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Stomach and Small Intestine
• Gastric wounds can be oversewn with a
running single-layer suture line or closed with
a stapler.
• If a single-layer closure is chosen, fullthickness bites should be taken to ensure
hemostasis from the well-vascularized gastric
wall.
Stomach and Small Intestine
• The most commonly missed gastric injury is the
posterior wound of a totally penetrating injury.
Injuries also can be overlooked if the wound is
located within the mesentery of the lesser
curvature or high in the posterior fundus.
• To delineate a questionable injury, the stomach
can be digitally occluded at the pylorus while
methylene blue-colored saline is instilled via a
nasogastric tube.
Stomach and Small Intestine
• Alternatively, air can be
introduced via the NG tube with
the abdomen filled with saline
Stomach and Small Intestine
• Partial gastrectomy may be required for
destructive injuries, with resections of the
distal antrum or pylorus reconstructed using a
Billroth procedure.
• Patients with injuries that damage both
Latarjet nerves or vagi should undergo a
drainage procedure
Small Intestine
• Small intestine injuries can be repaired using a
transverse running 3-0 PDS suture if the injury is
less than one- third the circumference of the
bowel.
• Destructive injuries or multiple penetrating
injuries occurring close together are treated with
segmental resection followed by end-to-end
anastomosis using a continuous, single-layer 3-0
polypropylene suture.
• Mesenteric injuries may result in an ischemic
segment of intestine, which mandates resection.
Small Intestine
• Multiple studies have confirmed the
importance of early total enteral nutrition
(TEN) in the trauma population, particularly its
impact in reducing septic complications.
• The route of enteral feedings (stomach vs.
small bowel) tends to be less important,
because gut tolerance appears equivalent
unless there is upper GI tract pathology.
Small Intestine
• Although early enteral nutrition is the goal,
evidence of bowel function should be apparent
before advancing to goal tube feedings.
• Overzealous jejunal feeding can lead to small
bowel necrosis in the patient recovering from
profound shock.
• Patients undergoing monitoring for nonoperative
management of grade II or higher solid organ
injuries should receive nothing by mouth for at
least 48 hours in case they require an operation.
Small Intestine
• Although there is general reluctance to initiate
TEN in patients with an open abdomen, a
recent multicenter trial demonstrates TEN in
the postinjury open abdomen is feasible
Small Intestine
• For those patients without a bowel injury, TEN was
associated with higher fascial closure rates, decreased
complications, and decreased mortality.
• TEN in patients with bowel injuries does not appear to
alter fascial closure rates, complications, or mortality;
hence EN appears to be neither advantageous nor
detrimental in these patientsOnce resuscitation is
complete, initiation of
• TEN, even at trophic levels (20 mL/h), should be
considered in all injured patients with an open
abdomen.
Duodenum and Pancreas
• The spectrum of injuries to the duodenum
includes hematomas, perforation (blunt blowouts, lacerations from stab wounds, or blast
injury from gunshot wounds)
• and combined pancreaticoduodenal injuries
Duodenum
• The majority of duodenal hematomas are managed nonoperatively
with nasogastric suction and parenteral nutrition.
• Patients with suspected associated perforation, suggested by
clinical deterioration or imaging with retroperitoneal free air or
contrast extravasation, should undergo operative exploration.
• A marked drop in nasogastric tube output heralds resolution of the
hematoma, which typically occurs within 2 weeks; repeat imaging
to confirm these clinical findings is optional.
• If the patient shows no clinical or radiographic improvement within
3 weeks, operative evaluation is warranted.
Duodenum
• Small duodenal perforations or lacerations
should be treated by primary repair using a
running single-layer suture of 3-0
monofilament.
• The wound should be closed in a direction
that results in the largest residual lumen.
• Challenges arise when there is a substantial
loss of duodenal tissue
Duodenum
• Extensive injuries of the first portion of the
duodenum (proximal to the duct of Santorini)
can be repaired by debridement and endtoend anastomosis because of the mobility
and rich blood supply of the distal gastric
atrium and pylorus
Duodenum
• In contrast, the second portion is tethered to the head
of the pancreas by its blood supply and the ducts of
Wirsung and Santorini; therefore, no more than 1 cm
of duodenum can be mobilized away from the
pancreas, and this does not effectively alleviate tension
on the suture line.
• Moreover, suture repair using an end-to-end
anastomosis in the second portion often results in an
unacceptably narrow lumen
• defects in the second portion of the duodenum should
be patched with a vascularized jejunal graft.
Duodenum
• Duodenal injuries with tissue loss distal to the
papilla of Vater and proximal to the superior
mesenteric vessels are best treated by Rouxen-Y duodenojejunostomy with the distal
portion of the duodenum oversewn
Roux-en-Y duodenojejunostomy
Duodenum
• Pyloric exclusion is used to treat combined
injuries of the duodenum and the head of the
pancreas as well as
• isolated duodenal injuries when the duodenal
repair is less than optimal.
• The pylorus is oversewn through a gastrotomy,
which is subsequently used to create a
gastrojejunostomy.
