Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_815_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 18
Presentation and diagnosis of
biliary injury
Clinical presentation of the vast majority of bile duct
injuries can be divided into two broad categories.
The first contains patients in whom clinical signs
or associated injury lead to laparotomy with
early diagnosis and surgical management (early
presentation); these patients generally present with
hypovolaemic shock or signs of an acute abdomen.
The second category of patient has a delay
24 hours) in diagnosis and definitive therapy
(>
(delayed presentation). These patients comprised
over half the cases (53.2%) in a review of combined
68
series.
representing a very small proportion of those
who sustain a bile duct injury, may present with
obstructive jaundice months or even years after the
initial trauma (late presentation). In these patients,
the bile duct injury is always isolated. Compromise
of the blood supply to the duct may occur either at
the time of the primary injury or at operation during
the Pringle manoeuvre, and this may contribute to
the development of a late biliary stricture. Bourque
et al. reported that the delay between clinical
presentation and surgical intervention for isolated
bile duct injury averaged 18days, with a range from
several hours to 60days.
reported that biliary injury was not recognised
at initial operation in 11 (12%) of 91 patients
with extrahepatic biliary tract trauma,
Dawson and Jurkovich reported that 41% of bile
duct injuries were missed at initial laparotomy.
abdominal trauma is adopted, suspicion of an
extrahepatic bile duct injury may be raised by CT
evidence of a central liver injury involving the porta
hepatis or the head of the pancreas, the presence
of fluid collections in the subhepatic space, or
evidence of periportal tracking of haematoma.
The diagnostic procedure of choice is ERCP, and
if a duct injury is identified this may be treated by
endoscopic stenting.
requires a high index of suspicion. The presence
of free bile in the peritoneal cavity, or the presence
of bile staining in the hepatoduodenal ligament
or retroperitoneum, is a sign of injury to the
extrahepatic biliary tract. Biliary tract injury must
also be suspected if there is profuse bleeding from the
hepatic artery or portal vein, particularly following
blunt trauma, as the bile duct is also likely to be
injured. Penetrating wounds near the porta hepatis
require careful examination. If routine dissection
does not reveal the location of the injury, fine-needle
intraoperative cholangiography via the gallbladder
or common bile duct may identify the site. Cystic
duct cholangiography should be considered after
In addition, a third category of patient,
69
Michelassi and Ranson
68
whereas
70
If a non-operative course of management for
23
71
Intraoperative recognition of biliary tract injury
cholecystectomy for traumatic gallbladder injury to
avoid missing an associated bile duct injury.
It is possible for a patient who has sustained
blunt abdominal trauma to be discharged from
hospital only to return days or weeks later with
a combination of symptoms and signs, including
jaundice, abdominal distension, nausea, vomiting,
anorexia, abdominal pain, low-grade fever or
weight loss – a clinical picture similar to that seen in
patients with intraperitoneal bile leakage following
cholecystectomy. When jaundice develops after
abdominal trauma, missed extrahepatic biliary
injury must be considered.
Operative management of biliary
injury
Many patients with extrahepatic biliary tract injury
present in shock due to associated haemorrhage,
and the priority at laparotomy is to identify and
control haemorrhage. The report of Dawson etal.
demonstrates that these patients are at risk of
exsanguinating on the operating table.
65
Injuries to
the gallbladder are best treated by cholecystectomy.
Primary repair of a clean and simple partial or
complete transection of the common duct using
absorbable sutures such as 4/0 polydioxanone over a
T-tube inserted through a separate choledochotomy
has been described. However, this type of repair
is not appropriate if there is any evidence of duct
contusion, loss of ductal tissue or possible injury
to the hepatic artery as this may increase the risk
of late development of an ischaemic stricture. In
general, it is therefore safer to recommend that most
injuries should be managed by fashioning a Rouxen-Y hepatico-jejunostomy as in the management of
iatrogenic bile duct injuries. Such a repair should
be undertaken by a surgeon experienced in these
anastomoses, as the best outcomes are achieved at
the first repair.
