Diverticularization of the Duodenum and Pancreatic Drainage for Combined Duodenal and Pancreatic Trauma

Diverticularization of the Duodenum

Operative Indications

The surgical management of combined pancreatic and duodenal trauma can be very challenging to the trauma surgeon. These combined injuries carry a high morbidity and significant mortality.

Operative Technique

Virtually all patients with blunt or penetrating trauma should be explored through a long midline incision. Once the abdomen has been completely explored and only the pancreatic and duodenal injuries found, these lesions are attended to.

In this instance there is a contusion of the duodenum with two perforations and a stellate injury to the head and neck of the pancreas.

In such instances, if the patient is stable, one should rule out a major injury to the biliary tree and pancreatic duct radiographically. Occasionally the ampulla can be cannulated and cholangiography and pancreatography carried out through one of the duodenotomy wounds. If the ampulla is not easily accessible, contrast can be injected into the gallbladder and then forced into the biliary tree. However, with an unstable patient, visualization and palpation at the time of surgery may be all that one can do to rule in or out a major duct injury.

If combined pancreatic and duodenal trauma is so severe that the duodenum and ampulla are destroyed and reconstruction cannot be carried out, a pancreaticoduodenectomy may rarely be necessary. In most instances, however, duodenal repair can be carried out and pancreatic drainage performed.

If the duodenal and pancreatic lesions are severe but repairable, one may decide to perform the diverticularization procedure. This requires resection of the antrum of the stomach, closure of the duodenum to divert gastric flow, and decompression of the duodenum with a duodenostomy tube.

The duodenal injuries are repaired, and the pancreatic injury is drained. Enteric continuity is reestablished via a gastrojejunostomy. The mid portion of the stomach is divided between two sets of Kocher clamps (B). The first portion of the duodenum is divided between stone clamps, although a GIA stapler can also be conveniently used. The two duodenal perforations have been closed.

The end of the normal duodenum is closed around a Foley catheter, using two inverting purse strings of 3-0 silk. This catheter serves to decompress the duodenum and allows for safer healing of the contused duodenotomies. If one of the closed duodenal lesions opens and a duodenocutaneous fistula develops, having the duodenostomy tube in place should facilitate decompression of the duodenum and closure of the fistula.

The lesser curvature of the stomach is closed with an inner layer of 3-0 synthetic absorbable suture run in a horizontal mattress fashion underneath the Kocher clamp and then carried back in an over-and-over locking fashion.

An inverting outer layer of interrupted 3-0 silk sutures is placed on the lesser curvature, and then a gastrojejunostomy is performed to the proximal jejunal loop. This is carried out with an inner continuous layer of 3-0 synthetic absorbable sutures and an outer layer of interrupted 3-0 silk.

Often the surgeon will decide to perform a cholecystectomy and decompress the biliary tree by inserting a T-tube. This is particularly important if one has not been able to evaluate the biliary tree cholangiographically or if it has been identified cholangiographically and an injury is present.

The pancreatic injury is debrided carefully to remove devitalized tissue. Great care should be taken to avoid injuring the pancreatic duct.

The duodenal closures as well as the T-tube insertion site are drained with Penrose drains. The stellate pancreatic injury is drained with a silastic sump brought out through a separate stab wound in the right upper quadrant.

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