Penetrating Injuries to the Stomach Duodenum and Small Bowel

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108 Curr Trauma Rep 2015 1 107 112, and closure by secondary intention is a consideration that can be assisted by advancement of a nasogastric tube along the. should not be taken lightly In fasting patients the stomach greater curvature The nasogastric tube can then function as a. harbors low numbers of bacteria because of its low pH Trau handle to hold the stomach Care must be taken to avoid plac. ma patients however often arrive with full stomachs and a ing excess tension on the greater curvature of the stomach and. more neutral pH and a higher bacterial count in the leaking the short gastric vessels thus avoiding iatrogenic injury to the. stomach content can be expected If a gastric perforation is spleen The greater and lesser curvatures of the stomach. encountered we recommend that secondary or delayed prima should be closely inspected because the fatty omental attach. ry skin closure should be performed in view of the increased ments may obscure an underlying gastric wound Such inspec. risk of surgical site infection This is particularly true when tion is particularly important in the setting of a small caliber. significant hemorrhage or associated colon injury is present missile or stab wound The perforation can be remarkably. in which case the rate of intra abdominal abscess formation small and the serosal tissue damage in such cases is often. may be as high as 24 2 The incidence of wound compli subtle particularly in the setting of obesity Additionally. cations from isolated small bowel injury is relatively low 6 although a stab wound may result in a solitary gastric perfo. in a single institution study 3 and most surgeons recom ration gunshot wounds through hollow organs usually result. mend proceeding with primary closure in this scenario We in even numbers of full thickness injuries given the propen. prefer to err on the side of caution and will tend to leave the sity of the missile to pass through and through the injured. skin open to heal by secondary intention for such bowel inju organ The finding of an odd number of wounds shot prompt. ries reserving primary closure for cases where minimal bowel repeat inspection of the stomach for occult injury. contamination is encountered Repair of gastric wounds is dictated by their severity clas. The patient with severe abdominal injuries may benefit sified according to the grading system of the American Asso. from abbreviated laparotomy This approach has evolved from ciation for the Surgery of Trauma AAST Table 1 Intramu. a realization that the critically injured patient often requires ral hematomas grade I are managed by unroofing and evac. rapid lifesaving bailout techniques to arrest hemorrhage and uation of the hematoma followed by seromuscular closure. control enteric spillage to preempt the combined physiologic with interrupted silk suture Most gastric perforations are of. insult of the trauma and surgery from progressing to irrevers grades II or III and are manageable with primary repair Given. ible shock and death 4 With respect to hollow viscus injuries the tendency of the well vascularized gastric wall to bleed at. managed in this scenario reconstruction of intestinal continu the site of injury a two layer technique is recommended to. ity anastomosis following bowel resection is not performed secure hemostasis When the wound involves the pylorus. at the initial operation and is instead deferred to subsequent incorporation of the wound with a pyloroplasty prevents ste. laparotomy following resuscitation of the patient typically 24 nosis Suture repair of wounds at the cardioesophageal junc. to 48 h following the initial operation The damage control tion may be reinforced by gastric fundoplication. approach is employed to prevent or mitigate the development More extensive wounds are not amenable to primary repair. of acidosis coagulopathy and or hypothermia secondary to grades IV and V Such injuries include significant tissue loss. major blood loss and resuscitation This decision should be. made early in the operative course and be based on the rapid. Table 1 Stomach injury scale, recognition of injury patterns rather than the onset of physio. logic derangement which may herald the onset of irreversible Gradea Description of injury AIS 90. I Contusion hematoma 2,Partial thickness laceration 2. Injuries to the Stomach II Laceration 2 cm in GE junction or pylorus 3. 5 cm in proximal 1 3 stomach 3, Assessment of the stomach for injury commences with full 10 cm in distal 2 3 stomach 3. visualization of its anterior surface from the pylorus to the III Laceration 2 cm in GE junction or pylorus 3. esophagogastric junction The posterior surface of the stom 5 cm in proximal 1 3 stomach 3. ach is exposed by opening the gastrocolic ligament which 10 cm in distal 2 3 stomach 3. provides approach to the lesser sac On opening the IV Tissue loss or devascularization 2 3 stomach 4. gastrocolic ligament injury to the vascular arcade of the great V Tissue loss or devascularization 2 3 stomach 4. er curvature should be avoided With the stomach elevated. GE gastroesophageal, superiorly the transverse colon is retracted inferiorly to ex a.
