Pancreatic and Duodenal Injuries Update

8/18/2019 Pancreatic and Duodenal Injuries Update

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Warko Karnadihardja

PANCREATIC AND DUODENALINJURIES UPDATE

07-08


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WH IS IT I!PORTANCE "

Pr#o$#ra%i dia'no(i( o) %h#(#inj*ri#( i( o)%#n di+,*%

O$#ra%i .ana'#.#n% ,an /#

,o.$#

Th# $an,r#a( and d*od#n*. (har#/ood (*$$1 and in,id#n,# o)

,on,o.i%an% inj*r1 i( ,o..on


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INCIDENCER#a%i1 *n,o..on702 %o 7324 d*# %o $#n#%ra%in' inj*r15 602 o) a/do.ina %ra*.a /*%r#$r#(#n% a .ajor dia'no(%i, ,ha#n'#*n% inj*r1 i( .o(% ,o..on in ,hidr#n#n#ra1 o,,*r( )ro. ,r*(hin' inj*r1o) %h# $an,r#a( /#%9##n %h# ($in# andano%h#r o/j#,%( :#;'; (%##rin' 9h##4

hand# /ar4 or /*n% 9#a$on


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ASSOCIATED INTRAADO!INAL INJUR-6

= >02 o) $an,r#a%i, inj*ri#(

= 302 .or/idi%1 and i..#dia%#

d#a%h a((o,ia%#d 9i%h &a(,*arinj*r1

302 %o 732 .ajor &a(,*ar inj*r1:Ao4 C?4 L?C4 P?< ,a*(#d /1

$#n#%ra%in' $an,r#a%i, inj*ri#(4 and6@2 o) /*n% $an,r#a%i, inj*ri#(


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In%ra a/do.ina or'an( .o(%,o..on1 inj*r#d in ,onj*n,%ion

9i%h $an,r#a%i, inj*r14 9h#%h#r/*n% or $#n#%ra%in'4 in,*d# ir4($##n4 d*od#n*.4 and (.ain%#(%in#

Ear1 d#a%h )ro. h#.orrha'#4 and

La%# d#a%h )ro. in)#,%ion

ASSOCIATED INTRAADO!INAL INJUR-@


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DIANOSISSho*d /# (*($#,%#d /a(#d on !ISTPh1(i,a #a.ina%ion B a((#((.#n%S#r*. a.1a(# #(

ASTDPLCT-S,anERCP

!RCPI(oa%#d $an,r#a%i, inj*r1 i(

*n,o..on


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CRITIUE ONASSESS!ENT

S#r*. a.1a(# #( ar# n#i%h#r(#n(i%i nor ($#,i,DPL i( no% r#ai/#

CT .a1 id#n%i)1 $#ri$an,r#a%i,h#.a%o.a( /*% .a1 no% id#n%i)1$an,r#a%i, a,#ra%ion( or #n,o.$#%# %ran(#,%ion( #ar1 in %h#$o(% inj*r1 $#riodERCP and !RCP ,an /# *(#d %o

dia'no(# $an,r#a%i, d*,%a inj*r1 inh#.od1na.i,a1 (%a/# $%(


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Foto abdomen : udara retroperitoneal,

perforasi duodenum


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Foto abdomen : udara retroperitoneal,perforasi duodenum


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Ruptur duodenum


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Ka(*(Pria 67 %h4 KLL %#r#.$ar dari

(#$#da .o%or4 $#r*% k#na (%an'; F

ja. da%an' k# RSHSTanda@ $#ri%oni%i( :G


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INTRAOPERATI?EDIANOSIS

D#$#nd( on &i(*a in($#,%ion and/i.an*a $a$a%ion o) %h# $an,r#a( /1O$#nin' 'a(%ro,oi, i'a.#n%En%#rin' #((#r (a,P#r)or.in' a Ko,h#r .an#*r!o/iia%ion o) ($##nO$#nin' r#%ro$#ri%on#*. %o )a,ii%a%#$a$a%ion ,on%*(ion or %ran(#,%ion"In%rao$#ra%i,hoan'io$an,r#a%o'ra$h1 9i%h iodin#,on%ra(% or 9i%h .#%h1#n# /*#


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SUSPECTED PANCREATIC INJURIES

SHOULD E SURICALL EPLORED

I!PORTANT POINT


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I!PORTANT POINT

IDENTIICATION O INJUR TO THE

!AJOR DUCT IS THE CRITICAL ISSUEIN INTRA OPERATI?E !ANAE!ENTO PANCREATIC INJUR


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INJUR

Hi'h ind# o) (*($i,ion!ini.a ndin'( or

#*i&o,a #a.

