It is difficult to accurately estimate the extent of pancreatic injury before operation. At present, it is advocated that conservative treatment is feasible for patients suspected of pancreatic injury except mild peritoneal irritation, and surgical exploration should be actively carried out for patients with obvious peritoneal irritation. Comprehensive treatment with surgical treatment as the core is the most important treatment for pancreatic injury, and timely surgical exploration is the key to reduce complications and improve the cure rate.
For patients with suspected pancreatic injury, general anesthesia should be used to ensure full relaxation of abdominal muscles and extensive intra-abdominal exploration. General anesthesia can also ensure adequate oxygen supply and effective gas exchange during the operation, which is also necessary for some critically ill patients.
The preoperative preparation of patients with pancreatic injury is the same as that of patients with severe abdominal injury. If there is traumatic hemorrhagic shock, active anti-shock treatment should be given, including rapid infusion of crystal and colloidal solution. Therefore, it is best to use vascular infusion of superior vena cava system. If possible, the superior vena cava should be intubated to monitor the central venous pressure and ensure the speed of blood transfusion. After active treatment, surgery can increase the safety of surgery. If the shock does not improve or worsen, emergency surgery should be performed to deal with possible internal bleeding.
Preoperative use of broad-spectrum antibiotics is helpful to prevent postoperative abdominal infection and septicemia.
For the exploration of pancreatic trauma, it is best to choose the median incision of upper abdomen or the incision through rectus abdominis. This kind of incision can be extended in all directions, which ensures that the incision through rectus abdominis can be extended to the thoracoabdominal incision more conveniently. However, it is sometimes inconvenient to deal with organ damage in the contralateral abdominal cavity. It seems inconvenient to choose incision according to the most obvious position of abdominal signs and the position of pancreatic injury suggested by imaging examination.
1. Surgical exploration of pancreatic trauma includes three aspects: directly exploring the pancreas through whole body exploration and determining the degree of pancreatic injury.
(1) General exploration: After entering the abdominal cavity, you should follow the principles and procedures of general exploration of abdominal trauma. In general exploration, we should not be satisfied with the damage of liver, spleen or hollow organs and ignore the next direct exploration of pancreas. When the pancreatic injury is first found in the exploration, the general exploration of the whole abdominal cavity should not be abandoned. Also pay attention to whether there are other organ injuries, such as pancreatic head injury combined with duodenal injury combined with spleen injury, gastrocolon and peripancreatic vascular injury. In particular, we can see that pancreatic bleeding is not obvious, and abdominal bleeding occurs during exploration.
(2) Direct exploration of the pancreas: pancreatic injury or retroperitoneal duodenal rupture, due to visceral injury in the upper abdomen, exploratory laparotomy may miss the diagnosis. If the following phenomena are found in the general exploration process, it is necessary to directly explore all parts of the pancreas: ① there is bloody liquid or brown liquid in the abdominal cavity, and no bleeding source is found; ② There are fat necrosis and saponification spots in omentum or mesentery; ③ Transverse colon contusion leads to transverse mesenteric root or mesenteric hematoma; ④ Hematoma, edema or local bile yellow staining and pneumatosis near retroperitoneal duodenum.
There are several ways to expose the pancreas by surgery, and one of them can be selected or combined as needed. After exposing the pancreas, the hematocele should be sucked out first. Examine carefully whether there is pancreatic injury and the degree of multiple injuries combined with injuries under direct vision. First, cut off the right hepatic colon ligament, so that the hepatic curvature of the colon is free to the lower right, and then cut off the gastrocolon ligament in front of the splenomegaly (via the gastrocolon ligament route) at the lateral side of the vascular arch of the greater curvature of the stomach by ligation. When the stomach is pulled up through the colon and pulled down, the front surface of the pancreas can be satisfactorily exposed. At this time, if the pancreatic head is damaged or local bile yellow staining and pneumatosis are found in the hematoma near the duodenum, it is necessary to cut the duodenal peritoneum (Kocher incision). Bluntly free the back of duodenum and pancreatic head with fingers until it reaches the front of abdominal aorta, so that the whole duodenum and pancreatic head rotate inward and downward, pulling the hepatic curvature of colon, and continuing to passively separate mesentery from the horizontal part of duodenum. The duodenum and pancreatic head can be examined comprehensively under direct vision, and the deep tissue of pancreatic head and the lower end of common bile duct can also be examined by double palpation. If subcapsular hematoma is found in the front of the pancreas, the pancreatic capsule must be cut to remove the hematoma to determine the degree of injury at the tail of the pancreas. Injury requires incision of the posterior peritoneum at the upper and lower edges of the pancreatic body and tail to fully relax the pancreatic body and tail, so as to examine the posterior surface. If necessary, the spleen can be dissociated and removed from the incision. Sometimes the omentum can be separated from the transverse colon and entered the omentum cavity from the upper edge of the transverse colon for exploration. Passing through the hepatogastric ligament is the most convenient way for patients with gastroptosis, which can fully expose the front and upper and lower edges of the whole pancreas.
