TRAUMATIC GI INJURIES
From the 36th Annual Phoenix Surgical Symposium, sponsored by Banner Health and the Phoenix Surgical Society
Gregory J. Jurkovich, MD, Professor of Surgery, University of Washington School of Medicine, and Chief of Trauma
Services, Harborview Medical Center, Seattle, WA
Educational Objectives
| The goal of this program is to improve the diagnosis and management of duodenal, liver, and portal triad injuries. After
hearing and assimilating this program, the clinician will be better able to:
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 | 1. Recognize the challenges of diagnosing blunt and penetrating duodenal injuries and explain the consequences of delayed
diagnosis.
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| 2. Describe the surgical options for managing duodenal trauma, including preferred procedures for treating simple and
complex injuries.
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| 3. Discuss the role of nonoperative management (including its advantages and potential complications) in the treatment
of liver trauma.
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| 4. Follow the recommended steps for managing the liver trauma patient who presents with hemoperitoneum and hemodynamic
instability.
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| 5. Identify the patient with juxtahepatic venous injury.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, the faculty and the planning committee reported
nothing to disclose.
Acknowledgements
Dr. Jurkovich spoke at the 36th Annual Phoenix Surgical Symposium, held February 13-16, 2008, in Phoenix, AZ, and
sponsored by Banner Health and the Phoenix Surgical Society. The Audio-Digest Foundation thanks Dr. Jurkovich,
Banner Health, and the Phoenix Surgical Society for their cooperation in the production of this program.
| Case example: 38-yr-old man with single gunshot wound to right upper quadrant of abdomen; patient intubated in field
and arrives at emergency department (ED) neither hypotensive nor tachycardic; Glasgow Coma Scale (GCS) score of 3;
initial work-up—chest x-ray unremarkable; abdominal x-ray demonstrates bullet overlying transverse process of L2 vertebra;
single-shot intravenous pyelography (IVP) shows 2 functioning kidneys and no blood in urine; speaker strongly
advocates taking this type of patient directly to operating room (OR); treatment
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| Duodenal injuries: relatively uncommon (only 3%-5% of cases of abdominal trauma include injury to duodenum); majority
due to penetrating wounds, but cases of blunt duodenal injury exist; such cases particularly difficult to manage (often
seen in cases of direct or isolated blow to epigastrium, eg, compression against steering wheel, direct blow or kick to
abdomen, blow from handlebar in bicycle accident)
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| Diagnosis: penetrating injury—diagnosis made by laparotomy (operate on patient and look for duodenal injury with
good mobilization; follow trajectory of penetrating missile or knife blade from beginning to end and look for wounds in
between); blunt trauma—diagnosis somewhat more difficult; physician often has to perform laparotomy to look for injury;
although problematic, prompt diagnosis of duodenal injury critically important (studies show delay in diagnosis dramatically
increases morbidity and mortality)
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| Signs of injury and challenges of diagnosis: presence of retroperitoneal air, loss of psoas shadow, and scoliosis
key signs of duodenal injury on plain x-ray, but present in <30% of cases; computed tomography (CT) can accurately detect
retroperitoneal duodenal rupture only (even with intravenous [IV] and oral contrast) in ≈50% of cases; diagnostic
peritoneal lavage (DPL) and focused assessment by sonography in trauma (FAST) examination less reliable in detecting
isolated injuries (however, DPL can sometimes be helpful, since ≈40% of duodenal injuries associated with other intra-
abdominal injuries that result in positive findings); presence of amylase in lavage fluid may occasionally be helpful as indicator
of possible duodenal injury (but serum amylase elevated in only ≈50% of patients, so not completely reliable
sign)
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| Principles of operative management: first step to stop bleeding; next, control contamination; lastly, make definitive
repair; type of repair dependent on patient’s overall hemodynamic status, time since injury, and location and severity of
injury; surgical options—primary repair; primary repair buttressed with overlying omental or serosal flap; duodenal segmental
resection and primary anastomosis; delayed repair; complicated repair (eg, panctreaticoduodenectomy); most
mild duodenal injuries can be effectively managed with primary repair or resection and primary anastomosis; more severe
injuries require more complex treatment strategies
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| Determinants of injury severity: mild—low velocity mechanism of injury (eg, stab wound); size <75% of duodenal
wall; distal location; time to repair <24 hr; no common bile duct injury; severe—blunt or missile (gunshot) injury; complete
