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Cedera Pada Pankreas Dan Duodenum
Cedera Pada Pankreas Dan Duodenum
DOI 10.2310/7800.S07C09
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Figure 1. Contusion to the body of the pancreas. Illustrated is the appearance of a contusion to the body of the pancreas
overlying the vertebral column, as seen from the lesser sac (a). The pancreas is mobilized to determine whether a fracture is
present and to assess the likelihood of a duct injury. This exposure is best accomplished by dissecting along the inferior border of
the gland, dividing the inferior mesenteric vein if necessary, and reflecting the pancreas superiorly (b).
intraoperative evaluation
Classification of pancreatic injuries is based on the status
of the pancreatic duct and the site of injury relative to the
neck of the pancreas. Careful pancreatic inspection and injury
classification are often complicated by the extent and severity
of associated injuries and occasionally by the reluctance of the
surgeon to mobilize retroperitoneal structures. Clues suggesting potential pancreatic injury include the injury mechanisms
previously described, the presence of upper abdominal wall
contusion or abrasion, and concomitant lower thoracic spine
fractures. The presence of a upper abdominal central retroperitoneal hematoma, edema about the pancreatic gland and
lesser sac, and retroperitoneal bile staining mandate thorough
pancreatic inspection.
Inspection of the pancreas requires complete exposure of
the gland. The initial steps in exposure are to open the lesser
sac through the gastrocolic ligament just outside the gastroepiploic vessels. Carry this exposure far to the patients left,
fully opening the lesser sac and freeing up the transverse
colon. The transverse colon is retracted downward and the
stomach upward and anteriorly [see Figure 1]. Frequently, a
few adhesions between the posterior stomach and the anterior
surface of the pancreas need to be incised. A complete Kocher
maneuver is required next to provide adequate visualization
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Duodenum
AAST
Grade*
AIS-90 Score
AIS-2005
Score
II
2; 3
III
IV
2; 3
II
2; 4
III
IV
AAST = American Association for the Surgery of Trauma; AIS-90 = Abbreviated Injury Score, 1990 version; AIS-2005 = Abbreviated Injury Score, 2005 version;
CBD = common bile duct.
*Advance one grade for multiple injuries, up to grade III.
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Grade I
Grade II
Grade III
Grade V
Provide nonoperative
management.
Repeat CT as needed.
Provide operative or
nonoperative management.
Repeat CT between 4 and
24 hours.
Perform distal
pancreatectomy, with
or without splenic salvage.
Perform
pancreaticoduodenectomy
(Whipple procedure).
Operation
Nonoperative management
Grade IV
Unroofing: Carefully
inspect to confirm
absence of duct injury;
close suction drainage.
Duct injury
If duct injury is confirmed,
perform either transductal
stenting or operative
exploration as a Grade III-V.
Figure 2. Treatment of pancreatic injury. Algorithm outlining the treatment of pancreatic injury. CT = computed tomography;
ERCP = endoscopic retrograde cholangiopancreatography.
underwent distal pancreatic resection (8 blunt, 13 penetrating).34 The increased operative time and potential blood loss
incurred while performing pancreatectomy without splenectomy must be balanced against the slight risk of overwhelming postsplenectomy sepsis. The balance would seem to favor
splenic salvage only when the patient is completely hemodynamically stable and normothermic and the pancreatic injury
is isolated or present with only minor associated injuries.
proximal transection or injury with probable duct
disruption
Injuries to the pancreatic head represent the most challenging management dilemmas. The key principles of immediate
management are, in order, control bleeding, halt contamination, and define the anatomy of the injury. Effective management can only follow these steps. It is essential that the
surgeon define the pancreatic duct anatomy in proximal
pancreatic injuries. This can usually be accomplished by local
inspection and exploration of the defect to determine the
duct status. Techniques of intraoperative pancreatography
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Figure 3. Distal pancreatectomy with and without splenic salvage. Illustrated is distal pancreatectomy with salvage of the
spleen (a) and without splenic salvage (b).
and anastomosis of the open end of the divided distal pancreas to the Roux-en-Y jejunal limb. A review of 399 patients
with pancreatic injury from four separate publications revealed
that only 2 (0.5%) patients underwent Roux-en-Y drainage
of the distal segment of a transected pancreatic gland.34,54,83,84
Although rarely employed and complicated by the need for
a combination of pancreatic resection, pancreatic-jejunal
anastomosis, and construction of the Roux-en-Y limb, this
operation needs to be in the armamentarium of trauma
surgeons.
