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Isolated and Combined Duodenal and Pancreatic Injuries: A Review and Update

  • Trauma Surgery (J. Diaz, Section Editor)
  • Published:
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Abstract

Purpose of Review

Duodenal and pancreatic injuries are challenging to diagnose and treat. Over the last several decades, appropriate and optimal surgical management of these injuries have been debated. This is a review of the latest literature regarding diagnosis and operative management of these injuries.

Recent Findings

In duodenal injury, primary repair should be pursued for partial or complete transection with little tissue loss and no ampulla involvement. In more complex injuries, where tension-free repair is not possible, Roux-en-Y duodenojejunostomy or pyloric exclusion with diverting gastrojejunostomy can be utilized. Wide external closed suction drainage is recommended for grade I, II, and IV pancreatic injuries. Distal pancreatectomy with or without splenectomy is recommended for grade III injuries. Pancreatoduodenectomy in a staged procedure is safe for grade V combined injuries with ductal disruption.

Summary

Delayed diagnosis contributes to increased mortality in pancreatic and duodenal trauma. Establishing early diagnosis and ductal involvement followed by appropriate surgical intervention improves outcomes.

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Fig. 1
Fig. 2

Reproduced with permission of Lippincott Williams & Wilkins, from Efron et al. Operative Management of Pancreatic Trauma. In: Fischer JE, ed. Mastery of Surgery 5th Edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 1320–1323.

Fig. 3

Reproduced with permission of Lippincott Williams & Wilkins, from Efron et al. Operative Management of Pancreatic Trauma. In: Fischer JE, ed. Mastery of Surgery 5th Edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 1320–1323.

Fig. 4

Reproduced with permission of Lippincott Williams & Wilkins, from Efron et al. Operative Management of Pancreatic Trauma. In: Fischer JE, ed. Mastery of Surgery 5th Edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 1320–1323.

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Reference

Papers of particular interest, published recently, have been highlighted as: ∙ Of importance

  1. Larrey Baron DJ. Memoirs of military surgery and campaigns [Translated from the French by R.W. Hall]. Vol. 3. Joseph Cushing, Baltimore. 1814;3:309–9.

  2. Travers B. Rupture of the pancreas. Lancet. 1827;12:384.

    Google Scholar 

  3. Lucas CE, Ledgerwood AM. Factors influencing outcome after blunt duodenal injury. J Trauma. 1975;15(10):839–46.

    Article  CAS  Google Scholar 

  4. Cuddington G, Rusnak CH, Cameron RD, Carter J. Management of duodenal injuries. Can J Surg. 1990;33(1):41–4.

    CAS  PubMed  Google Scholar 

  5. Synder WH 3rd, Weigelt JA, Watkins WL, Bietz DS. The surgical management of duodenal trauma. Precepts based on a review of 247 cases. Arch Surg. 1980;115(4):422–9.

    Article  Google Scholar 

  6. Ivatury RR, Nallathambi MA, Gaudino J, Rohman M, Stahl WM. Penetrating duodenal injuries. Analysis of 100 consecutive cases. Ann Surg. 1985;202(2):153–8.

    Article  CAS  Google Scholar 

  7. Ballard RB, Badellino MM, Eynon CA, Spott MA, Staz CF, Buckman RF Jr. Blunt Duodenal rupture: a 6-year statewide experience. J Trauma. 1997;43(2):229–32.

    Article  CAS  Google Scholar 

  8. Allen GS, Moore FA, Cox CS Jr, Mehall JR, Duke JH. Delayed diagnosis of blunt duodenal injury: an avoidable complication. J Am Coll Surg. 1998;187(4):393–9.

    Article  CAS  Google Scholar 

  9. Allen TL, Mueller MT, Bonk RT, Harker CP, Duffy OH, Stevens MH. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma. 2004;56(2):314–22.

    Article  Google Scholar 

  10. Rickard MJ, Brohi K, Bautz PC. Pancreatic and duodenal injuries: keep it simple. ANZ J Surg. 2005;75(7):581–6.

    Article  Google Scholar 

  11. Talving P, Nicol AJ, Navsaria PH. Civilican duodenal gunshot wounds: surgical management made simpler. World J Surg. 2006;30(4):488–94.

    Article  Google Scholar 

  12. Velmahos GC, Constantinou C, Kasotakis G. Safety of repair for severe duodenal injuries. World J Surg. 2008;32(1):7–12.