Outcome after biliary injury
Injuries of this nature are associated with a mortality
rate of 10% from concomitant injuries.
complications and bile leakage account for most
of the early morbidity and may require operative
intervention. Late morbidity after repair of a
traumatic biliary tract injury is unusual; however,
jaundice or episodes of ascending cholangitis
suggest a stricture of the ductal system.
67
Pancreatic trauma
Injuries to the pancreas are uncommon, accounting
for 1–4% of severe abdominal injuries, and usually
72
Septic
312
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
occur in young men. In a report of 51 425 patients
from the Trauma Register of the German Society
of Trauma Surgery, 9268 (18%) had documented
abdominal injuries and 284 (3.1%) had a pancreatic
73
injury.
Mechanisms of pancreatic injury
Deceleration injury and direct blunt trauma are
major mechanisms of pancreatic trauma, with the
neck of the gland being at risk of transection across
the vertebral column. In children, the classic injury
arises from bicycle handlebars. The deep location
of the pancreas means that considerable force is
needed to cause an injury and this level of force will
often be sufficient to damage other organs.
Diagnosis of pancreatic injury
Pancreatic injury should be suspected in any patient
with penetrating trauma to the trunk, particularly
if the entry site is between the nipples and the iliac
crest, and in any patient with blunt compression
trauma of the upper abdomen.
In an early study, Moretz etal. found that there
was no reliable correlation between initial serum
amylase and pancreatic injury.
Takishima et al. retrospectively studied admission
serum amylase values in a series of 73 patients
with blunt pancreatic trauma treated in a single
institution over a 16-year period.
of these patients had a raised serum amylase level.
Of interest, the serum amylase level was found to
be abnormal in all patients admitted more than 3
hours after trauma. Recent studies suggest that
lipase may be a more sensitive marker of pancreatic
injury than amylase.
76
For those patients not requiring immediate
laparotomy for haemodynamic instability, contrastenhanced CT is the investigation of choice
Fig. 18.7) for pancreatic injury and to exclude
(
concomitant intra-abdominal visceral injury.
Reported CT features of pancreatic injury include free
intraperitoneal fluid, localised fluid in the lesser sac,
retroperitoneal fluid, pancreatic oedema or swelling
and changes in the peripancreatic fat. The presence
of fluid in the lesser sac between the pancreas and the
splenic vein is reported by Lane etal. to be a reliable
sign in blunt pancreatic injury.
Eichelberger reported that this radiological sign was
rarely the only abnormal CT finding in pancreatic
78
injury.
It should be borne in mind that many of
these CT features are also seen in acute pancreatitis
(and furthermore that acute pancreatitis may occur
as a result of blunt abdominal trauma). There is
also evidence from older studies that CT tends to
underdiagnose pancreatic injury. Akhrass et al.
74
In a later report,
75
Sixty-one (84%)
77
However, Sivit and
Hepatobiliary and pancreatic trauma
Figure18.7 • CT showing a complete transection of the
neck of the pancreas in an 8-year-old boy who had fallen
out of a tree.
evaluated the clinical course of 72 patients with
pancreatic injury admitted over a 10-year period.
79
Seventeen of these patients underwent CT as part
of their initial assessment and this was reported as
normal in nine. Eight of these patients underwent
laparotomy (principally for suspected associated
splenic injury) and three were found to have
pancreatic injury requiring distal pancreatectomy.
Newer, non-invasive imaging modalities such as
magnetic resonance cholangiopancreatography
(MRCP) have been reported in the assessment
of patients with suspected pancreatic trauma.
80
Increased sophistication with the use of this
technique may allow for accurate assessment of
pancreatic ductal integrity; however, this is not
indicated in the acute situation with a hypotensive
patient and is best reserved for delayed imaging
when ductal injury is suspected.