The report by Patton and colleagues from Memphis,
supported by the experience of University of Mississippi
reported by Duchesne and colleagues, is compelling for the
effectiveness of drainage alone rather than extended pancreatectomy, particularly for proximal pancreatic gland injury
in which the duct status is unclear.2,34 In the Patton and
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Figure 4. Roux-en-Y pancreaticojejunostomy. If a patient has a grade IV injury to the pancreatic head and there is concern
regarding whether the proximal residual gland would have adequate endocrine and exocrine function if the distal gland is
resected in an extended distal pancreatectomy, an option is to preserve the uninjured portion of the distal gland. This is done by
dividing the pancreas at the site of the injury and performing a Roux-en-Y pancreaticojejunostomy to allow the distal pancreas to
drain into the jejunal limb.
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Grade I or II hematoma
If hematoma is detected at laparotomy,
treat with evacuation.
If hematoma is detected by nonoperative
means, observe patient, and support with
NG suction and TPN.
Grade III
Attempt primary suture closure as first option, with
concomitant pyloric exclusion.
If primary repair is technically not feasible, treat as
follows:
Injury proximal to ampulla: perform antrectomy plus
gastrojejunostomy and stump closure.
Injury distal to ampulla: perform Roux-en-;
duodenojejunostomy to proximal end of duodenal
injury, with oversewing of distal duodenum.
Grade I or II laceration
Grade IV or V
Figure 5. Treatment of duodenal injury. Algorithm outlining the treatment of duodenal injury. CBD = common bile duct;
NG = nasogastric; TPN = total parenteral nutrition; WBC = white blood cell count.
occlusion.92 Marginal ulceration at the site of gastrojejunostomy has been reported from 5 to 33% of patients in whom
a vagotomy was not performed.9093 Pyloric exclusion is generally reserved for severe combined duodenal and pancreatic
head and duodenal injuries in which a Whipple procedure
is not required. Few advocate pyloric exclusion for isolated
pancreatic injuries.
In very massive injuries of the proximal duodenum and
head of the pancreas, destruction of the ampulla and proximal pancreatic duct or distal common bile duct may preclude
reconstruction. In addition, because the head of the pancreas
and the duodenum have a common arterial supply, it is
essentially impossible to entirely resect one without making
the other ischemic. In this situation, a pancreatoduodenectomy is required. Between 1961 and 1994, 184 Whipple
procedures were reported for trauma, with 26 operative
deaths (14%) and 39 delayed deaths, for a 64% overall survival rate.88 However, more recent experience suggests that
with appropriate selection criteria, pancreatoduodenectomy
for injury can be performed with morbidity and mortality
similar to those described for resections done for cancer.9496
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Figure 6. Duodenal
diverticularization. Duodenal
diverticularization consists
of antrectomy with gastrojejunostomy, tube duodenostomy,
vagotomy, and peripancreatic
drainage.
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Table 2
10 days, ERCP is indicated and can be most helpful in establishing the cause of the persistent fistula and planning further
therapy. Nutritional support must be provided throughout
this period. The surgeons foresight in placing a feeding
jejunostomy at the time of initial trauma laparotomy is now
rewarded. Low-fat, higher pH elemental feeding formulas
cause less pancreatic stimulation than standard enteral formulas and should be tried prior to committing the patient to
total parenteral nutrition.73 A somatostatin analogue (octreotide acetate [Sandostatin]) has shown promise in treating
prolonged, high-output pancreatic fistulae, but only after
eradicating any infection and in the absence of pancreatic
duct obstruction or stricture.106
Octreotide as an adjuvant to standard fistula management
probably diminishes fistula output, but its shortening of the
time to fistula closure remains to be proven.107 Somatostatin
analogues do seem to prevent postoperative complications
and fistula formation in patients undergoing elective pancreatic resection, although nonrandomized reports on the efficacy of somatostatin analogues in pancreatic trauma patients
are contradictory.108,109 In addition, the trials demonstrating a
decrease in postoperative complications with octreotide use
in elective pancreatic resection initiated octreotide in the preoperative period, a time frame not applicable to the trauma
setting.109 Treatment typically begins with 50 g subcutaneously every 12 hours but can increase to 1,000 g/day.
