Page 1644 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 120: Torso Trauma 1163

examination of the stomach and duodenum with contrast agents reveals Postoperatively, patients with pancreatic injury are at risk for develop-
the presence of an intramural hematoma. If this is the only injury, treat- ment of complications such as pancreatic abscess and pseudocyst. The
ment can be conservative, with nasogastric suctioning and intravenous former is suggested by a continued septic course with the development
fluids until the hematoma resolves. If the lesion is found at laparotomy, of a peripancreatic mass, which is identified by CT. This lesion requires
the hematoma is evacuated easily through an incision in the duodenal drainage and antibiotic coverage.
wall. The principle of treatment is to débride the area of injury, remov- The complication of pancreatic pseudocyst results from pancreatic
ing all devitalized tissue. If, after this is accomplished, the edges of the secretions and debris in the lesser sac. Symptoms may be those of a mass
duodenum can be approximated without undue tension, primary suture effect and may include gastric outlet obstruction with vomiting. The
closure is appropriate. The defect also may be closed by a serosal patch presence of a symptomatic mass in these patients requires decompres-
from adjacent small bowel or a resection and end-to-end anastomosis. sion of the pseudocyst. However, if the pseudocyst is not symptomatic,
When these techniques are not possible, then roux-en-Y anastomosis it may be observed for up to 6 weeks, at which time, if there are no signs
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between the duodenal ends and the small bowel needs to be conducted. of spontaneous decrease in size, it should be drained. There is much
When there is concern about the duodenal closure, it is wise to place controversy as to whether drainage should be conducted internally or
a periduodenal drain. If the anastomosis is not secure, the resulting externally. If the external route is chosen, percutaneous drainage may
duodenal fistula will be controlled and can be treated by observation be done under ultrasound or CT guidance. In any event, if this tech-
and parenteral nutrition until the fistula tract matures, after which nique is attempted and the catheter is incapable of draining the very
the drainage tube is removed. Severe duodenal injuries require pyloric thick secretions, internal drainage should be performed via pseudocyst
exclusion procedures in which the gastric contents are diverted through gastrostomy or cystenterostomy or endoscopically. Apart from the mass
a gastrojejunostomy. effect of the pseudocyst, these patients require frequent monitoring of
■ PANCREATIC INJURIES the serum amylase level, which often remains elevated during the active
phase when the pseudocyst is enlarging. Percutaneous drainage also is
Injuries to the pancreas usually result from blunt trauma and are caused unlikely to be effective when the pseudocyst is multiloculated.
difficult because the retroperitoneal position of this organ prevents early ■ INTESTINAL INJURIES
by impact of the pancreas against the vertebral column. Diagnosis is often
physical signs of peritoneal irritation. Frequently, the diagnosis is made Acceleration-deceleration injuries are most likely to occur at points
at laparotomy for other associated conditions. However, the diagnosis is of fixation of the bowel, for example, the ligament of Treitz, the ileoce-
suggested by an increase in the serum amylase level. If the diagnosis is cal junction, and the rectosigmoid area. Blowout perforations of the
suspected and findings on physical examination are minimal, upper gas- small bowel, however, can occur at any site. Another mechanism for
trointestinal radiographic studies with Gastrografin may demonstrate a bowel perforation and injury is related to the lap seat belt. The presence
widening of the duodenal loop. CT of the abdomen allows assessment of of contusion on the abdominal wall from a lap seat belt often makes it
the retroperitoneum and pancreatic area for evidence of retroperitoneal difficult to assess the abdomen for signs of peritoneal irritation. In these
hematomas or even ductal injury. Peritoneal lavage frequently is negative circumstances, ultrasound or CT examination of the abdomen is quite
in the presence of severe retroperitoneal pancreatic injuries. helpful in determining whether or not there is a seat belt-related intesti-
Treatment of these injuries depends largely on whether or not the nal injury. The presence of peritoneal signs will necessitate laparotomy.
pancreatic duct has been violated. In simple contusions of the pancreas, A high index of suspicion and aggressive investigation using ultrasound
drainage of the area is all that is required after mobilization of the and CT are required to minimize missed small bowel injuries because
pancreas and full inspection to rule out any associated ductal injury. these injuries occur frequently in the setting of associated injuries.
Any devitalized area should be débrided, and bleeding points should be Treatment of injuries to the small bowel involves débridement of
controlled by direct suture ligations combined with cautery. devitalized tissue and control of any associated bleeding points with
Ductal injury usually is identified during laparotomy. However, primary suture. Devitalized areas may require formal resection of
in exceptional circumstances where endoscopic retrograde cholan- segments of bowel; this is usually followed by primary anastomosis with
giopancreatography (ERCP) is immediately available in an otherwise excellent results.
stable patient, this may allow assessment of ductal integrity prior to the The treatment of injuries to the colon depends on the time elapsed
laparotomy. When the duct has been injured, there is often a mixture between injury and surgery, the degree of contamination, the stability
of pancreatic fluid and blood over the surface of the pancreas, which of the patient, and the presence of associated injuries. If there is mini-
should be exposed for complete inspection. Although ductal injury mal gross contamination, the operation is being performed within 3 to
involving the body and tail of the pancreas may be treated by transection 4 hours of the injury, and the patient is not in shock, primary anasto-
and anastomosis of the ends of the duct to the small bowel, this injury mosis may be conducted safely. Devitalization of a large portion of the
is treated more appropriately by distal pancreatic re-section without an right colon often necessitates resection of the ileum and ascending colon
enteroanastomosis. When the head of the pancreas is involved, a roux- with an ileocolic anastomosis. Left colonic lesions are more likely to be
en-Y anastomosis of the distal pancreatic segment is advisable. This associated with frank fecal spillage. However, if there is very minimal
type of injury usually is a combined pancreaticoduodenal injury and spillage and no evidence of continued hemorrhage or associated injury,
may require a Whipple procedure (pancreaticoduodenectomy). This even these injuries may be treated by primary closure. Whenever there
procedure carries a high mortality and should be conducted only when is doubt, however, the safest technique for treating left-sided colonic
more conservative measures are unsuccessful. An alternative approach injuries is the fashioning of a colostomy together with repair of the
to combined pancreaticoduodenal injury is the diverticulization proce- laceration and irrigation of the peritoneal cavity. In situations where the
dure, in which the pylorus is closed internally, and a gastrojejunostomy is lacerated bowel can be exteriorized, the resection may be performed
constructed with an added option of drainage of the duodenum through and the ends of the bowel brought out as a proximal defunction-
a tube duodenostomy after repair of the duodenal injury and wide ing colostomy and a mucous fistula. This technique is preferable to a
drainage of the pancreas. The entire area is drained, with drains placed defunctioning colostomy and Hartmann’s procedure (oversewing of the
around the peripancreatic and duodenal area and exiting posteriorly. It rectal stump in the pelvis), which is associated with greater difficulty in
should be emphasized that pancreaticoduodenal resection should be a subsequent reanastomosis of the large bowel.
last resort because of the high associated mortality. Less aggressive treat- Management of injuries to the rectum has undergone significant
ment should be instituted initially if possible. Even though this approach change. The triad of colostomy, presacral drainage, and rectal washout
is more likely to result in complications such as pancreatic abscess, the have been questioned in light of recent studies. Intraperitoneal injuries
overall mortality is still less with drainage than with resection. are managed in a similar manner to colonic injuries. Extraperitoneal

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