S#ria #n1.#(

Nor.aM CT-S,an

R#$#a% CT-S,an

D*,%a in%#'ri%1

ERCP!RCP


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NORMAL DUCT ON MRCP

EXTRAVASATION ON MRCP


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!RCP ON TRAU!A

A r#ia/# nonin&a(i dia'no(%i,%oo %o d#%#r.in# %h# (%a%*( o) %h#

.ain $an,r#a%i, d*,%Ho9#r4 !RCP i( a$$i,a/# on1 %o

%ho(# $%( 9ho ar# h#.odina.i,a1(%a/# and ha .ini.a or no o%h#r

(#rio*( inj*ri#(


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PANCREATIC B DUODENALTRAU!A

Morbidity

• Early hemorrhage

• Late hemorrhage

• Pancreatic pseudocyst

• Pancreatic fistula

• Duodenal fistula

• Intraabdominal abscess

• Obstruction

• Malabsorption

• Diabetes

Mortality

• Early

• Hemorrhage

• Late

• Hemorrhage

• Duodenal fistula

• Pancreatitis

• Uncontrolled sepsis

• MOF


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PRINCIPLES O TRAT!ENTO PANCREATIC INJURIES

6; Con%ro h#.orrha'#

@; D#/rid# d#&i%ai#d $an,r#a(4 9hi,h,an r#*ir# r#(#,%ion

; Pr#(#r .ai.a a.o*n% o) &ia/#$an,r#a%i, %i((*#

; Wid# draina'# o) $an,r#a%i,r#(#,%ion( 9i%h ,o(#d (*,%ion drain(

3; ##din' j#j*no(%o.1 )or $o(%o$#ra%i,ar# 9i%h (i'ni,an% #(ion(


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O$#nin' #((#r (a,O$#nin' r#%ro$#ri%on#aE#&a%in' %h# /od1 o) %h# $an,r#a(

Di&id# %h# 'a(%roh#$a%i, o.#n%*.

EPOSURES


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Tran(#,%ion o) Li'a.#n%*. Tr#i%E$o(*r# o) %h# %h $or%ion o) %h#

d*od#n*. and d*od#n*j#j*na

j*n,%ion

SURICAL EPOSURES


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SURICAL EPOSURES

Ko,h#r !an#*r

!#dia ro%a%ion o)

D*od#n*.

Pan,r#a%i, h#ad

Di(%a CD


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Ca%%# raa(,h !an#*rRi'h% a/do.ina &i(,#ra ro%a%ion

T#,hni*# o) #$o(*r# o) rd

and%h $or%ion( o) d*od#n*.

SURICAL EPOSURES


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SURICAL EPOSURES

Aird !an#*r!#dia ro%a%ion o) ($##n and %aio) %h# $an,r#a(


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INTRA OPERATIVE DIAGNOSISOF PANREATI D!TA"IN#!R$Wha% %o do

% Corr#a%# inj*r1o,a%ion

and d*,%a ana%o.1

% *oro(,o$i,,ho#,1(%o

,hoan'io'ra$h1

% I? o$ia%#(

Wha% no% %o do

% O$#n %h#d*od#n*.

% Tran(#,% %h# %ai%o

,ann*a%# %h#d*,%

Optional

• Secretin stimulation

• Intra operatie E!"P


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CO!PLETE TRANSECTION

D#/rid# %o &ia/# %i((*#

Pri.ar1 r#$air 9i%h ($a%*a%ion

In%#rr*$%#d a/(or/a/# (*%*r#


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CHOLECSTOCHOLANIORAPH

L#((#r (a, i( o$#n %o &i(*ai# %h#$an,r#a(

Radio'ra$hi, ,on%ra(% .a%#ria and.#%h1#n# /*# i( inj#,%#d in%o 'a

/add#r or %h# CD-ra1 i( %ak#n ookin' )or #%ra&a(a%ion

Pan,r#a( in($#,%#d )or #%ra &a(a%ion o).#%h1#n# /*#

!#%h1#n# /*# $an,r#a%o'ra$h1I;?; )#n%an1 ,a*(#( ($a(. o) %h#

S$hin,%#r Oddi

!#%h1#n# /*# ,hoan'io'ra$h1$r#,i(#1 id#n%i#( %h# (i%# o) inj*r1


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INJUR

A aan,in' A,% o)