transection of wall; proximal location; time to repair >24 hr; common bile duct injury
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| Role of more complicated repairs: in study of 10 patients with duodenal injury, 6 had primary repair, 1 had primary
anastomosis, and 3 required slightly more complex repair (not required very often, but sometimes necessary); in Pennsylvania
study, 16 of 30 patients with blunt injury had primary repair, others required more complex repairs; in Western
Trauma Association (WTA) multi-institutional trial, 90 of 164 patients had primary repair; 27 underwent pyloric exclusion;
“a few” had Whipple procedures, duodenojejunostomies or duodenostomies; one patient had formal diverticulization,
and one had drainage of hematoma alone; most common approach to complex repair pyloric exclusion, followed by
anastomosis of duodenum or jejunum up to transected duodenal limb
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| Speaker’s approach to pyloric exclusion: make anterior gastrotomy large enough to insert Babcock clamp; reach
in and grab pylorus with Babcock clamp; pull pylorus out through hole, hold it out, and whip-stitch pylorus closed with
size 0 Maxon polydioxanone (PDS) absorbable suture; tie knot on running stitch, and drop pylorus back in (totally occludes
pylorus for 3 wk to 3 mo; all open up eventually); afterwards, perform gastrojejunostomy to protect injury and repair
from stomach reflux; almost always necessary to insert gastrostomy tube for decompression and distal feeding
jejunostomy tube to provide enteral nutrition
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| Role of tube duodenostomy: in general (when doing primary repair), lateral tube duodenostomy not required; when
performing pyloric exclusion, tube duodenostomy required, but only for distal feeding jejunostomy; in WTA study, 60%
of patients who had duodenostomy developed tube-related complications (authors concluded no apparent role for tube
duodenostomy); nevertheless, still some proponents of procedure (review of 8 retrospective series by JD Hasson et al;
tube used for retrograde decompression in majority of cases; authors found duodenal fistula and overall mortality rates
lower in patients who had retrograde jejunostomy tube drainage than in patients who did not have decompression)
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| Comments: no role for “sucker patch” or decompressive ostomy patch in managing duodenal injuries (not recommended;
data show that, in cases of gunshot wounds, technique associated with 64% incidence of abdominal sepsis and
27% mortality rate; in cases of stab wounds, technique associated with 50% incidence of abdominal sepsis)
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| Conclusions: primary repair preferred and most common procedure for managing duodenal injuries (even when duodenal
wall totally transected); in patients with mild injuries, only primary repair required; lateral tube duodenostomy not required;
pyloric exclusion best choice for adjunctive procedure (simplest; low morbidity; essentially reverses itself; allows
surgeon to put in retrograde duodenostomy decompression tube as well as feeding tube; protects complicated anastomosis);
in highest risk patients, speaker performs pyloric exclusion with retrograde decompression of duodenum
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| LIVER AND PORTAL TRIAD INJURIES: OPERATION, EMBOLIZATION, AND OBSERVATION
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| Introduction: liver injuries common (can occur in up to 50% of cases of blunt abdominal trauma); 50% of blunt liver injuries
result from injured party being unrestrained (ie, not wearing seat belt) during motor vehicle accident (MVA); data
suggest that approach to management of liver injuries changes approximately every 50 yr; currently, emphasis on damage
control, although also option of primary control; among management issues, whether treatment should be operative or
nonoperative; if operative, whether to do damage control or primary control; role of primary angiography and other adjuncts
for enhancing coagulation (since hemorrhage and exsanguination leading causes of mortality in liver injuries) also
at issue; historical background of liver injury management
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| Case examples: 37-yr-old man (pedestrian struck by car); 62-yr-old woman (unrestrained front seat passenger in T-bone
MVA); 47-yr-old man (construction worker with blunt trauma [heavy wood plank jammed into abdomen])
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| Factors influencing management decisions: some suggestion that “lethal triad” of coagulopathy, hypothermia, and
acidosis indication to quit operating and take different approach; when making decisions, take into account total amount
of blood loss, severity of liver and other injuries, and amount of available resources
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| Comments: case examples illustrate level of judgment necessary when managing patients with liver injury; evolution of
nonoperative management based primarily on ability of 3-D (or cross-sectional) imaging to accurately represent extent of