Classification of pancreatic injury
Of the various proposed classification schemes,
Lucas suggested in an early report that appropriate
treatment be formulated according to the type of
81
injury.
injuries into three groups:
• grade I – superficial contusion with minimal
• grade II – deep laceration or transection of the
• grade III – injury of the pancreatic head
Trauma (AAST) Organ Injury Scale is widely
used to classify pancreatic trauma (Table 18.2).
The most common site of injury is the neck of
the pancreas. The relative frequency of pancreatic
injuries reported in collected reviews is represented
in
This classification system divides pancreatic
damage;
left portion of the pancreas;
(Fig.18.8).
The American Association for the Surgery of
Fig. 18.9.
82
The AAST organ injury scale is the
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
313
Chapter 18
Figure18.8 • Operative photograph of a transection
injury along the neck of the pancreas resulting from a
direct blow to the abdomen. This injury was managed by
distal pancreatectomy and splenectomy.
most widely used and can be used to determine the
management.
Initial management of pancreatic
injury
In a major retrospective clinical casenote review
of pancreatic trauma from six hospitals, Bradley
et al. demonstrated a significant association
between pancreas-related morbidity and injury to
the main pancreatic duct.
(due to delay in recognition of main pancreatic
duct injury) was associated with high morbidity.
In this study, CT was unreliable for the assessment
of main pancreatic ductal integrity and an accurate
assessment required ERCP; however, MRCP with
contrast could be used.
Assessment of the integrity of the main
pancreatic duct is critical to the treatment of
pancreatic injury.
83
Delayed intervention
Operative management of
pancreatic injury
The mainstay of treatment remains operative
as pancreatic injuries are usually diagnosed at
laparotomy undertaken because of injury to
surrounding structures. The region of the head
of the pancreas should be thoroughly inspected
and retroperitoneal blood, gas or bile around the
duodenum or head of pancreas are markers of an
injury that requires further thorough evaluation.
Equally in blunt trauma laparotomy, the body of
the pancreas should always be inspected for injury.
The important principles at operation are to
gain good access to allow thorough inspection of
the gland. Access to the lesser sac is best done by
creating a window in the gastrocolic omentum
outside the gastroepiploic arcade to allow
examination of the body of the pancreas. A Kocher
manoeuvre is necessary to permit palpation of
the head of the pancreas between the thumb and
fingers. A thorough inspection of the base of the
transverse mesocolon is also undertaken. Injury
to the pancreas is suspected if retroperitoneal
haemorrhage can be seen through the base of the
mesocolon or the lesser omentum. Absence of
any sign of haemorrhage over the pancreas and
duodenum makes injury unlikely.
Experience of patients with pancreatic injury from
Durban led to the recommendation for operative
treatment in patients with penetrating or gunshot
injury and signs of peritoneal irritation.
large series of 152 patients with pancreatic trauma
presenting over a 5-year period, 63 patients had
been shot, 66 stabbed and 23 had blunt trauma. The
mainstay of treatment was exploratory laparotomy
followed by drainage of the pancreatic injury site.
Large-bore soft Silastic drains were used to minimise
the risk of drain erosion into a major vessel. The
mortality rates were 8% after gunshot injury, 2%
after stab wounds and 10% after blunt trauma. The
majority of these deaths were attributed to damage
of other organs. The proportions of patients that
84
In this
Table18.2 • Classification of pancreatic from the American Association for the Surgery of Trauma (AAST)
Grade* Type of injury Description of injury
I
II
III
IV
V
Haematoma
Laceration
Haematoma
Laceration
Laceration
Laceration
Laceration
*Advance one grade for multiple injuries up to grade III.
†
Proximal pancreas is to the patient’s right of the superior mesenteric vein.