Octreotide has been included in total parenteral nutrition
solutions, although this remains controversial and is not
recommended by the 1997 package insert because of the
formation of glycosyl octreotide conjugates that may decrease
efficacy.110 Major side effects are unpredictable changes in
serum glucose, pain at the injection site, and a variety of
nonspecific gastrointestinal complaints.
abscesses
The incidence of abscess formation after pancreatic trauma
ranges from 10 to 25%, depending on the number and type
of associated injuries. Early operative or percutaneous decompression or evacuation is critical, although the mortality rate
in this group of patients remains about 25%.82,111 The intraabdominal abscess is most often subfascial or peripancreatic;
a true pancreatic abscess is unusual, resulting from inadequate dbridement of dead tissue or inadequate initial
drainage.61,84,104,112 True pancreatic abscesses are often not
amenable or responsive to percutaneous drainage, and prompt
surgical dbridement and drainage are required. Percutaneous decompression may be helpful in distinguishing between
abscess and pseudocyst.
Factor
Degree of Injury
Mild
Stab
Size of injury
f 75% of circumference
D3, D4
D1, D2
f 24 hr
> 24 hr
Absent
Present
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Severe
Means of injury
pancreatitis
Transient abdominal pain and a rise in the serum amylase
concentration may be anticipated in 8 to 18% of postoperative patients.23,84,113 This type of pancreatitis is treated with
nasogastric decompression, bowel rest, and nutritional support and can be expected to resolve spontaneously. A much
more infrequent but deadly complication is hemorrhagic
pancreatitis. The first sign of this complication may be bloody
pancreatic drainage or a fall in the serum hemoglobin
concentration, with the patient rapidly becoming desperately
ill. It is fortunate that this complication occurs in less than
2% of operative pancreatic trauma patients since mortality
may approach 80% with no effective treatment.61,75
secondary hemorrhage
Postoperative hemorrhage requiring blood transfusion may
occur in 5 to 10% of pancreatic trauma patients, particularly
when inadequate external drainage has been afforded after
pancreatic dbridement or when intra-abdominal infection
has developed.113,114 These patients generally require reoperation for control, although angiographic embolization may be
an effective alternative.
pseudocysts
Missed blunt pancreatic injuries, or those intentionally
managed nonoperatively, often result in the formation of a
pseudocyst. One report tabulated 22 pseudocysts in 42 blunt
pancreatic trauma patients managed nonoperatively.27
The status of the pancreatic duct is the key determinant to
References
1. Houben CH, Ade-Ajayi N, Patel S, et al.
Traumatic pancreatic duct injury in children:
minimally invasive approach to management.
J Pediatr Surg 2007;42:62935.
2. Duchesne JC, Schmieg R, et al. Selective
nonoperative management of low-grade
blunt pancreatic injury: are we there yet?
J Trauma 2008;65:4953.
3. Leva E, Huscher C, et al. Management of
traumatic complete pancreatic fracture in a
child: case report and review of literature.
J Laparoendosc Adv Surg Tech A 2008;18:
3213.
4. Kao LS, Bulger EM, et al. Predictors of
morbidity after traumatic pancreatic injury.
J Trauma 2003;55:426905.
5. Jurkovich GJ, Bulger E. Duodenum and
pancreas. In: Moore EE, Feliciano DV,
Maattox K, editors. Trauma. 5th ed. New
York, McGraw-Hill; 2004. p. 70933.