injury, and to more accurately exclude associated injuries; historically, many patients with blunt abdominal trauma (up to
85% of patients with liver injuries) who underwent surgery had “relatively negative” or nontherapeutic and/or unhelpful
laparotomies; therefore, nonoperative management becoming increasingly more common, particularly as researchers
have looked at high mortality rates associated with operating on otherwise hemodynamically stable liver trauma patients;
WTA multi-institutional trial found mortality could be lowered for all grades of injury through nonoperative management
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| Circumstances in which nonoperative management contraindicated: patient who is clearly hemodynamically
unstable requires intervention (may be angiography and embolization, but only effective when dealing with arterial
injury, which is relatively uncommon in liver trauma); perforated colon or perforated bowel clear indication for operation;
blushing or pooling of contrast on CT also warrants intervention (angiography at speaker’s institution); overall, patient’s
physiology should determine type of management
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| Advantages of nonoperative management: fewer transfusions required; less intra-abdominal infection; lower mortality
rate; successful in 85% of cases
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| Potential complications of nonoperative management: hemorrhage can occur ≤2 wk late in ≤3% of patients;
biloma can develop in 3% of patients (often does not present until several days to weeks afterwards); abscess formation
(in 1% of patients); missed other injuries (rare)
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| Risk factors for hepatic morbidity after nonoperative management: multi-institutional trial looked at delayed
complications in patients with grades III, IV, and V liver injuries who had nonoperative management; demonstrated
relationship between grade of injury and amount of shock (ie, number of blood units transfused), and probability
of developing complications (eg, patients with grade IV injuries who required >20 U of blood had ≈50% complication
rate); bleeding problems and abdominal compartment syndrome tend to occur early; bilomas and infection problems occur
slightly later
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| Management of delayed hemorrhage: in hemodynamically unstable patient—requires abdominal exploration; in
stable patient—repeat CT; if injury unchanged, look for another cause of hemorrhage; if injury worse or evidence of
pooling of CT contrast, consider angioembolization or abdominal exploration
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| Follow-up after nonoperative management, and time to return to normal activities: no good objective
data on length of time required for liver injury to heal; speaker’s protocol—in grade I, II, or III injuries, no follow-up imaging
studies; patients allowed to return to normal activities in 6 wk; in grade IV and V injuries, speaker more hesitant; of
course, any patient with unexpected change in clinical course requires repeat imaging study; if patient remains stable,
protocol more nebulous; speaker obtains repeat CT 8 wk after injury only if patient has to resume sanctioned physical activities
(and only in cases involving grade IV or V injuries)
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| Operative principles: help in OR—have retractor in place to help provide exposure; if unable to see beyond dome of
liver and need to access that area, sternotomy “totally fine extension” for getting above liver; requires blood bank that is
prepared; extra hands if necessary; primary tenets of surgery—first, stop bleeding; second, control contamination; lastly,
be prepared for bile leak that may occur
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| Operative approach: hemoperitoneum with instability—options include compression for resuscitation (ie, manually
pushing liver back to its preinjury anatomic location and holding it together while anesthesia provider helps with resuscitation;
done to achieve hemodynamic stability); if bleeding has stopped, surgeon can pack around liver and decide
whether to operate or curtail procedure; if simple packing does not control bleeding, next step Pringle maneuver (inflow
occlusion); if bleeding then stops, option available of performing hepatotomy and repair (debridement of devitalized tissue,
omental drainage, and packing best approach); if bleeding continues, consider retrohepatic vena cava or hepatic vein
injury
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| Bile leaks: once repair done and liver and bleeding sites under control, important to look for bile leaks (postoperative
leaks extremely difficult to manage); pack omentum after bile leaks repaired, adequately drain with close-suction drains,
and exit procedure
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| Juxtahepatic venous injuries: extremely lethal; produce rapid intra-operative exsanguination; wide exposure and direct
venous repair necessitated in most cases, but if bleeding can be stopped with compression, occasionally these injuries
(particularly retrohepatic vena caval injuries) seal on their own; may occasionally have opportunity to put in venous stent