Minor contusion without duct injury
Superficial laceration without duct injury
Major contusion without duct injury or tissue loss
Major laceration without duct injury or tissue loss
Distal transection or parenchymal injury with duct injury
†
Proximal
transection or parenchymal injury involving ampulla
Massive disruption of pancreatic head
314
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
140
217
Hepatobiliary and pancreatic trauma
167
241
237
182
of 124 pancreatic injuries at the University of
Tennessee
85
also advocate simple drainage alone for
proximal pancreatic injuries. Of 37 (30%) patients
with proximal injuries, the ‘pancreas-related’
morbidity was 11% – principally the sequelae of
pancreatic fistulas. Of 87 distal pancreatic injuries,
the integrity of the main pancreatic duct was not
established in 54 (62%). Patients thought to have
a high probability of duct transection were treated
by distal pancreatectomy. A concern with simple
drainage for injuries in the head of the pancreas
is persistent pancreatic fistula, and thus a surgical
alternative is to drain the head of the pancreas into
a Roux-en-Y limb of jejunum.
Moncure and Goins described their experience
over a 6-year period with a consecutive series
of 44 patients with pancreatic injury,
86
of which
penetrating abdominal trauma accounted for the
majority of cases. Coexistent duodenal injuries
were treated by primary closure in 21% and more
complex duodenal exclusion techniques were used
in 20%. The most frequent complications were
intra-abdominal abscesses (31%) and pancreatic
fistulas (16%).
Krige etal. reported on a series of 110 patients
with pancreatic injuries after blunt trauma.
87
One
353
Figure18.9 • Distribution of pancreatic injuries in the world literature. Note the preponderance of injuries in the
junctional area of the neck of the gland.
Reproduced from Frey CF, Wardell JW. Section9. Injuries to the pancreas. In: Trede M, Carter DC, editors. Surgery of the
pancreas. Edinburgh: Churchill Livingstone; 1993. With permission from Elsevier.
47
developed pancreatic fistulas in the three groups
were 14%, 9% and 13%, respectively. The authors
concluded that ‘conservative’ surgical drainage
(avoiding pancreatic resection) was justified after
pancreatic injury.
The management of pancreatic injuries of the
body/tail depends on the integrity of the pancreatic
duct. For AAST grade I and II injuries where there
is only a haematoma or laceration of the duct but
no duct injury, closed system drainage is all that is
required.
Grade III injuries involve the pancreatic duct and
are to the left of the superior mesenteric vein (SMV).
These are managed by distal pancreatectomy,
with closure of the duct by suture or staples and
placement of a closed drain system.
Spleen-preserving distal pancreatectomy is
occasionally performed in the elective setting;
rarely it is possible in pancreatic trauma, and only
when the patient is haemodynamically stable and
the injury is limited to the pancreas. Grade IV
injuries are to the right of the SMV and involve
the parenchyma and duct but not the ampulla;
drainage is advocated.
Simplified management guidelines based on the
treatment protocols developed during the treatment
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
315
Chapter 18
hundred and one patients underwent a total of 123
operations, including drainage of the pancreatic
injury (n
= 73), distal pancreatectomy (n = 39) and
Whipple resection (n = 5). The overall complication
rate was 74.5% and the mortality rate was 16.4%.
Only two of the 18 deaths were attributable
to the pancreatic injury. Mortality increased
exponentially as the number of associated injuries
increased.
Finally, in grade V injuries where there is
devitalisation of the head of the pancreas with
massive disruption, damage control techniques
should be applied as the initial part of a staged
Whipple procedure. These are a major challenge,
but fortunately are relatively rare, occurring in
approximately 5% of all pancreatico-duodenal
injuries.
