CHALLENGE
OF
ACS
Delayed duodenal injury following abdominal gunshot wound Geoffrey C. Garst, MD, Heidi J. Miller, MD, Pak S. Leung, MD, and Mark J. Kaplan, MD With expert commentary by Walter L. Biffl, MD
Figure 1. Initial duodenal injury.
A
29-year-old male who sustained two abdominal gunshot wounds became hemodynamically unstable in the trauma bay and was thus taken immediately to the operating room for exploratory laparotomy. Massive hemoperitoneum was discovered upon abdominal entry. After packing four quadrants, controlling hemorrhagic vessels branching from the superior mesenteric artery and superior mesenteric vein, packing a large liver laceration, performing partial small bowel resection and right hemicolectomy, a Grade 3 laceration along the second portion of the duodenum was discovered and closed primarily (Fig. 1). With an open abdomen, the patient
Figure 2. Devascularization of D3 to D4.
was stabilized in the surgical intensive care unit. Reexploration was performed on hospital day (HD) 3; transverse colectomy, reanastomosis of the small bowel, feeding jejunostomy, and end ileostomy were performed. The repaired duodenal injury was evaluated and appeared viable. The abdomen was not yet amenable to closure. On further exploration on HD 5, a bilious fluid collection was discovered in the duodenal region. The distal second portion of the duodenum and the third and fourth portions of the duodenum were found to be necrotic secondary to complete devascularization (Fig. 2). The previously repaired site and the adjacent pancreas appeared to be unaffected.
What Would You Do? A. Pancreaticoduodenectomy B. Resection of the affected duodenum with primary duodenojejunal anastomosis and placement of a transgastric jejunal feeding tube C. Duodenal diverticularization with pyloric exclusion, gastrojejunostomy, vagotomy, biliary drainage, and placement of feeding jejunostomy D. Resection of the affected duodenum with antrectomy, side gastrojejunostomy with vagotomy, biliary drainage, and placement of feeding jejunostomy
From the Albert Einstein Medical Center, Philadelphia, Pennsylvania. Address for reprints: Geoffrey C. Garst, MD, MPH, Albert Einstein Medical Center Department of Surgery, 5501 Old York Road, Klein 510, Philadelphia, PA 19141. email: [email protected]. DOI: 10.1097/TA.0000000000000449
796
J Trauma Acute Care Surg Volume 77, Number 5
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg Volume 77, Number 5
Garst et al.
What We Did and Why B. Resection of the affected duodenum with primary duodenojejunal anastomosis and placement of a transgastric jejunal feeding tube Because of the devascularization and subsequent necrosis consistent with delayed kinetic injury, we resected the entire third and fourth portions of the duodenum free from the retroperitoneal area and transected the jejunum distal to the previously placed feeding jejunostomy. This portion was brought to the right side of the abdomen and then retracted laterally and cephalad, which allowed for a second portion of the duodenum to be safely dissected free from the head of the pancreas to a level proximal to the area of the injury. We chose this approach to adequately remove the entirety of the injury from the duodenum while preserving the blood supply to the pancreas, which remained uninjured. An enterotomy was made to visually confirm that this level was still distal to the ampulla of Vater to ensure that biliary and pancreatic secretions would continue to drain enterally without the need for ampullary reimplantation. The duodenum was then transected using an Endo-GIA stapler. We then brought the proximal jejunum up and approximated it to the remnant duodenum using silk stay sutures to allow for a tension-free process (Fig. 3). The posterior layer of the anastomosis was completed using Lembert sutures of 3-0 silk popoffs. Enterotomy was then made in the jejunum juxtaposed to the enterotomy already made in the duodenum. Handsewn anastomosis was completed using running Vicryl sutures. We wanted to preserve the native function of the stomach to avoid the potential complications associated with resection and vagotomy while simultaneously providing gastric decompression and enteral nutrition to augment healing. Thus, before closure of the anastomosis, a transgastric jejunal tube was placed through the anterior abdominal wall, and we created gastrotomy and threaded through the py-
Figure 3. Duodenojejunal anastomosis.
lorus and beyond the anastomosis to the proximal jejunum. Gastropexy was performed to secure the tube to the anterior abdominal wall. Finally, the duodenojejunal anastomosis was buttressed with an omental patch to further augment healing and reduce the risk of developing anastomotic leak. Thereafter, the abdomen was closed. The patient slowly recovered from his injuries, was discharged in good condition on HD 17, and eventually made a full recovery (G.C.G., H.J.M., M.J.K., P.S.L.).
