Duodenal and Pancreatic Trauma

Abstract

The difficulty in diagnosing injuries to the duodenum and pancreas is attributed to the fact that they are retroperitoneal structures, therefore, well protected by the surrounding viscera. As a result, injuries to these organs are rare and also easily missed. Most trauma surgeons have limited experience in treating them. The epidemiologic study from Trauma Audit and Research in the UK found a combined incidence of 4.7% for pancreatic and duodenal injuries among patients with abdominal trauma.1 The retroperitoneal location of these organs results in a delay of symptomatology and frequently diagnosis. Injuries requiring surgical repair are more common as a consequence of a penetrating mechanism. In most cases, trauma to the duodenum and pancreas is associated with other injuries potentially changing the surgical approach. Moreover, in patients with pancreatic or duodenal injury, a complete evaluation must be performed in order to rule out an associated visceral injury. Injuries caused by blunt or penetrating trauma with high mechanisms can continue to evolve over time such as contusion of the mesentery or blunt trauma to the bowel. This is particularly important when evaluating injuries to the pancreas and the duodenum, since injuries that might have appeared insignificant can result in ischemia and perforation if not treated appropriately.2 There are significant implications of a joint pancreatic and duodenal injury. Injury to the pancreatic duct results in uncontrolled leak of pancreatic enzymes that become a threat to any repair. Secretion of pancreatic enzymes increases morbidity and mortality secondary to suture line dehiscence and secondary intra-abdominal sepsis.3 The outcomes of these injuries have improved over the years secondary to increased awareness, earlier diagnosis and treatment, appropriate resuscitation to euvolemia avoiding secondary physiological insult to the patient, and advances in adjuncts for nutritional support.4 The following chapter will focus on clinical presentation and operative techniques that can help the surgeon treat these complicated patients. An Ato m I c A l co n s I d e r At I o n s Vascular Supply The vascular supply to the duodenum and pancreas is provided by the superior and inferior pancreaticoduodenal arteries, which are branches from celiac and superior mesenteric arteries, respectively. Both pancreaticoduodenal arteries provide anterior and posterior branches. In turn these branches have several small vessels entering the duodenal wall and the head of the pancreas. Therefore, dissecting and isolating the duodenum from the pancreas is a difficult maneuver due to bleeding. Duodenal devascularization is always a concern. The right gastric artery and the splenic artery give rise to additional arterial branches to the duodenum and the body and tail of the pancreas. The venous drainage follows the arteries and provides tributaries to the splenic vein and superior mesenteric vein. Both drain into the portal vein.