Parenchymal preseration• !is#y anastomosis

• $ctiated fistula

• Secondary hemorrhage

• %ound complications

Parenchymal resection

• Pancreatic insufficiency

• Malabsorption

• Diabetes mellitus

• & '() resection


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WHAT IS TREAT!ENTOPTIONS OR

6; Pan,r#a%i, ,on%*(ion or ,a$(*ara,#ra%ion 9i%ho*% d*,%a inj*r1"

@; Pan,r#a%i, %ran(#,%ion di(%a %o %h#S!A"

; Pan,r#a%i, %ran(#,%ion %o %h# ri'h% o)%h# S!A " :no% in&o&in' %h# a.$*a<

; S#r# inj*r1 %o %h# /o%h %h# h#ad o)%h# $an,r#a( and %h# d*od#n*. "


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Pan&reati&oduodene&tom'


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aput Pan(reas dipoton)de(at tempat trauma

Distal pankreas didrainase secara

Roux-en-Y


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Vas(ularisasi saluran empedu e(stra*epati(


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COROSION CAST O ADULT LI?ER

?an Da..# and on%# J ?a(,*ar Ana%o.1 o) inA/do.ina S*r'; Thi#.# 6>>0

LOOD SUPPLY TO C D

Surgical "lin *+ $m,-../

TRAU!A TO THE


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TRAU!A TO THEDUODENU!

Co.$#%# %ran(#,%ionS%o$ h#.orrha'#E$o(*r#

Lo,a%ion o) inj*r1Pri.ar1 r#$airPro%#,%ion o) r#$air

ANATO! O THE


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ANATO! O THEDUODENU!

Th# d*od#n*. (har#( i%( /ood (*$$1 9i%h%h# $an,r#a(Th#r# ar# $ar%(6(% $or%ion d*od#n*. Q (*$#rior $or%ion

in%ra $#ri%on#a@nd Por%ion d*od#n*. Q d#(,#ndin'$or%ion4 ,on%ain( a.$*a ?a%#rird Por%ion d*od#n*. Q %ran(r(#$or%ion-#%#nd( )ro. %h# a.$*a ?a%#ri %o

S!A an%#rior14 and %h# *r#%#r4 I?C4 and Ao$o(%#rior1%h Por%ion d*od#n*. Q a(,#ndin' $or%ion4/#'in( a% S!A and #nd( a% %h# j#j*n*.


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DIANOSIS O DUODENALINJURIES

Cini,a (*($i,ion i( /a(#d in !IST

*n% inj*r1!id#$i'a(%ri, or RU $ain and %#nd#rn#((

Can ha $#ri%on#a (i'n(Th# (1.$%o.( and ndin'( ,an /# (*/%#-ra1 (%*d1R#%ro$#ri%on#a air

O/i%#ra%ion o) %h# ri'h% $(oa( .ar'inDia'no(i( i( '#n#ra1 .ad# a%a$aro%o.1

OS S O O


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Wi%h $#n#%ra%in' .#,hani(.(D*od#na inj*r1 i( )o*nd a%a$aro%o.14 *(*a1 )or SW

CT-ndin'(

Parad*od#na h#.orrha'#Air or ,on%ra(% ora #ak

U$$#r 'a(%ro-in%#(%ina (%*d1Ad#*a%# in%ra o$#ra%i #$o(*r# i(

&i%a d*od#na inj*ri#( ar# a.on'%h# .o(% ,o..on1 .i((#d a%a$aro%o.1

DIANOSIS O DUODENALINJURIES

DUODENU! INJUR B


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DUODENU! INJUR BOPERATI?E !ANAE!ENT

rad# I or II H#.a%o.a( (in'# or.*%i$# (#'.#n%(Non o$#ra%iNT )or 6 %o @ 9##k(S*r'i,a #&a*a%ion and(#ro.*(,*ar r#$air o) 'rad# I or IIa,#ra%ion(