In the process of exploring the pancreas, we should pay special attention to whether there are indirect signs of pancreatic head and duodenal injury such as hematoma, edema, pneumatosis and local bile yellow staining near the root of transverse mesocolon and upper duodenal fold. The retroperitoneal hematoma on the lateral side of duodenal curvature may come from the injury of pancreatic head and duodenum or the contusion and laceration of right kidney. Peritoneal exploration after incision can avoid missed diagnosis of fatal duodenal injury.
(3) Determination of the degree of pancreatic injury: The determination of the degree of pancreatic injury mainly refers to the determination of the clinical and pathological classification of pancreatic injury, including the determination of whether there is a large pancreatic duct injury, which directly affects the reasonable choice of surgical methods and the prognosis of patients. Therefore, it is necessary to correctly determine whether there is a large pancreatic duct injury before deciding the surgical method. In one of the following cases during the operation, it can be considered that there is a large pancreatic duct injury: ① the pancreas is completely transected; ② The tear or rupture of the great pancreatic duct can be clearly seen on the fracture surface of pancreas; ③ The rupture and tear of pancreas is larger than the diameter of pancreas (1/2), especially the rupture of pancreatic neck and upper part of pancreatic body; ④ Large area penetrating injury in the center of pancreas; ⑤ Severe pancreatic tissue contusion is close to fragmentation. It is sometimes difficult to determine whether severe pancreatic contusion is accompanied by severe pancreatic duct injury, such as obvious swelling of pancreatic subcapsular hematoma and pancreatic hemorrhage after pancreatic contusion. Or the naked eye can only see the subcapsular hematoma of the pancreas, but there can also be a rupture of the large pancreatic duct. When it is uncertain whether there is a large pancreatic duct injury, 1ml methylene blue can be injected into the normal pancreatic tissue at the distal end of the injury, and methylene blue can overflow from the injured pancreatic duct. If you still can't judge, you can cut the front wall of the descending part of the duodenum and insert a small plastic tube or silicone tube through the ampulla of the duodenum to observe whether there is a diluted methylene blue solution, and you can always pay attention to whether there is a large pancreatic duct injury.
2. Basic principles of surgical treatment of pancreatic injury.
(1) Tight hemostasis of pancreatic wound: The most common complication of pancreatic injury is postoperative secondary bleeding, so it is necessary to tightly stop bleeding at each bleeding point during operation (dark color without bleeding). It is necessary to clean up the exposed bleeding blood vessels. Because the blood supply of the pancreas is rich, the blood vessels are thin, and the pancreatic tissue is fragile, it is impossible to clamp the bleeding point of the pancreas for hemostasis or large ligation. A number of intermittent mattress-type shallow suture lines parallel to the wound surface must be made of thin lines that are not absorbed, and the knots should not be too tight. Otherwise, ligature is easy to split the pancreatic tissue and suture the large pancreatic duct, causing complications. Attention should be paid to avoid small bleeding points, and electrocoagulation can be used to stop bleeding. Sometimes gauze can be used to compress bleeding and the gut can be digested.