EXPERT OPINION This case typifies the penetrating duodenal injury, a destructive lesion with associated vascular injury in an unstable patient. The damage-control approach is imperative in such a patient. Primary repair of a Grade III duodenal laceration is appropriate in this setting because the alternativeVdrainage and delayed repairV would likely result in the need for more extensive debridement of wound edges due to leakage of duodenal contents. Ischemic necrosis of the duodenum was probably unavoidable as superior mesenteric artery branches were ligated, but there was no
role for any type of prophylactic resection. Indeed, the duodenum appeared healthy at reexploration on HD 3. Necrosis of the distal second through fourth portions of the duodenum mandates resection. Two factors weigh in the decision on the extent of resection: (1) the status of the bile duct and ampulla; and (2) the condition of the pancreas. If both are severely injured, pancreaticoduodenectomy is probably the only option. With a healthy pancreas, pancreaticoduodenectomy is unnecessaryVthe duodenum can be resected, and a roux-en-Y limb of the jejunum can be brought up to the common hepatic duct and proximal duodenum. In this case, the pancreas is uninjured, and the bile duct and ampulla are intact. Thus, the necrotic segment of duodenum must be resected and continuity be restored. Duodenal diverticularization is mentioned but is of historical interest only. Antrectomy with gastrojejunostomy would bypass the injury but does not provide optimal drainage of the duodenum. The best option is the one the authors selected, that is, duodenojejunostomy. Enteral nutritional support is critical. The authors selected transgastric jejunostomy, passing the catheter across the anastomosis. There is nothing wrong with this approach; an alternative would be a jejunostomy. A decompressive gastric tube provides a measure of safety in case of ileus and to try to decrease pressure on the healing anastomosis. Omental buttressing of the repair is an unproven adjunct but is not likely harmful. Similarly, whether a two-layer anastomosis is superior to a single-layer anastomosis in the duodenum is dubious. Some feel it may be more likely to create some ischemia of the suture line. The authors did not mention leaving a periduodenal drain, which may be appropriate in this setting (W.L.B.).
DISCLOSURE The authors declare no conflicts of interest.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
797
OF
ACS
Delayed duodenal injury following abdominal gunshot wound Geoffrey C. Garst, MD, Heidi J. Miller, MD, Pak S. Leung, MD, and Mark J. Kaplan, MD With expert commentary by Walter L. Biffl, MD
Figure 1. Initial duodenal injury.
A
29-year-old male who sustained two abdominal gunshot wounds became hemodynamically unstable in the trauma bay and was thus taken immediately to the operating room for exploratory laparotomy. Massive hemoperitoneum was discovered upon abdominal entry. After packing four quadrants, controlling hemorrhagic vessels branching from the superior mesenteric artery and superior mesenteric vein, packing a large liver laceration, performing partial small bowel resection and right hemicolectomy, a Grade 3 laceration along the second portion of the duodenum was discovered and closed primarily (Fig. 1). With an open abdomen, the patient
Figure 2. Devascularization of D3 to D4.
was stabilized in the surgical intensive care unit. Reexploration was performed on hospital day (HD) 3; transverse colectomy, reanastomosis of the small bowel, feeding jejunostomy, and end ileostomy were performed. The repaired duodenal injury was evaluated and appeared viable. The abdomen was not yet amenable to closure. On further exploration on HD 5, a bilious fluid collection was discovered in the duodenal region. The distal second portion of the duodenum and the third and fourth portions of the duodenum were found to be necrotic secondary to complete devascularization (Fig. 2). The previously repaired site and the adjacent pancreas appeared to be unaffected.
What Would You Do? A. Pancreaticoduodenectomy B. Resection of the affected duodenum with primary duodenojejunal anastomosis and placement of a transgastric jejunal feeding tube C. Duodenal diverticularization with pyloric exclusion, gastrojejunostomy, vagotomy, biliary drainage, and placement of feeding jejunostomy D. Resection of the affected duodenum with antrectomy, side gastrojejunostomy with vagotomy, biliary drainage, and placement of feeding jejunostomy
From the Albert Einstein Medical Center, Philadelphia, Pennsylvania. Address for reprints: Geoffrey C. Garst, MD, MPH, Albert Einstein Medical Center Department of Surgery, 5501 Old York Road, Klein 510, Philadelphia, PA 19141. email: [email protected]. DOI: 10.1097/TA.0000000000000449
796
J Trauma Acute Care Surg Volume 77, Number 5
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg Volume 77, Number 5
Garst et al.