Pri.ar1 r#$airS%a$#d4 do*/# a1#r or (in'#a1#r

AND OPERATI?E


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AND OPERATI?E!ANAE!ENT

rad# III or I? a,#ra%ionLar'#?#r1 ar'#Inj*r#d a.$*aInj*r#d di(%a CD

!ana'#.#n%Pri.ar1 r#$air

R#(#,%ion ana(%o.o(i(Ro*-#n- d*od#noj#j*no(%o.1

TREATIN THE DUODENAL


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TREATIN THE DUODENALINJUR

A aan,in' A,%

Mild

• Secondary to stab 0ound

• 1 23) circumference

• 4rd to /th portion

• In5ury to repair interal 1 6/ hr

• *o associated pancreatic or

biliary in5ury

*o

Seere

• 7lunt or gun shot 0ound

• & 23) circumference

• -st or 6nd portion

• In5ury to repair interal & 6/ hr

• $ssociated biliary or pancreatic

in5ury

8es

DECO!PRESSI?E


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DECO!PRESSI?EPROCEDURES

Thr## %*/# %#,hni*#a(%ro(%o.1 or'a(%rod*od#no(%o.1

R#%ro'rad# d*od#no(%o.1##din' j#j*no(%o.1

T*/# d*od#no(%o.1

E%#rna draina'#

DI?ERSIONAR


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DI?ERSIONARPROCEDURES

D*od#na dir%i,*a%ionP1ori, #,*(ion

T#.$orar1 I d1(,onn#,%ion

E%#rna draina'#


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Simple duodenorap*'Duodeno+e+unostom'


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#e+unal serosal pat&* Rese(sise)ementalden)an anastomosis

endtoend


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E(s(lusi p'lorus untu( di-ersi duodenum


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WHIPPLE OR TRAU!A

rad# ? $an,r#a%i, inj*r1!a((i di(r*$%ion o) $an,r#a%i,h#ad

rad# ? d*od#na inj*r1!a((i di(r*$%ion o)d*od#no$an,r#a%i, ,o.$#D*od#na d#&a(,*aria%ionNon r#,on(%r*,%a/# inj*r1 %o$an,r#a(4 d*od#n*. and di(%aCD


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WHIPPLE OR TRAU!A

?#r1 9# (*i%#d )or (%a'#d $ro,#d*r#6; Con%ro o) h#.orrha'# B r#(#,%ion

d#/rid#.#n%

@; R#(*(,i%a%ion in %h# ICU

; a(%roin%#(%ina r#,on(%r*,%ion A,hi#( H## B $an,r#a%i, r#.nan%

ana(%o.o(i( A%#rna%i( D*,%a i'a%ion

Pan,r#a%i,o'a(%ro(%o.1 To%a $an,r#a%#,%o.1 I(#% ,# a*%o %ran($an%a%ion


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Pan&reati&oduodene&tom'


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SECRETION

i# 6000.da1

Pan,r#a%i, j*i,#( 800-6000.da1

a(%ri, j*i,#( 6;300-@;300.da1

!i in %h# d*od#n*.


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TREAT!ENT OPTIONS

6; In%ra.*ra d*od#na h#.a%o.a@; D*od#na $#r)ora%ionI(oa%#d inj*r1 %o %h# d*od#n*.A((o,ia%#d &a(,*ar inj*r1*n% inj*r1!i((i# inj*r1A((o,ia%#d ,o..on /i# d*,% inj*r1

; = 732 o) %h# 9a in&od

; = @ ho*r( (in,# inj*r13; Co./in#d inj*ri#( %o %h# d*od#n*.

and %h# h#ad o) $an,r#a(F; Or'an inj*r1 (,a#


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OUTCO!E-6

!or%ai%1 ra%# 02 i) dia'no(i( i(d#a1#d = @ ho*r(

!or%ai%1 @2 %o 662 i) (*r'#r19i%hin @ ho*r( o) inj*r1

D*od#na d#hi(,#n,# 9i%h r#(*%an%(#$(i( a,,o*n%( )or n#ar1 302 o)

%h# d#a%h(Co.$i,a%ion( o,,*r in F2


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R#%ro'rad# %o /# d#,o.$r#((ion,an /# a((o,ia%#d 9i%h a d#,r#a(#d.or%ai%1 ra%#

>2 9i%h %o /# d#,o.$r#((ion &(6>;2 9i%ho*%D*od#na (%*a ra%# 9a(

@;2 9i%h d#,o.$r#((ion &(66;82 9i%ho*%P1ori, #,*(ion ,an a(o $ro&id#

ad#*a%# d#,o.$r#((ion

OUTCO!E-@


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THANK OU

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Pancreatic and Duodenal Injuries Update