(2) Reasonable resection of necrotic pancreatic tissue: It is necessary to fully debride and preserve pancreatic function as much as possible. If the necrotic pancreatic tissue is not completely left after debridement, complications such as pancreatic fistula and peripancreatic abscess will inevitably occur after operation, which is sometimes the direct cause of postoperative death. When the pancreas is seriously injured, it is necessary to remove part of the pancreas, but it is necessary to take into account the extensive protection of the internal and external secretion functions of the pancreas (such as pancreatectomy on the right side of superior mesenteric vein). It can be accompanied by temporary or permanent pancreatic insufficiency. When both can't be completely taken into account, it is more important to thoroughly debride and remove necrotic pancreatic tissue to prevent fatal pancreatic fistula and peripancreatic abscess after operation.
(3) Adequate drainage around the pancreas: After pancreatic injury, some small pancreatic ducts are bound to rupture. Even if the surgical exploration is extremely meticulous, the laceration can still be ignored, resulting in postoperative pancreatic fistula. If the leaked pancreatic juice is sealed or restricted, pancreatic pseudocyst or abscess can be formed. Severe pancreatic injury can be caused by intense stimulation of digestive juices such as pancreatic juice and duodenal juice, resulting in severe exudation and inflammation in abdominal cavity and retroperitoneum. Coupled with surgical trauma, secondary infection of abdominal effusion and pancreatic fistula and various serious pancreatic injuries are inevitable after operation. Serious complications and deaths are mostly related to pancreatic juice overflow and secondary abdominal infection. Adequate and effective drainage of abdominal cavity and peripancreatic space is one of the key measures to ensure the therapeutic effect of pancreatic injury and prevent complications. Drainage can not prevent pancreatic fistula, but it can reduce the accumulation of spilled pancreatic juice around the pancreas, reduce the digestion and corrosion of pancreatic juice to its own tissues, prevent serious infection in abdominal cavity, peripancreatic abscess and pancreatic cyst, and prevent small pancreatic fistula from being closed early and reoperation.
There are many kinds and methods of drainage. Sometimes, several kinds of drainage must be used at the same time. Commonly used thick silicone tube or double-tube drainage tube. Depending on the degree of pancreatic injury and the surgical method adopted, one or more drainage tubes can be used. Drainage tubes can be placed on the upper and lower edges of pancreatic head, duodenum, pancreatic body and pancreatic tail, and can also be placed under diaphragm and pelvic cavity after operation. Ensure that the drainage tube is unobstructed. If necessary, rinse repeatedly with normal saline. The drainage tube around the pancreas can be determined according to its characteristics and drainage volume. Keep it for at least 5 ~ 7 days. If pancreatic fistula, duodenal fistula or biliary fistula are suspected, the drainage tube can be kept for a longer time. If pancreatic fistula has occurred, this drainage tube may become a treatment for pancreatic fistula. Sometimes it may take several months to completely close the pancreatic fistula or decide to have another operation. Multiple drainage tubes should be pulled out one by one, and each drainage tube should be pulled out step by step. Negative pressure suction can also be used to promote the discharge of liquid, but negative pressure suction should not be too large. Excessive negative pressure will make the drainage tube open for drainage. If serious infection has been found in abdominal cavity or retroperitoneal space during operation, another thin catheter or plastic tube can be placed next to the double tube, and the pus cavity can be washed with effective antibiotic solution, which is beneficial to control infection.
(4) Severe pancreatic injury should be supplemented by biliary decompression: because the common bile duct and the main pancreatic duct often have "* * *", in order to reduce the pressure in the pancreatic duct and prevent bile from flowing back into the pancreatic duct to activate pancreatin to induce traumatic pancreatitis, some scholars advocate cholecystostomy or T-tube drainage of the common bile duct, which is often used for duodenal diverticulum surgery and for severe pancreatic head and duodenal injury. T-tube drainage of common bile duct is a part of this operation. Most bile can be taken out of the body by bypass, which can definitely reduce the secretion of pancreatic juice and is conducive to the healing of pancreatic injury. However, cholecystostomy is sometimes inaccurate for bile duct decompression, and T-tube drainage of common bile duct can sometimes lead to the late stage of bile duct unexpanded.