88
However, where indicated it is the
only option for survival and can be performed
successfully. Where trauma pancreaticoduodenectomy is required, a staged approach
is essential. Removal of the resection specimen
should represent the end of the first stage. The
stomach and jejunum may be left stapled, and
the bile duct tied off (to allow dilatation and
an easier hepatico-jejunostomy) or drained. The
cut surface of the pancreatic neck should also
be drained. The surgeon may also consider total
pancreatectomy at this point, especially if it is
judged that the patient would not survive a later
pancreatico-jejunostomy leak. The second stage
would follow temporary abdominal closure (using
an Abthera device) and a period of resuscitation
on ICU (24–48 hours). Ideally the reconstruction
would then be performed with a physiologically
well patient, free of inotropic or pressor organ
support. The principles of treatment are to ensure
that haemorrhage from concomitant injuries is
dealt with first, as this is likely to be the major
source of mortality. Similarly, a prolonged
operative procedure should be avoided in a
potentially unstable patient and the involvement
of an experienced pancreatic surgeon is desirable.
Duodenal injuries can be closed primarily or
drained into a Roux loop. Bile duct injuries may be
repaired primarily over a T-tube or drained into a
Roux limb of jejunum.
etal. reported the incidence of these complications to be
15%, 9%, 6% and 4%, respectively.
89
The principles
regarding management are similar to those for treating
these complications when they arise as a result of
pancreatitis or pancreatic surgery. Inflammation of the
pancreas after trauma behaves in much the same way
as acute biliary or acute alcohol-induced pancreatitis,
with the possible exception that there is a higher
incidence of development of local complications
such as pseudocyst – possibly relating to the nature
of duct disruption in trauma. The Cape Town group
reported that, of a series of 64 patients with pancreatic
trauma, pseudocysts developed in 15 patients (23%),
of whom eight had a duct injury demonstrated by
endoscopic retrograde pancreatography.
90
Patients
with pseudocysts related to distal duct injury were
treated successfully by percutaneous aspiration. Three
patients with duct injuries in the neck/body region
underwent distal pancreatectomy. Pseudocysts related
to ductal injury in the head of the pancreas were
drained internally by Roux-en-Y cyst-jejunostomy.
The authors concluded that traumatic pancreatic
pseudocysts associated with a peripheral duct injury
may resolve spontaneously, whereas those associated
with injuries to the proximal duct would more
likely require surgical intervention. Alternative
treatment strategies include endoscopic transpapillary
or transmural drainage of the pseudocyst.
The incidence of pancreatic fistula after surgery for
trauma is dependent on the type of procedure, with
some evidence that the fistula rate is higher after
drainage procedures than after resection. Successful
insertion of pancreatic duct stents has been reported
for management of major pancreatic duct disruption;
however, the incidence of long-term ductal stricture
is high and therefore the role of pancreatic duct
stenting needs to be further defined.
Management of post-traumatic pseudocysts and
fistulas will depend on the time from injury, presence
of ongoing ductal leak, site of leak and presence of
debris within a pseudocyst cavity. The optimal
treatment strategy should involve a multidisciplinary
approach in a specialist unit employing similar
principles to those of managing these complications
following an attack of acute pancreatitis.
91
Trauma pancreatico-duodenectomy is indicated
in rare cases of severe pancreatico-duodenal
complex disruption.
Conclusion
The contemporary management of patients with
suspected liver, biliary or pancreatic injury involves
Complications of pancreatic injury
simultaneous clinical assessment and haemostatic
resuscitation followed, in haemodynamically stable
The most common post-traumatic complications
include necrotising pancreatitis, pseudocyst formation,
pancreatic abscesses and pancreatic fistula. Cerwenka
patients, by CT. If surgical intervention is required,
the mainstay of treatment is to control haemorrhage.
In European healthcare systems, the optimum care
316
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
Hepatobiliary and pancreatic trauma
of the patient may consist of packing followed by
transfer to a regional hepato-pancreato-biliary unit.
A paper by Hoyt etal. examining preventable causes
of death in 72 151 admissions with abdominal
trauma to North American level I trauma centres
identified abdominal injury as the cause of death
in 287, with liver injury being responsible for 92
92
deaths.
preventable cause of death, as was a need for better
Delays in packing were highlighted as a
understanding of the endpoints to be achieved by
packing. The conclusion of this large survey was
that the management of liver injury remains a major
technical challenge.