to transgress injury (fairly new technique and not well explored, but remains option)
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| Atriocaval shunts: at one time, 132 patients recorded using atriocaval shunts (with 23 survivals); technique has largely
fallen out of favor
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| Vascular isolation: requires venovenous bypass (useful technique; can be done percutaneously); allows for controlled operative
exposure (must be set up early; difficult to achieve)
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| Establishing need for hepatic resection: primarily at times when injury “has virtually done the resection itself”; ie,
when there has been total destruction of parenchyma and extent of injury precludes packing; cannot reconstruct liver in
these cases; resection sole mode of hemorrhage control
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| Role of damage control: damage control not one-time event; can pack injuries multiple times (and this can be done
within one setting, eg, OR); initial packing controls bleeding in ≈50% of patients; repacking controls bleeding in another
≈50%; third attempt at packing controls ≈75% of those who continue to bleed; after that, diminished returns (physician
should consider some other approach); abscess rate high after packing (10%-30%; related to number of days packs remain
in place; for every additional day after 3 days, complication rate increases by ≈10%)
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| Concluding comments: exsanguination primary cause of death from liver injury; therefore, number one priority to
control bleeding; role of adjunctive therapies (eg, recombinant factor VIIa) remains controversial, particularly in liver
trauma, but speaker expects they will continue to be explored
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Suggested Reading
Asensio JA et al: Pancreaticoduodenectomy: a rare procedure for the management of complex pancreaticoduodenal
injuries. J Am Coll Surg 197:937, 2003; Biffl WL et al: Venovenous bypass and hepatic vascular isolation as adjuncts
in the repair of destructive wounds to the retrohepatic inferior vena cava. J Trauma. 45:400, 1998; Bozkurt B
et al: Operative approach in traumatic injuries of the duodenum. Acta Chir Belg 106:405, 2006; Buckman RF: Injuries
of the inferior vena cava. Surg Clin North Am 81:1431, 2001; Christmas AB et al: Selective management of
blunt hepatic injuries including nonoperative management is a safe and effective strategy. Surgery 138:606, 2005;
Coimbra R et al: Nonoperative management reduces the overall mortality of grades 3 and 4 blunt liver injuries. Int
Surg 91:251, 2006; Cox JC et al: Routine follow-up imaging is unnecessary in the management of blunt hepatic injury.
J Trauma 59:1175, 2005; Degiannis E, Boffard K: Duodenal injuries. Br J Surg 87:1473, 2000; Fang JF et
al: Surgical treatment and outcome after delayed diagnosis of blunt duodenal injury. Eur J Surg 165:133, 1999;
Gourgiotis S et al: Operative and nonoperative management of blunt hepatic trauma in adults: a single-center report.
J Hepatobiliary Pancreat Surg 14:387, 2007; Huerta S et al: Predictors of morbidity and mortality in patients
with traumatic duodenal injuries. Am Surg 71:763, 2005; Jurkovich GJ: “Duodenum and Prancreas,” in Trauma
(4th ed), McGraw-Hill, New York: 735, 2000; Jurkovich GJ et al: Portal triad injuries. J Trauma 39:426, 1995;
Kozar RA et al: Risk factors for hepatic morbidity following nonoperative management: multicenter study. Arch
Surg 141:451, 2006; Lee SK, Carrillo EH: Advances and changes in the management of liver injuries. Am Surg
73:201, 2007; Lee TY et al: Anatomic resection for severe blunt liver trauma. Int Surg 90:266, 2005; Liu PP et al:
Use of a refined operative strategy in combination with the multidisciplinary approach to manage blunt juxtahepatic
venous injuries. J Trauma 59:940, 2005; Lopez PP et al: Recent trends in the management of combined pancreatoduodenal
injuries. Am Surg 71:847, 2005; Nicoluzzi JE et al: Hepatic vascular isolation in treatment of a complex
hepatic vein injury. J Trauma 63:684, 2007; Pearl J et al: Traumatic injuries to the portal vein: case study. J
Trauma 56:779, 2004; Phelan H et al: Retrohepatic vena cava and juxtahepatic venous injuries. South Med J
94:728, 2001; Rickard MJ et al: Pancreatic and duodenal injuries: keep it simple. ANZ J Surg 75:581, 2005; Seamon
MJ et al: A ten-year retrospective review: does pyloric exclusion improve clinical outcome after penetrating
duodenal and combined pancreaticoduodenal injuries? J Trauma 62:829, 2007; Talving P et al: Civilian duodenal
gunshot wounds: surgical management made simpler. World J Surg 30:488, 2006; Trunkey DD: Hepatic trauma:
contemporary management. Surg Clin North Am 84:437, 2004; Velmahos GC et al: Complex repair for the management
of duodenal injuries. Am Surg 65:972, 1999; Velmahos GC et al: Safety of repair for severe duodenal injuries.
World J Surg 32:7, 2008; Wahl WL et al: Diagnosis and management of bile leaks after blunt liver injury.
Surgery 138:742, 2005; Yutan E et al: Blunt duodenal rupture: complementary roles of sonography and CT. AJR
Am J Roentgenol 175:1600, 2000.
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