

Authors and Affiliations

  1. 1.Northern General HospitalSheffieldUK
  2. 2.Red Cross HospitalAthensGreece

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