    Article  Google Scholar 

  13. Cogbill TH, Moore EE, Feliciano DV, Hoyt DB, Jurkovich GJ, Morris JA, Mucha P Jr, Ross SE, Strutt PJ, Moore FA, et al. Conservative management of duodenal trauma: a multicenter perspective. J Trauma. 1990;30(12):1469–75.

    Article  CAS  Google Scholar 

  14. Berne CJ, Donovan AJ, White EJ, Yellin AE. Duodenal “diverticulization” for duodenal and pancreatic injury. Am J Surg. 1974;127(5):503–7.

    Article  CAS  Google Scholar 

  15. Summers JEIX. The treatment of posterior perforations of the fixed portions of the duodenum. Ann Surg. 1904;39(5):727–32.

    Article  CAS  Google Scholar 

  16. Asensio JA, Feliciano DV, Britt LD, Kerstein MD. Management of duodenal injuries. Curr Probl Surg. 1993;30(11):1023–93.

    Article  CAS  Google Scholar 

  17. Dubose JJ, Inaba K, Teixeira PG, Shiflett A, Putty B, Green DJ, Plurad D, Demetriades D. Pyloric exclusion in the treatment of severe duodenal injuries: results from the National Trauma Data Bank. Am Surg. 2008;74(10):925–9.

    PubMed  Google Scholar 

  18. Nassoura ZE, Ivatury RR, Simon RJ, Kihtir T, Stahl WM. A prospective reappraisal of primary repair of penetrating duodenal injuries. Am Surg. 1994;60(1):35–9.

    CAS  PubMed  Google Scholar 

  19. Jansen M, Du Toit DF, Warren BL. Duodenal injuries: surgical management adapted to circumstances. Injury. 2002;33(7):611–5.

    Article  Google Scholar 

  20. Stone HH, Fabian TC. Management of duodenal wounds. J Trauma. 1979;19(5):334–9.

    Article  CAS  Google Scholar 

  21. Hasson JE, Stern D, Moss GS. Penetrating duodenal trauma. J Trauma. 1984;24(6):471–4.

    Article  CAS  Google Scholar 

  22. Asensio JA, Petrone P, Roldan G, Kuncir E, Demetriades D. Pancreaticoduodenectomy: a rare procedure for the management of complex pancreaticoduodenal injuries. J Am Coll Surg. 2003;197(6):937–42.

    Article  Google Scholar 

  23. Desai KM, Dorward IG, Minkes RK, Dillon PA. Blunt duodenal injuries in children. J Trauma. 2003;54(4):640–5.

    Article  Google Scholar 

  24. Jewett TC Jr, Caldarola V, Karp MP, Allen JE, Cooney DR. Intramural hematoma of the duodenum. Arch Surg. 1988;123(1):54–8.

    Article  Google Scholar 

  25. Krige JE, Kotze UK, Hameed M, Nicol AJ, Navsaria PH. Pancreatic injuries after blunt abdominal trauma: an analysis of 110 patients treated at a level 1 trauma centre. S Afr J Surg. 2011;49:62–4.

    Google Scholar 

  26. Young PR, Meredith JW, Baker CC, Thomason MH, Chang MC. Pancreatic injuries resulting from penetrating trauma: a multi-institution review. Am Surg. 1998;64:838–43.

    PubMed  Google Scholar 

  27. Vasquez JC, Coimbra R, Hoyt DB, Fortlage D. Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center. Injury. 2001;32:753–9.

    Article  CAS  Google Scholar 

  28. Chinnery GE, Krige JE, Kotze UK, Navsaria P, Nicol A. Surgical management and outcome of civilian gunshot injuries to the pancreas. Br J Surg. 2012;99(Suppl. 1):140–8.

    Article  Google Scholar 

  29. Olah A, Isselkutz A, Haulik L, Makay R. Pancreatic transection from blunt abdominal trauma: early versus delayed diagnosis and surgical management. Dig Surg. 2003;20:408–14.

    Article  Google Scholar 

  30. Mahajan A, Kadavigere R, Sripathi S, Rodrigues GS, Rao VR, Koteshwar P. Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review. Injury. 2014;45(9):1384–93.

    Article  Google Scholar 

  31. Patton JH Jr, Lyden SP, Croce MA, Pritchard FE, Minard G, Kudsk KA, Fabian TC. Pancreatic Trauma: a simplified management guideline. J Trauma. 1997;43(2):234–9.