(5) Correctly handle the combined injuries of other organs and blood vessels: pancreatic injuries are often combined with injuries of upper abdominal organs, such as rupture of liver and spleen or digestive tract, and injuries of large blood vessels (such as portal vein, mesenteric vein, splenic vein, inferior vena cava and hepatic artery) combined with intra-abdominal hemorrhage and shock; If the treatment is not timely, he may die of hemorrhagic shock, so early and timely treatment of hemorrhagic shock and reasonable treatment of visceral complications and vascular injury are the keys to prevent the patient from early death.
If there are multiple abdominal organ injuries, the pancreatic injury can be left to the last treatment, that is, the hemorrhagic injury, such as vascular ligation or repair of liver and spleen rupture, is treated first, and then the digestive tract rupture that pollutes the abdominal cavity is treated, and finally the pancreatic injury is treated.
(6) Treatment when the timing of operation is delayed: Some patients can only undergo open surgery several days after trauma, and the diagnosis may be delayed due to serious injuries and other reasons. At this time, the pancreatic tissue is inflamed, congested and edematous, and the texture is fragile, which is slightly separated from the surrounding tissues, resulting in massive bleeding, and it is impossible to dissociate the pancreas and perform other complicated operations. To this end, the damaged necrotic tissue can be removed and the bleeding stopped carefully, and then the broken pancreas can be mattress-stitched with thin lines and multiple locally placed drainage tubes. Posterior pancreatic fistula is almost inevitable. If we pay attention to keep the drainage unobstructed, adjust the balance of water and electrolyte, and strengthen nutritional support treatment, pancreatic fistula may still heal itself, and those who fail to heal for a long time may be treated again.
3. Selection of surgical methods for pancreatic injury
(1) Surgical choice of mild pancreatic contusion and laceration: mild pancreatic contusion and laceration (type Ⅰ A pancreatic injury) has no large pancreatic duct and intact capsule, which usually occurs after mild upper abdominal contusion, resulting in so-called traumatic pancreatitis. After surgical exploration, if there is no other organ injury, drainage can only be placed around the injured part of the pancreas, but the subcapsular laceration of the pancreas should be carefully explored and excluded. If there is a rupture or shallow tear in the pancreatic sac, it can be sutured with thin thread. If you find a small hematoma under the pancreatic capsule, you should cut the capsule to remove the hematoma. If there is obvious pancreatic tissue defect, it can't be sutured with thin thread to stop bleeding. When the membrane is closed but there is no serious pancreatic duct injury, adequate and effective drainage can only be carried out after bleeding is controlled (Figure 2). No matter how slight the pancreatic injury is, drainage around the pancreas or the omentum cavity is necessary. Although pancreatic fistula can occur after simple drainage in some cases, surgical treatment is feasible if pancreatic fistula can heal itself after a period of time.
(2) Selection of surgical methods for severe pancreatic injury: Severe pancreatic injury includes severe pancreatic contusion and laceration (type I B pancreatic injury) and partial or complete pancreatic laceration (type ic pancreatic injury). Severe pancreatic contusion and laceration may or may not be accompanied by pancreatic duct injury. If it is difficult to diagnose, pancreatic laceration should generally be treated as pancreatic duct injury, usually accompanied by different degrees of pancreatic duct injury or even complete rupture of pancreatic duct.
① Severe pancreatic injury mainly involving the pancreatic tail: Severe pancreatic injury at the pancreatic tail, including severe pancreatic contusion and laceration, partial or complete rupture of the pancreatic tail, and partial or complete rupture of the junction of the pancreatic body and tail, should be removed and the broken end of the pancreatic head sutured for repair (Figure 3). This operation is simple and easy with few postoperative complications.
The pancreatic section or part of the pancreatic tissue on the section of the pancreatic head may suffer from severe contusion and lose vitality, such as pancreatic fistula and pseudocyst after improper treatment. Therefore, the pancreatic section on the head of the pancreas should be properly debrided, and the basic principle is the same as general debridement. During the operation, the pancreatic body near the pancreatic section can be pinched with fingers to remove necrotic and possibly necrotic pancreatic tissue under the condition of controlling active bleeding. If it can be found in the process of cleaning the pancreatic tissue with good blood circulation, it is ideal to ligate the main pancreatic duct with filaments alone, but most of the pancreatic ducts are small at this time, so it is difficult to dissect the active bleeding point on the proximal section of the pancreas. After debridement with filament ligation or suture, the upper and lower edges of the pancreas were sutured with filament intermittent mattress.