Acknowledgement
The authors wish to thank John-Joe Reilly.
Key points
• Management of patients with suspected liver, biliary or pancreatic injury involves simultaneous clinical
assessment and haemostatic resuscitation.
• Haemodynamic instability resistant to blood resuscitation associated with clinical signs of peritonism
is an indication for immediate laparotomy.
• Patients who are haemodynamically stable or who respond to initial fluid resuscitation should
undergo immediate CT.
• Laparotomy is generally required for patients with an abdominal gunshot wound.
Liver trauma
• Non-operative management of liver trauma is now a well-established treatment option and should be
augmented with angiographic techniques where a contrast blush is detected on CT.
• Significant liver haemorrhage can initially be controlled at operation by manual compression of the
liver parenchyma, appropriate liver packing, or application of the Pringle manoeuvre.
• Perihepatic packing is a highly effective technique to control venous bleeding from the liver.
• Resectional debridement of non-viable hepatic parenchyma may be undertaken successfully where
infow/outflow vessels are injured.
• Other techniques to control haemorrhage include hepatotomy and suture ligation of vessels within
the laceration, although this technique should only be employed by surgeons experienced in both
trauma and liver surgery.
• Postoperative complications include bile leakage or sepsis, and may require radiological, endoscopic
or surgical intervention.
Extrahepatic biliary tract trauma
• This uncommon injury is more likely to be due to penetrating rather than blunt abdominal trauma.
• It is rarely diagnosed before operation and is usually recognised incidentally at laparotomy.
• Concomitant vascular injury of the portal vein or hepatic artery is rare.
• ERCP may demonstrate bile leakage and allow therapeutic insertion of a biliary stent.
• Definitive operative intervention for gallbladder trauma is cholecystectomy.
• Roux-en-Y hepatico-jejunostomy is the operation of choice for most injuries to the bile duct.
Pancreatic trauma
• This is most commonly diagnosed by CT; however, in the non-acute setting, contrast MRCP may
be undertaken to assess pancreatic duct integrity and may allow therapeutic stenting if leakage of
contrast is identified.
• Exploratory laparotomy and drainage of the pancreas is recommended for pancreatic parenchyma
injuries.
• Main pancreatic duct injuries in the neck, body and tail may be managed by distal pancreatectomy.
• Pancreatico-duodenectomy is indicated in rare cases of severe pancreatico-duodenal complex
disruption.
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
317
Chapter 18
Full references available at http://expertconsult.
inkling.com
Key references
39. Croce MA, Fabian TC, Menke PG, et al.
Nonoperative management of blunt hepatic trauma
is the treatment of choice for hemodynamically
stable patients: results of a prospective trial. Ann
Surg 1995;221(6):744–53; discussion 53–5. PMID:
7794078.
This study concluded that non-operative management was
safe and the procedure of choice for haemodynamically
stable patients and that this was independent of the CT
grade of the liver injury.
87. KrigeJE, Kotze UK, HameedM, et al. Pancreatic
injuries after blunt abdominal trauma: an analysis
of 110 patients treated at a level 1 trauma centre.
S Afr J Surg 2011;49(2):58, 60, 2–4 passim. PMID:
21614975.
This study reported on a series of 110 patients with
pancreatic injuries after blunt trauma. Excellent
results were achieved applying drainage, or distal
pancreatectomy depending on the location of the injury
and integrity of the pancreatic duct.
92. HoytDB, Bulger EM, KnudsonMM, et al. Death
in the operating room: an analysis of a multi-center
experience. J Trauma 1994;37(3):426–32. PMID:
8083904.
This study reported on the preventable causes of death
in 72 151 admissions with abdominal trauma to North
American level I trauma centres. Abdominal injury
was identified as the cause of death in 287, with liver
injury responsible for 92 deaths. The importance of
early application of liver packing as the predominant
surgical technique in the management of liver trauma
was highlighted.
318
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.