    Article  Google Scholar 

  32. Velmahos GC, Tabbara M, Gross R, Willette P, Hirsch E, Burke P, Emhoff T, Gupta R, Winchell RJ, Patterson LA, Manon-Matos Y, Alam HB, Rosenblatt M, Hurst J, Brotman S, Crookes B, Sartorelli K, Chang Y. Blunt pancreatoduodenal injury: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Arch Surg. 2009;144(5):413–9.

    Article  Google Scholar 

  33. Harrell DJ, Vitale GC, Larson GM. Selective role for endoscopic retrograde cholangiopancreatography in abdominal trauma. Surg Endosc. 1998;12(5):400–4.

    Article  CAS  Google Scholar 

  34. Asensio JA, Demetriades D, Berne JD, Falabella A, Gomez H, Murray J, Cornwell EE 3rd, Velmahos G, Belzberg H, Shoemaker W, Berne TV. A unified approach to the surgical exposure of pancreatic and duodenal injuries. Am J Surg. 1997;174(1):54–60.

    Article  CAS  Google Scholar 

  35. Kao LS, Bulger EM, Parks DL, Byrd GF, Jurkovich GJ. Predictors of morbidity after traumatic pancreatic injury. J Trauma. 2003;55:898–905.

    Article  Google Scholar 

  36. ∙ Ho VP, Patel NJ, Bokhari F, Madbak FG, Hambley JE, Yon JR, Robinson BR, Nagy K, Armen SB, Kingsley S, Gupta S, Starr FL, Moore HR 3rd, Oliphant UJ, Haut ER, Como JJ. Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma. 2017; 82(1):185–99. Current guidelines by the national trauma society, EAST, for pancreatic injury management.

    Article  Google Scholar 

  37. Krige JE, Beningeld SJ, Nicol AJ, et al. The management of complex pancreatic injuries. S Afr J Surg. 2005;43:92–102.

    CAS  PubMed  Google Scholar 

  38. Fabian TC, Kudsk KA, Croce MA, Payne LW, Mangiante EC, Voeller GR, Britt LG. Superiority of closed suction drainage for pancreatic trauma A randomized, prospective study. Ann Surg. 1990;211:724–30.

    Article  CAS  Google Scholar 

  39. Asensio JA, et al. Atlas and textbook of techniques in complex trauma surgery. Philadelphia: Saunders; 2005.

    Google Scholar 

  40. Van der Wilden GM, Yeh D, Hwabejire JO, Klein EN, Fagenholz PJ, King DR, de Moya MA, Change Y, Velmahos GC. Trauma whipple: do or don’t after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTBD). World J Surg. 2014;38(2):335–40.

    Article  Google Scholar 

  41. Krige JE, Nicol AJ, Navsaria PH. Emergency pancreatoduodenectomy for complex injuries of the pancreas and duodenum. HPB. 2014;16(11):1043–9.

    Article  Google Scholar 

  42. ∙ Krige JE, Kotze UK, Setshedi M, Nicol AJ, Navsaria PH. Surgical management and outcomes of combined pancreaticoduodenal injuries: analysis of 75 consecutive cases. J Am Coll Surg. 2016; 222(5):737–49. A recent study, completed in 2016, of 75 consecutive combined duodenal and pancreatic injuries; one of the largest series to date.

    Article  Google Scholar 

  43. ∙ Thompson CM., Shalhub S, DeBoard ZM, Maier RV. Revisiting the pancreaticoduodenectomy for trauma: a single institution’s experience. J. Trauma Acute Care Surg. 2013;75:225–28. A recent article reviewing their latest experience with pancreaticoduodenectomy in the traumatic setting.

    Article  Google Scholar 

  44. Nathan H, Cameron JL, Goodwin CR, Seth AK, Edil BH, Wolfgang CL, Pawlik TM, Schulick RD, Choti MA. Risk factors for pancreatic leak after distal pancreatectomy. Ann Surg. 2009;250(2):277–81.

    Article  Google Scholar 

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Authors and Affiliations

  1. Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA

    Rachel L. Choron & David T. Efron

  2. 1800 Orleans Street, Suite 6107F, Baltimore, MD, 21287, USA

    Rachel L. Choron

Authors
  1. Rachel L. Choron
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  2. David T. Efron
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Correspondence to Rachel L. Choron.

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Rachel L. Choron and David T. Efron declare that they have no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical collection on Trauma Surgery.

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Choron, R.L., Efron, D.T. Isolated and Combined Duodenal and Pancreatic Injuries: A Review and Update. Curr Surg Rep 6, 20 (2018). https://doi.org/10.1007/s40137-018-0216-7

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