If there is obvious pancreatic contusion at the same time, it is suspected that the integrity of the pancreatic duct of the pancreatic head has been destroyed, which will affect the drainage of pancreatic juice into the duodenum. When the pancreatic tail is removed, the end of the pancreatic head can be anastomosed with the jejunum to avoid pancreatic fistula.
Because the pancreatic tail is closely related to the anatomy of the spleen, the traditional pancreatectomy or pancreatectomy is to remove the spleen at the same time. In recent years, it has been found that severe fulminant infection (OPSI) may be caused after splenectomy, so that the immune function of spleen to the body has been paid attention to. For pancreatectomy or pancreatectomy without malignant tumor, there are two basic operations, namely splenic artery and vein ligation and devascularization.
② Severe pancreatic body injury mainly involving pancreatic body: For extensive severe pancreatic body injury involving pancreatic tail, including contusion and laceration involving most pancreatic body and tail tissues, multiple fractures of pancreatic body and tail can only be repaired by resection of pancreatic tail, suture of pancreatic head side broken end or Roux-en-Y anastomosis of pancreatic head side broken end with jejunum (Figure 4). For localized severe contusion and laceration of the pancreatic neck (although the injury is serious, it is still limited). We can try to remove the damaged part to make it a complete rupture of pancreatic neck, and then treat it according to the following principles. Partial or complete rupture of pancreas mostly occurs on the left side of superior mesenteric vessels or at the junction of pancreatic neck and pancreatic body. This kind of pancreatic injury is caused by sudden and violent extrusion of the pancreas on the spine, accounting for about 8.5% abroad and 40% at home. There are many surgical methods for pancreatic neck rupture, as follows.
A. Suture repair of pancreatic rupture after pancreatoduodenectomy: If the local tissue damaged by the rupture is not serious, the most ideal surgical method is to anastomose the pancreatic duct at one stage, suture the broken part of the pancreatic neck and restore the pancreatic connection. In order to prevent the stricture of pancreatoduodenectomy or the overflow of pancreatic juice, a thin plastic tube or silicone tube can be placed in the pancreatic duct, and one end of the catheter is cut into several side holes, and the other end is introduced into the duodenum through bile and ampulla of the pancreas, and then led out of the body through the abdominal wall (Figure 5). Martin successfully treated 2 cases of pancreatic neck rupture in children by this operation, but the pancreatic duct is very thin in the non-obstructive state, and intubation is not easy to succeed, so the operation technique is quite difficult. If the pancreatic duct is successfully inserted, this operation will have a good effect.
B. Repair the broken end of the pancreas by suture. Pancreatic body and tail resection: The simplest, safest and less complications treatment method is to remove the broken end of the pancreas (pancreatic body and tail resection). Double ligation and intermittent suture of pancreatic duct at the broken end of pancreatic head are simple and effective. However, if more functional pancreatic tissue is removed, the endocrine function of the pancreas will be insufficient. It is generally believed that 70% of healthy pancreas can be resected without affecting the function of pancreas. However, it should also be considered that islets are mainly distributed in the pancreatic tail, which can retain 70% of the pancreatic tail, which may lead to pancreatic endocrine loss. If the pancreatic tissue retained after operation is chronically inflamed due to pancreatic fistula infection, pancreatic secretion dysfunction will be inevitable. This operation should not be considered as a pancreatic neck fracture.