• The authors frequently use needle-catheter
jejunostomy tube feedings for these patients
Pyloric exclusion
Duodenum
• In particular, injuries in the distal third and
fourth portions of the duodenum (behind the
mesenteric vessels) should be resected, and a
duodenojejunostomy performed on the left
side of the superior mesenteric vessels.
Colon and Rectum
• three methods for treating colonic injuries are
used: primary repair, end colostomy, and
primary repair with diverting ileostomy.
Colon and Rectum
• Primary repairs include lateral suture repair or
resection of the damaged segment with
reconstruction by ileocolostomy or
colocolostomy.
• All suturing and anastomoses are performed
using a running single-layer technique
• The advantage of definitive treatment must be
balanced against the possibility of anastomotic
leakage if suture lines are created under
suboptimal conditions
Colon and Rectum
• Alternatively, although use of an end
colostomy requires a second operation, an
unprotected suture line with the potential for
breakdown is avoided. Numerous large
retrospective and
• several prospective studies have now clearly
demonstrated that primary repair is safe and
effective in virtually all patients with
penetrating wounds
Colon and Rectum
• Colostomy is still appropriate in a few patients, but the
current dilemma is how to select which patients should
undergo the procedure.
• Currently, the overall physiologic status
of the patient, rather than local factors,
directs decision making.
• Patients with devastating left colon injuries requiring
damage control are clearly candidates for temporary
colostomy.
• Diverting ileostomy with colocolostomy, however, is
used for most other high-risk patients.
Colon
Colon
• A.The running, single-layer suture is started at
the mesenteric border.
• B. Stitches are spaced 3 to 4 mm from the
edge of the bowel and advanced 3 to 4 mm,
including all layers except the mucosa.
• C. The continuous suture is tied near the
antimesenteric border.
Rectal injuries
• Rectal injuries are similar to colonic injuries with
respect to the ecology of the luminal contents,
overall structure, and blood supply of the wall,
but access to extraperitoneal injuries is limited
due to the surrounding bony pelvis.
• Therefore, indirect treatment with intestinal
diversion usually is required.
• The current options are loop ileostomy and
sigmoid loop colostomy.
Rectal injuries
• For sigmoid colostomy,
• technical elements include:
• (a) adequate mobilization of the sigmoid colon so that
the loop will rest on the abdominal wall without
tension,
• (b) maintenance of the spur of the colostomy (the
common wall of the proximal and distal limbs after
maturation) above the level of the skin with a one-halfinch nylon rod or similar device,
• (c) longitudinal incision in the tenia coli, and
• (d) immediate maturation in the OR
Loop colostomy will completely divert
the fecal flow
Rectal injuries
• If the injury is accessible (e.g., in the posterior
intraperitoneal portion of the rectum), repair
of the injury should also be attempted.
• However, it is not necessary to explore the
extraperitoneal rectum to repair a distal
perforation.
Rectal injuries
• If the rectal injury is extensive, another option
is to divide the rectum at the level of the
injury, oversew or staple the distal rectal
pouch if possible, and create an end
colostomy (Hartmann’s procedure).
Rectal injuries
• Extensive injuries may warrant presacral
drainage with Penrose drains placed along
Waldeyer’s fascia via a perianal incision
• In rare instances in which destructive injuries
are present, an abdominoperineal resection
may be necessary to avert lethal pelvic sepsis.
Complications
• Complications related to colorectal injuries include
intraabdominal abscess, fecal fistula, wound infection,
• and stomal complications.
• Intra-abdominal abscesses occur in approximately 10%
of patients, and most are managed with percutaneous
drainage.
• Fistulas occur in 1% to 3% of patients and usually
present as an abscess or wound infection with
subsequent continuous drainage of fecal output; the
majority will heal spontaneously with routine care
Stomal complications
• Stomal complications (necrosis, stenosis,
obstruction, and prolapse) occur in 5% of
patients and may require either immediate or
delayed reoperation.
• Stomal necrosis should be carefully
monitored, because spread beyond the
mucosa may result in septic complications,
including necrotizing fasciitis of the abdominal
wall.
osteomyelitis.
• Penetrating injuries that involve both the
rectum and adjacent bony structures are
prone to development of osteomyelitis.
• Bone biopsy is performed for diagnosis and
bacteriologic analysis
• treatment entails longterm IV antibiotic
therapy and occasionally debridement.
Damage Control Surgery
• Indications to limit the initial operation and
institute
DCS
techniques
include
a
combination of
• refractory hypothermia (temperature <35°C),
• profound acidosis, (arterial pH <7.2, base
deficit <15 mmol/L),
• refractory coagulopathy
Damage Control Surgery
• The second key component of DCS is limiting
enteric content spillage.
• Small GI injuries (stomach, duodenum, small
intestine, and colon) may be controlled using a
rapid whipstitch of 2-0 polypropylene.
• Complete transection of the bowel or segmental
damage is controlled using a GIA stapler, often
with resection of the injured segment.
• Alternatively, open ends of the bowel may be
ligated using umbilical tapes to limit spillage.