What We Did and Why B. Resection of the affected duodenum with primary duodenojejunal anastomosis and placement of a transgastric jejunal feeding tube Because of the devascularization and subsequent necrosis consistent with delayed kinetic injury, we resected the entire third and fourth portions of the duodenum free from the retroperitoneal area and transected the jejunum distal to the previously placed feeding jejunostomy. This portion was brought to the right side of the abdomen and then retracted laterally and cephalad, which allowed for a second portion of the duodenum to be safely dissected free from the head of the pancreas to a level proximal to the area of the injury. We chose this approach to adequately remove the entirety of the injury from the duodenum while preserving the blood supply to the pancreas, which remained uninjured. An enterotomy was made to visually confirm that this level was still distal to the ampulla of Vater to ensure that biliary and pancreatic secretions would continue to drain enterally without the need for ampullary reimplantation. The duodenum was then transected using an Endo-GIA stapler. We then brought the proximal jejunum up and approximated it to the remnant duodenum using silk stay sutures to allow for a tension-free process (Fig. 3). The posterior layer of the anastomosis was completed using Lembert sutures of 3-0 silk popoffs. Enterotomy was then made in the jejunum juxtaposed to the enterotomy already made in the duodenum. Handsewn anastomosis was completed using running Vicryl sutures. We wanted to preserve the native function of the stomach to avoid the potential complications associated with resection and vagotomy while simultaneously providing gastric decompression and enteral nutrition to augment healing. Thus, before closure of the anastomosis, a transgastric jejunal tube was placed through the anterior abdominal wall, and we created gastrotomy and threaded through the py-
Figure 3. Duodenojejunal anastomosis.
lorus and beyond the anastomosis to the proximal jejunum. Gastropexy was performed to secure the tube to the anterior abdominal wall. Finally, the duodenojejunal anastomosis was buttressed with an omental patch to further augment healing and reduce the risk of developing anastomotic leak. Thereafter, the abdomen was closed. The patient slowly recovered from his injuries, was discharged in good condition on HD 17, and eventually made a full recovery (G.C.G., H.J.M., M.J.K., P.S.L.).
EXPERT OPINION This case typifies the penetrating duodenal injury, a destructive lesion with associated vascular injury in an unstable patient. The damage-control approach is imperative in such a patient. Primary repair of a Grade III duodenal laceration is appropriate in this setting because the alternativeVdrainage and delayed repairV would likely result in the need for more extensive debridement of wound edges due to leakage of duodenal contents. Ischemic necrosis of the duodenum was probably unavoidable as superior mesenteric artery branches were ligated, but there was no
role for any type of prophylactic resection. Indeed, the duodenum appeared healthy at reexploration on HD 3. Necrosis of the distal second through fourth portions of the duodenum mandates resection. Two factors weigh in the decision on the extent of resection: (1) the status of the bile duct and ampulla; and (2) the condition of the pancreas. If both are severely injured, pancreaticoduodenectomy is probably the only option. With a healthy pancreas, pancreaticoduodenectomy is unnecessaryVthe duodenum can be resected, and a roux-en-Y limb of the jejunum can be brought up to the common hepatic duct and proximal duodenum. In this case, the pancreas is uninjured, and the bile duct and ampulla are intact. Thus, the necrotic segment of duodenum must be resected and continuity be restored. Duodenal diverticularization is mentioned but is of historical interest only. Antrectomy with gastrojejunostomy would bypass the injury but does not provide optimal drainage of the duodenum. The best option is the one the authors selected, that is, duodenojejunostomy. Enteral nutritional support is critical. The authors selected transgastric jejunostomy, passing the catheter across the anastomosis. There is nothing wrong with this approach; an alternative would be a jejunostomy. A decompressive gastric tube provides a measure of safety in case of ileus and to try to decrease pressure on the healing anastomosis. Omental buttressing of the repair is an unproven adjunct but is not likely harmful. Similarly, whether a two-layer anastomosis is superior to a single-layer anastomosis in the duodenum is dubious. Some feel it may be more likely to create some ischemia of the suture line. The authors did not mention leaving a periduodenal drain, which may be appropriate in this setting (W.L.B.).
DISCLOSURE The authors declare no conflicts of interest.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
797