C. Roux-en-Y anastomosis of pancreatic body and tail and head-end suture of pancreas: Roux-en-Y anastomosis of pancreatic body and tail and head-end suture of pancreas are recommended for this kind of pancreatic injury at home and abroad (Figure 6). This is the first time that Letton and Wilson reported the complete rupture of pancreatic neck in 1959. Two cases of pancreatic neck were reported. After ligating the pancreatic duct on the head side of the pancreas, suture and repair the broken end. After Roux-en-Y pancreaticojejunostomy was successfully performed, this operation was widely used. Roux-en-Y pancreaticojejunostomy is the basic operation of pancreatic surgery. The following problems should be paid attention to when the neck is broken: a. The pancreatic tissue on the head side of the pancreas may have severe contusion, and some tissues have lost their vitality, which needs serious debridement. It is best to find out the main pancreatic duct, tie the pancreatic segment separately with silk thread and suture it intermittently; B) In order to prevent pancreatic fistula in pancreaticojejunostomy, the main pancreatic duct can be separated from the tail of the pancreatic body, inserted into a silicone tube, passed through the jejunum cavity, passed through the intestinal wall and abdominal wall and led out of the body; C 1 ~ 2 silicone drainage tube should be placed under and behind the pancreaticojejunostomy, leading out through the left abdominal wall, which is equivalent to the axillary front.
D Pancreatic body end-to-end anastomosis with duodenum: head-to-head anastomosis of pancreatic body and end-to-side anastomosis of pancreatic body end-to-end anastomosis with duodenal ascending part (Figure 7) is a simple internal drainage method for pancreatic injury.
E. Anastomosis of the pancreatic body end with the stomach: after the head end of the pancreatic body is sutured and repaired, the front and rear walls of the stomach are cut along the long axis, the pancreatic body end is implanted into the stomach cavity through the back wall of the stomach, the back wall of the stomach is anastomosed with the pancreas with silk thread, and then the front wall of the stomach is sutured (Figure 8).
Some scholars believe that there is still the risk of complications such as pancreatic fistula after suture repair of pancreatic head-side broken end. It is suggested that internal drainage should be carried out between the broken ends of pancreas and digestive tract. This operation adds a pancreatic anastomosis, which is technically difficult and can be applied to the pancreatic cephalic tissue with serious contusion. When the reflux of the proximal pancreatic duct may be affected, three kinds of operations can be briefly introduced in the literature: A free A-segment jejunum with vascular arch (both ends are cut off to preserve the mesentery). The proximal end of this jejunum was anastomosed with the caudal end of pancreatic body, then the distal end of jejunum was lifted to anastomose with the cephalad end of pancreatic body, and then jejunum and jejunum were anastomosed end to side twice (double Roux-en-Y anastomosis Figure 9). B. On the basis of standard Roux-en-Y anastomosis between the end of pancreatic body and jejunum, the end-to-side anastomosis between the head of pancreatic body and the distal wall of intestinal loop is increased (Figure10); C insert a jejunal loop between the two broken ends of the pancreas, seal the broken end of the empty intestine, and anastomose the two broken ends of the pancreas with the jejunum on both sides at the same level (figure 1 1).
③ Severe pancreatic injury mainly involving pancreatic head: Simple pancreatic head injury is rare, but it is often accompanied by duodenal injury. The treatment of mild injury involving pancreatic head is as follows:
A. When the pancreatic head contusion and laceration has been diagnosed with main pancreatic duct injury, if possible, it is best to perform pancreatic duct anastomosis and pancreatic tissue repair after debridement and hemostasis. To prevent pancreatic duct stenosis or pancreatic fistula, a thin plastic tube or silicone tube can be placed in the pancreatic duct and led out of the body through the duodenal cavity (Figure 12). However, due to severe trauma, pancreatic tissue and pancreatic duct are corroded and digested by trypsin, and pancreatic fistula and pancreatic duct stenosis appear after inflammatory edema. The surgical technique is quite difficult and the operation is not easy to succeed. Roux-en-Y pancreaticojejunostomy can be performed between the injured site and the jejunum if the wound at the contusion is located in front of the pancreas and the back of the pancreas is not damaged (Figure 13).
B It is sometimes difficult to judge the degree of injury due to bleeding on the wound surface of pancreatic injury, and it is not clear whether the main pancreatic duct is damaged during debridement. In the case of serious illness and lack of various surgical conditions, thin lines can be used to carefully align the pancreatic stump and place local drainage. Even after pancreatic fistula, some cases can still heal themselves. Those who cannot heal themselves can be treated as pancreatic fistula again.