Advance one grade for multiple lesions up to grade III Used with per. pose the posterior gastric wall Adhesions between the poste mission from Trauma and Acute Care Surgery The American Association. rior gastric wall and the pancreas if present should be care for the Surgery of Trauma I have obtained permission and have the form. fully divided to provide full exposure Grasping the stomach in my office. Curr Trauma Rep 2015 1 107 112 109, and or devascularization and often are associated with major thickness wounds grade II are repaired with limited debride. vascular injury as a consequence of the proximity of the major ment if necessary and closure Closure is performed in either. vessels and the force necessary to cause such a significant one or two layers we prefer a single layer closure and trans. injury Patients with these injuries often do not survive to verse closure is recommended to avoid luminal narrowing. hospital so these extensive gastric wounds are rarely encoun Larger full thickness wounds grade III may be repaired pri. tered Grade IV injuries can usually be managed by means of a marily in transverse orientation providing that luminal. partial gastrectomy Restoration of gastrointestinal continuity narrowing can be avoided Otherwise resection and anasto. is accomplished with either a gastroduodenostomy or a mosis should be performed Extensive wounds and wounds. gastrojejunostomy In the exceedingly rare event of complete associated with devascularization grades IV and V are treat. gastric devascularization or destruction a total gastrectomy ed with resection and anastomosis Once all bowel injuries are. would be required but we have yet to encounter this scenario accounted for the decision must be made whether to perform. primary repairs resections or some combination of the two. Primary repair of multiple low grade injuries preserves bowel. length and is generally preferred At the discretion of the op. Injuries to Small Intestine erating surgeon resection of a segment containing multiple. injuries may be performed to expedite the operation and min. The small intestine is assessed by Brunning the bowel The imize suture lines provided that the amount of bowel to be. small intestine and its mesentery are inspected from the liga resected is small enough that its loss would not have any effect. ment of Treitz to the ileocecal valve If active mesenteric on digestive function As discussed for gastric injuries an odd. bleeding is encountered it is controlled by isolation and indi number of gunshot wounds would be the exception to the rule. vidual ligation of the injured vessels rather than by mass su and should prompt further inspection of the bowel for missing. ture ligation of the mesentery which may result in bowel injury. ischemia As bowel perforations are identified temporary When mesenteric injury is encountered in the absence of. control measures such as the application of Babcock clamps bowel injury the adjacent bowel must be closely assessed for. may be performed in an effort to prevent excessive or ongoing evidence of vascular compromise If the bowel appears viable. soilage Low velocity injuries such as knife wounds or low the rent in the mesentery should be sutured closed avoiding. caliber gunshot wounds may be subtle particularly at the mesenteric vessel ligation after bleeding is controlled to pre. mesenteric border of the small intestine so close inspection vent an internal hernia If there is evidence of vascular com. of even the smallest hematomas is advocated when running promise bowel resection and anastomosis are indicated. the bowel Determination of intestinal viability begins with assess. Management of each wound is determined by its severity ment of the bowel s appearance Adjunctive measures such. according to the AAST grading system Table 2 Partial as the use of a handheld Doppler device or fluorescein infu. thickness injuries grade I are managed by closing the sion with Wood lamp illumination may help if bowel viability. seromuscular defect with simple sutures Small full is equivocal We prefer to use a handheld Doppler device. because it is easy to use and is readily available in our oper. ating rooms Audible Doppler signal at the antimesenteric side. Table 2 Small bowel injury scale of the bowel wall confirms the presence of arterial flow which. reliably verifies bowel viability,Grade Type of Description of injury AIS 90. Small bowel anastomoses are usually handsewn in one or. two layers although stapling devices may also be used. I Hematoma Contusion or hematoma 2 Handsewn techniques are generally favored by our group. without devascularization but the choice of technique depends largely on the surgeon s. Laceration Partial thickness no perforation 2 preference A multicenter retrospective study of trauma lapa. II Laceration Laceration 50 of circumference 3 rotomies suggested that stapled anastomoses had a higher. III Laceration Laceration 50 of circumference 3 complication rate than did sutured anastomoses Overall. without transection, IV Laceration Transection of the small bowel 4 13 of stapled anastomoses were associated with an intra. V Laceration Transection of the small bowel 4, abdominal postoperative complication compared with 5 of. with segmental tissue loss sutured anastomoses 5 As this study did not separate small. Vascular Devascularized segment 4 intestinal anastomoses from colonic anastomoses it is unclear. to what extent the results apply specifically to small bowel. Advance one grade for multiple injuries up to grade III Used with. permission from Trauma and Acute Care Surgery The American Association. anastomoses It is likely however that bowel edema contrib. for the Surgery of Trauma I have obtained permission and have the form in utes to staple line failure If bowel edema is evident or antic. my office ipated it may be wise to perform a sutured anastomosis. 110 Curr Trauma Rep 2015 1 107 112, Injuries to the Duodenum outlined by the AAST grading system Table 3 Partial.
thickness duodenal wounds are not commonly encountered. The duodenum is relatively small compared to the other hol as a result of penetrating mechanism They may be simply. low viscera and therefore less likely to be injured in the event oversewn with interrupted seromuscular sutures Full. of penetrating trauma Nonetheless injury to the duodenum thickness wounds provided they can be closed without ten. relative to the stomach or small bowel is more complicated sion or narrowing of the duodenum can be managed with. and fraught with risk given the close anatomic association to suture repair alone Compared to the other hollow viscus. the pancreas common bile duct and major vascular struc organs breakdown of the duodenal suture line and forma. tures In addition the relative infrequency with which duode tion of a fistula occurs with relative frequency up to. nal injuries are encountered has resulted in a less than robust 33 in a recent study 6 Multiple surgical adjunctive. reported clinical experience from which to draw measures to prevent this dreaded complication have been. To thoroughly explore the duodenum for wounds it is im advocated Herein the approach that our group has devel. portant to consider the anatomic divisions of the duodenum oped over time for the management of these wounds is. and the surrounding tissues that may mask the presence of described. injury The first portion of the duodenum is partially obscured For relatively simple duodenal wounds AAST grade 2. by the edge of the gastroduodenal ligament and full exposure suture repair alone generally suffices Simple wounds would. of the first portion often benefits from partial division of this be characterized more specifically as stab wounds low veloc. ligament at its attachment to the duodenum The second por ity gunshot wounds and wounds that do not involve the. tion of the duodenum is a retroperitoneal structure and re portion of the duodenum that apposes the pancreas Leaving. quires the Kocher maneuver for full exposure Ideally a com a periduodenal drain as a safety measure to control a duode. plete Kocher maneuver results in visualization of the left renal nal fistula should the suture line breakdown is not recom. vein The third portion of the duodenum is obscured by the mended the foreign body effect of the drain may in fact favor. penetrating injuries to the stomach small intestine and duo denum as practiced at the Elvis Presley Memorial Trauma Center in Memphis Tennessee The approach to diagnostic workup of penetrating abdominal injury is left for another discussion Herein we will focus on the conduct of the lapa rotomy in general and the specific management of

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