Trauma and Critical Care—Duodenal Trauma
Concept
Low incidence of injury and typically in conjunction with injury to other organ systems. Diagnosis is likely not made preoperatively. Often times may be in a young teenager after blunt abdominal trauma.
Way Question May be Asked?
“You are exploring a patient for a splenic laceration and find a periduodenal hematoma on your exploratory laparotomy. What do you want to do?” May be given the diagnosis of a hematoma on pre-op CT scan, might get the history of the patient receiving a blow to the epigastric region, or might get a patient referred to your hospital for definitive management after diagnosis made.
How to Answer?
As with nearly everything covered on the Orals, this is a management question.
Surgical Treatment
To identify/expose intra-op:
Wide Kocher maneuver to visualize posterior duode- num (extend mobilization to ligament of Trietz) Careful inspection of pancreas
(1) If find pre-op:
can observe if isolated injury
no evidence of leak on gastrografin swallow followed by negative Barium swallow observation limited to 2 weeks, at which time
you should explore pt (2) If find intra-op (or take to OR):
fully expose duodenum
determine amount of duodenal tissue loss determine location of injury (part 1 vs. 4) type/severity of other injuries (liver, spleen, colon,
ureter, . . .)
(a) simple laceration→ two layer closure, omental patch
(b) intramural hematoma→ can observe, usually no leak but once in OR, safer to explore and rule out laceration or leak
(c) more complicated lacerations→ debridement and closure as long as no luminal compro- mise/undue tension
(d) large laceration to second portion of duodenum or whenever unable to do primary repair→ Roux-en-Y or loop duodenojejunostomy (e) multiple complex lacerations→ duodenal
exclusion pyloric closure (staples or sewn) diverting gastrojejunostomy
primary repair of duodenal lacerations tube duodenostomy, external drainage,
+/− T-tube (f) always leave drain!
(g) always decompress post-op:
NGT decompression post-op or tube duo denostomy remote from injury!
(h) if associated contusion to head of pancreas, must look for CBD or pancreatic duct injury (i) avoid temptation to perform the “trauma
Whipple”→ only in the stable pt with combined pancreaticoduodenal injury where all other measures fail or severe ampullary injuries (j) leave J-tube for post-op feeding
Common Curveballs
Pt will have multiple other injuries Pt will have pancreatic injury
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Pt will become acidotic/coagulopathic intra-op and you will need to perform “damage control” surgery Pt will fail nonoperative management
Post-op leak
Pt will develop intra-op DIC (change scenario) Pt will have post-op fever
Asking your post-op management
Marginal ulcer post-op pyloric exclusion (change sce- nario with pt having UGIB)
Strikeouts
Not looking for other injuries (including pancreas) Not adequately visualizing duodenum (need to be able
to describe intra-op techniques)
Not having a variety of ways to treat duodenal injuries Not using NGT post-op or leaving an external drain Not considering “damage control” when appropriate
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