C. When the head of the pancreas is severely fractured and the pancreatic duct injury is difficult to repair, but the duodenum is not involved, subtotal pancreatectomy, ligation of the proximal pancreatic duct and Roux-en-Y pancreaticojejunostomy can be considered. When the pancreatic head is removed, the pancreatic tissue with the thickness of 1 ~ 1.5 cm should be preserved in the duodenum to ensure the blood supply to the duodenum, otherwise duodenal necrosis will occur (Figure 14).
④ Selection of surgical methods for combined pancreaticoduodenal injury: When combined pancreaticoduodenal injury is light (type Ⅱ A pancreatic injury), pancreaticoduodenal injury and pancreaticoduodenal injury are not serious, so suture repair and external drainage can be performed respectively.
A. Severe combined injury of pancreatic head and duodenum (type Ⅱ B pancreatic injury) refers to severe contusion or partial or complete rupture of pancreatic head and duodenum or any organ injury, including three situations: a. Severe injury of pancreatic head and mild injury of duodenum; B. the injury of pancreatic head is lighter than that of duodenum; The head of pancreas and duodenum were badly damaged. For patients with severe craniocerebral injury and mild duodenal injury, the pancreatic head can be treated according to the principle of severe contusion and laceration of the pancreatic head and rupture of the pancreatic head. For those with mild head injury and severe duodenal injury, the pancreatic head can be sutured and repaired for external drainage, and duodenal injury can be properly treated according to its severity. When the head of pancreas and duodenum are seriously injured, it is the most difficult to deal with.
Because of the close relationship between the pancreatic head and duodenum and the common bile duct and its surrounding great vessels, this joint injury of the pancreatic head and duodenum is often accompanied by the injury of the common bile duct and its surrounding great vessels. In the early stage, the patient may die because of the rupture of portal vein, mesenteric vein and hepatic artery. Edema and bleeding of local tissues in the head of pancreas and duodenum can easily lead to obstruction of drainage of pancreatic juice and bile. The rupture of bile duct in cholangiopancreatic duct may cause a large amount of bile and pancreatic juice to overflow into abdominal cavity, and pancreatin may be activated by duodenal juice, leading to rapid digestion and necrosis of tissues, leading to
For this kind of severe pancreaticoduodenectomy combined injury, if conservative simple suture repair and external drainage are carried out, serious complications will inevitably occur. If active pancreaticoduodenectomy is performed, it is difficult to perform this complicated operation in a serious emergency, so it is very difficult to deal with this kind of injury, and its mortality rate is very high.
B duodenal diverticulum: Berne first reported the application of duodenal diverticulum in the treatment of severe pancreaticoduodenal injury or simple duodenal injury in 1968. Berne first reported 16 cases, of which 3 cases died of multiple injuries within 24 hours after operation. Later, this operation was widely used to treat severe pancreaticoduodenal injury and achieved satisfactory results. A standard operation for duodenal diverticulum with intestinal injury includes several basic parts, namely, antrectomy, vagotomy, end-to-side gastrojejunostomy, duodenal suture atresia, duodenal fistula, local debridement and repair of pancreatic head injury, T-tube drainage and repair of common bile duct, and multiple drainage tubes in abdominal cavity. The principle of this operation is as follows: a. Resection of gastric antrum and anastomosis of stomach and jejunum to prevent food from passing through duodenum is beneficial to the healing of duodenal injury; Gastric antrectomy and vagotomy reduce gastric acid secretion. Low gastric acid reduces the secretion of duodenal juice and pancreatic juice, inhibits the activation of pancreatin, and prevents stress ulcer and marginal ulcer. C. Duodenal fistula can reduce the pressure in the duodenal cavity, reduce the tension at the suture repair site of duodenal injury, and make the damaged duodenal side fistula become a more self-healing end fistula; D. T-tube drainage of common bile duct can reduce the pressure of common bile duct, which is beneficial to drainage of pancreatic juice to reduce pancreatic juice overflow and tissue self-digestion of pancreatic injury site.
Compared with pancreaticoduodenectomy, duodenal diverticulum surgery is simple, less invasive and less complicated.
C. Improved operation of duodenal diverticulum: Cogbill reported an improved operation of duodenal diverticulum in 1982, that is, the anterior wall of gastric antrum was cut, pylorus was sutured through the gastric antrum with absorbable suture, and then the gastric antrum incision was anastomosed with jejunum, so that the gastric contents could enter jejunum from the anastomosis, instead of cutting off the gastric antrum and vagus nerve (Figure 15), which could shorten the operation time of diverticulum.
