Pancreatico-Duodenal Trauma: Drain, Debride, Divert, Despair BACKGROUND EPIDEMIOLOGY 9/11/2018

Transcription

1 Pancreatico-Duodenal Trauma: Drain, Debride, Divert, Despair Rochelle A. Dicker, M.D. Professor of Surgery and Anesthesia UCLA BACKGROUND Lancet 1827: Travers, B Rupture of the Pancreas British Journal of Surgery 1943: Aldis AS..while at work on Monday in the colliery, he was knocked down by a runaway coal truck which struck him in the upper abdomen EPIDEMIOLOGY 1 of 250,000 admits 3-12% of all injuries Average ISS: % from MVC Isolated: 41.5% Main duct involvement: 37% 20% mortality 1

2 DIAGNOSTIC MODALITIES Physical Examination Abdominal pain ~ 78% Other signs: Abdominal tenderness, ecchymosis, seat belt sign, Chance fracture FAST exam Other older modalities Serum Amylase Elevated in ~ 14-78% Increased time from injury=increased amylase No correlation to injury severity DIAGNOSTIC MODALITIES Multi-slice Computed Tomography Findings: Disruption, swelling, heterogeneity, peripancreatic fluid Sensitivity for unspecified pancreatic injury ~ 71% Sensitivity for predicting ductal injury~ 43% May be normal in up to 40% needing operation 2

3 ADVANCES IN DIAGNOSTICS Endoscopic Retrograde Pancreatography First reported for trauma in 1978 High sensitivity for duct disruption Critical role in patients considered for nonoperative management with amylase Pitfalls:? Availability at night and in children 3

4 ADVANCES IN DIAGNOSTICS Magnetic Resonance Cholangiopancreatography First described in 1991 Increased signal on T2-weighted images of pancreatic secretions Advantages: No contrast, non-invasive Disadvantages: Non-therapeutic, duct missed in 20%, logistics in the acute setting PediSurgIntl (2018) 34:

5 AAST PANCREATIC ORGAN INJURY SCALE GRADE TYPE DESCRIPTION I Hematoma Minor contusion Laceration Superficial II Hematoma Major contusion Laceration Deep III Laceration Distal transection and duct injury IV Laceration Proximal transection V Laceration Massive disruption of pancreatic head MANAGEMENT Basis for recommendations: Retrospective data Grade I Blunt Injuries (60% of all): Non-operative management if no peripancreatic fluid on CT Follow physical exam and amylase Consider ERCP if amylase increasing 5

6 MANAGEMENT Grade II Injuries (20%) of all: Exploration and closed suction drainage Consider ERCP if effluent from drain persistently high in amylase Data on closed suction drains The role of interventional radiology Grade III Injuries: Exploration and distal pancreatectomy (56% of gland) Closed suction drainage MANAGEMENT MANAGEMENT Grade IV Injuries: Exploration and closed suction drainage Evaluation of duct integrity: Intraoperatively by inspection or pancreatography ERCP 6

7 MANAGEMENT: Children Recent analysis of 467 patients in NTDB Wide variability in treatment in AIS 3-5 Outcomes for operative and non-operative management showed no difference Delayed management led to worsened outcomes JACS 2016;222: Pediatric Surg International (2018) 34; MANAGEMENT OF DUCT INJURY If suspicious, may give 1unit/kg IV of secretin Near total pancreatectomy if proximal Emerging experience with stent placement Outcomes data not yet available May have a role in low-grade injuries that fail non-operative management Limitations in children 7

8 MANAGEMENT Grade V (rare): Almost always associated with duodenal injuries ADJUVENT TREATMENT Octreotide Data is retrospective-selection bias No evidence that it decreases fistula rate Elemental diet Pancreatitis studies Postpyloric feeding tube at time of operation Managing the Complications Missed injury and inadequate drainage What can we glean from the latest in pancreatitis treatment- Complications from operative management: 17% leak rate Fistula rate 8-69% Intl J. Care Injured 45 (2014)

9 Western Trauma Association: Management Algorithm for Pancreatic Injuries Biffl, Walter L.; Moore, Ernest E.; Croce, Martin; Davis, James W.; et al. Journal of Trauma and Acute Care Surgery. 75(6): , December Copyright 2014 Journal of Trauma and Acute Care Surgery. Published by Lippincott Williams & Wilkins. 25 Pancreatico-duodenal injuries The Trauma Whipple In the setting of damage control Very little data Duodenal Injuries-Diagnosis CT scan: Misses up to 48% of injuries Air and fluid in retroperitoneum Wall thickening Diminished enhancement Operative approach It is necessary to perform an extended Kocher maneuver and perhaps LOT dissection 5-6% of blunt trauma, 10-11% with GSW 9

10 Grade I and II Duodenal hematomas Nasogastric decompression Parenteral versus enteral feeds for 7-10 days days: Reimage Laparotomy if not resolving Small lacerations Partial thickness-seromuscular single layer Full-thickness-two-layer transverse closure 10

11 Grades III, IV, V THOROUGH INSPECTION at laparotomy If Grade III or IV: duodenal duodenostomy or retrocolic Roux-en-Y duodenojejunostomy Consider pyloric exclusion DAMAGE CONTROL Control hemorrhage and contamination, closed suction drainage and DELAY the Whipple if Grade V injury? Consider pyloric exclusion The American Surgeon November 2017-DV Feliciano Surgical Clinics N Amer 2017 Coleman, Zarzaur Adjuvant therapies Pyloric exclusion and loop gastrojejunostomy Pylorus usually reopens in 6-12 weeks Associated with marginal ulcers Outcome studies are too small to make conclusions Wide drainage Western Trauma Algorithm 11

12 9/11/2018 Managing Complications Over 1400 patients with duodenal injuries 64% had complications Asencio, Feliciano, et al Current Problems in Surgery 1993 Risk factors: 1st and 2nd portion of duodenum, delay in repair >24 hours, bile duct injury Managing Complications Abscess, pancreatitis, duodenal fistula Closed suction drainage as indication Divert flow to get control of the drainage/sepsis Try to feed distally if possible The dreaded enteroatmospheric fistula THANK YOU 12