6. Subramanian A, Dente CJ, et al. The
management of pancreatic trauma in the
modern era. Surg Clin North Am 2007;
87:151532.
7. Shilyansky J, Sena LM, et al. Nonoperative
management of pancreatic injuries in
children. J Pediatr Surg 1998;33:3439.
8. Kouchi K, Tanabe M, et al. Nonoperative
management of blunt pancreatic injury in
childhood. J Pediatr Surg 1999;34:17369.
9. Nadler EP, Gardner M, et al. Management
of blunt pancreatic injury in children. J
Trauma 1999;47:1098103.
10. Meier DE, Coln CD, et al. Early operation
in children with pancreas transection. J
Pediatr Surg 2001;36:3414.
11. Mattix KD, Tataria M, et al. Pediatric pancreatic trauma: predictors of nonoperative
management failure and associated outcomes. J Pediatr Surg 2007;42:3404.
12. Travers B. Rupture of the pancreas. Lancet
1827;12:384.
13. Mickulicz-Radicki JV. Surgery of the
pancreas. Ann Surg 1903;38:127.
14. Stern E. Traumatic injuries to the pancreas.
Am J Surg 1930;8:5874.
15. Kulenkampff D. Ein Fall von Pancreasfistel. Berl Klin Wochenschr 1882;19:102.
16. Robson AWM, Cammidge P, editors. The
pancreas: its surgery and pathology.
Philadelphia: WB Saunders; 1907.
17. Whipple A. Observations on radical surgery
for lesions of the pancreas. Surg Gynecol
Obstet 1946;82:62331.
18. Otis G. The medical and surgical history
of the War of the Rebellion, part II, vol II.
Surgical history. Washington (DC):
Government Printing Office; 1876.
19. Poole H. Wounds of the pancreas. In:
Coates JJ, DeBakey M, editors. Surgery
in World War II, vol 2: general surgery.
Washington (DC): Office of Surgeon
General; 1955. p. 2.
20. Culotta R, Howard J, et al. Traumatic
injuries to the pancreas. Surgery 1956;40:
3207.
21. Baker R, Dippel W, et al. The surgical
significance of trauma to the pancreas.
Trans Western Drug Assoc 1962;70:3617.
22. Heitsch R, Knutson C, et al. Delineation of
critical factors in the treatment of pancreatic
trauma. Surgery 1976;80:5239.
23. Smego DR, Richardson JD, et al. Determinants of outcome in pancreatic trauma. J
Trauma 1985;25:7716.
24. Berni G, Bandyk D, et al. Role of intraoperative pancreatography in patients with
injury to the pancreas. Am J Surg 1982;
143:6025.
25. Teh SH, Sheppard BC, et al. Diagnosis and
management of blunt pancreatic ductal
injury in the era of high-resolution computed axial tomography. Am J Surg 2007;193:
6413; discussion 643.
26. Fulcher AS, Turner MA, et al. Magnetic
resonance
cholangiopancreatography
(MRCP) in the assessment of pancreatic
duct trauma and its sequelae: preliminary
findings. J Trauma 2000;48:10017.
27. Kudsk K, Temizer D, et al. Post-traumatic
pancreatic sequestrum: recognition and
treatment. J Trauma 1986;26:3204.
28. Leppaniemi A, Haapiainen R, et al. Pancreatic trauma: acute and late manifestations.
Br J Surg 1988;75:1657.
29. Carr ND, Cairns SJ, et al. Late complications of pancreatic trauma. Br J Surg 1989;
76:12446.
30. Lin BC, Chen RJ, et al. Management of
blunt major pancreatic injury. J Trauma
2004;56:7748.
31. Leppaniemi AK, Haapiainen RK. Risk
factors of delayed diagnosis of pancreatic
trauma. Eur J Surg 1999;165:11347.
32. Horst H, Bivins B. Pancreatic transection. A
concept of evolving injury. Arch Surg 1989;
124:10935.
33. Smith D, Stanley R, et al. Delayed diagnosis
of pancreatic transection after blunt abdominal trauma. J Trauma 1996;40:100913.
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106.
107.
108.
109.
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