Pyloric Exclusion and Pancreatic Drainage for Combined Duodenal and Pancreatic Trauma

Pyloric Exclusion

Operative Indications

Operative Techniquen some instances of combined duodenal and pancreatic trauma, the injury may not be extensive enough to warrant a hemigastrectomy and diverticularization of the duodenum. In addition, the patient may be unstable, and the surgeon may prefer not to perform a hemigastrectomy but still desire to divert gastric contents away from the injured duodenum. In these instances pyloric exclusion is an attractive alternative to duodenal diverticularization.

Operative Technique

All abdominal trauma patients are explored through a midline incision.

The abdomen is thoroughly explored to identify all intraperitoneal injuries. 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. As in the prior procedure (see pages 454-461), an attempt should be made, if the patient is stable, to look for a major duct injury. If the ampulla has been exposed by one of the duodenal injuries, cholangiography and pancreatography might be possible; if not, contrast can be injected into the gallbladder and then forced into the biliary tree.

If one decides to perform pyloric exclusion, a distal gastrotomy is made with the electrocautery, and the pylorus is closed from within using a continuous 3-0 synthetic absorbable suture.

The gastrotomy is closed with an inner continuous layer of 3-0 synthetic absorbable suture and an outer layer of interrupted 3-0 silk sutures.

A gastrojejunostomy is performed to empty the stomach for the two- or three-week period that the pyloric closure stays intact. The gastrojejunostomy is carried out with an inner continuous layer of 3-0 synthetic absorbable suture and an outer interrupted layer of 3-0 silk sutures.

A vagotomy should be performed if the clinical situation allows. If not, the patient will require long-term treatment with H2 blockers.

The duodenal injuries are repaired, using two-layer closures if possible. As with duodenal diverticularization, if adequate cholangiography has not been obtained, or if a biliary injury has been identified, the gallbladder should be removed and the common duct decompressed with a T-tube. Insertion of a duodenotomy tube in this instance is optional.

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