⑤ Pancreatoduodenectomy: Only pancreatoduodenectomy can be considered when the serious injury of the head of pancreas and duodenum involves a wide range and there is obvious blood supply disorder or necrosis. Emergency pancreaticoduodenectomy has some characteristics: a. The patient is in a state of severe traumatic hemorrhagic shock, which increases the risk of operation and postoperative complications; B. There may be other organ injuries in the patient's abdominal cavity, such as rupture of liver, spleen or intestine, which increases the complexity and invasiveness of surgical injuries; C most patients do not have expanded pancreaticojejunostomy, and cholangiojejunostomy is very difficult, and pancreatic fistula and biliary fistula are easy to occur after operation. Therefore, the mortality rate of emergency pancreatoduodenectomy combined with pancreatoduodenectomy is very high, reaching 30% ~ 40%. Therefore, pancreaticoduodenectomy can not be considered as a suitable operation for severe pancreatic injury, but only as the last choice when any of the above operations are difficult to implement.
Whipple (anastomosing with jejunum in the order of bile duct-pancreas-stomach) or Child method (anastomosing with jejunum in the order of pancreas-bile duct-stomach) can be used for digestive tract reconstruction. Sub-methods are advocated at present.
4. Polisel's therapy
Postoperative management of pancreatic injury is generally the same as other surgical operations or pancreatic operations, and some special problems directly related to pancreatic injury and pancreatic injury surgery are not repeated here.
(1) Most severe pancreatic injuries belong to the scope of severe trauma, and it is easy to be complicated with adult respiratory distress syndrome (ARDS) or multiple organ dysfunction syndrome (MOBS). Attention should be paid to the monitoring of vital signs and respiratory management in the near future. If there are obvious signs and conditions, you should receive intensive care treatment in ICU.
(2) It is not advisable to eat early after operation. Even if the intestinal peristalsis has recovered, the eating time should be postponed to 7 ~ 10 days after operation. Long-term fasting after operation can reduce the secretion of pancreatic juice, which is beneficial to the repair of pancreatic injury and reduce the occurrence of pancreatic fistula.
(3) Extensive pancreatic tissue injury and resection can lead to islet dysfunction, which is more likely to lead to relative endogenous insulin secretion deficiency in severe trauma and postoperative stress. Blood sugar and urine sugar should be monitored regularly after operation, and whether to give exogenous insulin and insulin dosage should be adjusted according to the monitoring results of blood sugar and urine sugar.
(4) Drugs that inhibit the secretion of pancreatic juice, such as fluorouracil and somatostatin produced commercially in recent years, or drugs that inhibit pancreatic enzyme activity, such as aprotinin, can be used.
(5) All drainage tubes must be kept unobstructed to achieve the purpose of effective drainage and avoid premature slippage. If necessary, the drainage tube can be washed with normal saline or liquid containing antibiotics. In the process of drainage, we must pay attention to keep the skin around the drainage tube dry. Zinc oxide ointment and tannic acid ointment can be coated on the skin around the drainage tube or given local infrared radiation to prevent skin from being corroded and digested by pancreatic juice and causing skin erosion.
(6) Many patients are in a state of severe stress or high catabolism for a long time, and various complications such as fasting gastrointestinal decompression, pancreatic fistula, intestinal fistula and intra-abdominal infection after operation aggravate the negative nitrogen balance. A large number of structural proteins in the body are consumed as energy-supplying substances, which will lead to serious mixed malnutrition for a long time. Postoperative nutritional support therapy is an important measure to ensure the smooth recovery of patients after operation. Clinically, elemental diet can be fed with total parenteral nutrition through deep vein intubation or through jejunostomy tube and nasogastric tube according to the patient's condition and illness.
(2) Prognosis
The prognosis of pancreatic injury is mainly related to whether the diagnosis of the location and degree of injury is timely and accurate, whether the treatment is timely, whether there are other organ injuries and whether there are complications. Simple pancreatic injury is rare and has a good prognosis.