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GASTRIC INJURIES 15. Demetriades D, Karaiskakis M, Alo K, et al: Role of postoperative computed tomography in patients with severe liver Br J Surg 90(11):13981400, injury. 2003 16. . Robin AP, Andrews JR, Lange DA, et al: Selective management of anterior abdominal stab J Trauma 29(12):16841689, 1989. 17. wounds. Demetriades D, Rabinowitz B: Indications for operation in abdominalwounds. A prospective study of 651 stab Ann Surg 205(2): patients. 1987. 129132, 18. Hauser CJ, Huprich JE, Bosco P, et al: Triple-contrast computed tomography in the evaluation of penetrating posterior abdominal Arch injuries. Surg 122(10):11121115, 1987. 19. Velmahos GC, Demetriades D, Toutouzas KG, et al: Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should laparotomy still be the standard of routine Ann Surg234(3):395403, care? 2001. 20. Fackler ML: Civilian gunshot wounds and ballistics: dispelling the myths. Emerg Med Clin North Am 16(1):1728, 1998. 21. Murray JA, Demetriades D, Asensio JA, et al: Occult injuries to the dia- phragm: prospective evaluation of laparoscopy in penetrating injur ies to left lower J Am Coll Surg187(6):626630, 1998. the 22. chest. iades D, Gomez H, Chahwan S, et al: Gunshot injuries to the Demetr liver: the role of selective nonoperative J Am Coll Surg 188(4): management. 343348, 1999.

7. Cocanour CS, Moore FA, Ware DN, et al: Age should not be a consider- for nonoperative management of blunt splenic ation J Trauma injury. 48(4):606612, 2000. 8. Harbrecht BG, Peitzman AB, Rivera L, et al: Contribution of age and gender to outcome of blunt splenic injur y in adults: multicenter study Eastern Association for the Surgery of of the J Trauma 51(5): Trauma. 2001. 887895, 9. Malhotra AK, Latifi R, Fabian TC, et al: Multiplicity of solid organ injury: uence on management and outcomes after blunt abdominal in trauma. J Trauma54(5):925929, 2003. 10. Nix JA, Costanza M, Daley BJ, et al: Outcome of the current management splenic Trauma 50(5):835842, 2001. of 11. injuries. Bochicchio GV, Kramer N, et al: Nonoperative management Haan JM, of blunt splenic injury: a 5-year J Trauma58(3):492498, 2005. 12. experience. KH, Frumiento C, Rogers FB, et al: Nonoperative Sartorelli management splenic, and renal injuries in adults with multiple of hepatic, injuries. J Trauma49(1):5662, 2000. 13. Toutouzas KG, Karaiskakis M, Kaminski A, et al: Nonoperative manage- of blunt renal trauma: a prospective ment Am Surg 68(12): study. 10971103, 2002. 14. Carrillo EH, Spain DA, Wohtlmann CD, et al: Interventional techniques are useful adjuncts in the nonoperative management of hepatic injur ies. J Trauma46(4):619624, 1999.

GASTRI I NJURIELawrence Diebel

C

N.

S

he stomach is a relatively thick-walled, well-vascularized that organis variably positioned in the peritoneal cavity. partially protected by the lower rib cage, its size and location put Although stomach at risk for injury, particularly with injury from the trauma to penetrating the abdomen or lower The chest. generous blood supply to the stomach includes (1) the gastric artery, a branch of the celiac axis; (2) the right gastric artery, left a branch of the common hepatic artery; (3) the right artery, a branch gastroepiploic of the gastroduodenal artery; (4) the left gastroepiploic artery, a branch of the splenic artery; and (5) the short gastric arteries, which also arise from the splenic artery. Because of the plentiful blood supply, gastric injuries can cause signifi cant bleeding require precise hemostasis in their repair. However, the and blood supply to the stomach contributes to the good results of the excellent surgical repair of most gastric injuries in even the worst clinical cumstances cir. The stomach has a number of important anatomic including the diaphragm, liver, spleen, pancreas, and transverse colon relationships, and mesocolon. Concomitant injuries to these adjacent often dictate the priority of management of the ultimate outcome structures both blunt and penetrating gastric for trauma.

t

The stomach is at risk for injury after stab wounds to the left thoracoabdominal region of the body. A single perforation occurs in over 50% of these cases.2 However, injury to adjacent organs is Gunshot wounds result in two or more gastric wounds in 90% common. cases. of 2 Although often associated with some surrounding tissue age todam- stomach, this is usually only signifi cant with highthe missiles. velocity Shotgun wounds at close range ( 15 feet) are often associated with massive destruction of the abdominal wall, stomach, other and intra-abdominal organs. Blunt injury to the stomach is most often the result of motor hicle crashes, or motor vehiclepedestrian 5 7 Less vecauses trauma.include falls, assaults, and improperly performed cardiopulmocommon nary resuscitation. Blunt gastric injuries include linear lacerations complete gastric rupture. The postulated mechanisms for blunt and injury gastricinclude sudden increases in intraluminal pressure resulting in balloon-bursting type of phenomenon of a full stomach, compression a against the spine (seat-belt injury), or a deceleration injury with ing forces resulting in a laceration of the anterior stomach shearwall.

MECHANISM INJURY

OF

DIAGNOSISGastric perforations caused by blunt forces are often large, and intraperitoneal contamination is usually signifi cant. Peritoneal signs usually obvious, leading to early surgical intervention. Patients are blunt with gastric rupture are frequently in shock related to other signifi cant injuries including spleen and/or liver wounds. with stab wounds and hypotension, peritonitis, or both Patients should undergo laparotomy immediately. Asymptomatic without patients central nervous system injury (brain or spinal cord or drug injury) or alcohol involvement may be observed with physical repeated exams. In other patients, local wound exploration, tic peritoneal lavage (DPL), or laparoscopy are alternatives. Laparosdiagnoscopy is most helpful with thoracoabdominal stab wounds in ing associated injuries to the 8 Focused identifyassessment diaphragm. sonography for trauma (FAST) may not identify the small amount with uid of initially associated with hollow viscus injury, and thus may misleading with isolated gastric be injuries.

INCIDENCEGastric injuries usually result from penetrating trauma and occur approximately 20% of gunshot wounds and 10% of stab wounds. 1 3 in Blunt gastric trauma is much less common. The American for the Surgery of Trauma (East) multi-institutional study on Association viscus hollow injury reported that the prevalence of blunt gastric rupture 0.06% in patients undergoing evaluation for blunt abdominal was and 2.1% of all patients found to have hollow viscus4 trauma injury.

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Early operation is indicated for symptomatic gunshot wounds the to abdomen. Occasionally, a tangential gunshot wound in a patient stable may be observed, or such a wound may be found after the patient undergoes either DPL or laparoscopy. Abdominal CT is also helpful in this situation. In patients suspected to have either blunt penetrating gastric injury, the placement of a nasogastric tube or helpful. Not only does proper placement of a nasogastric tube is mize mini- the risk of aspiration, but a bloody aspirate when present is highly suspicious for a gastric injury. In patients with blunt injury gastricand no obvious peritoneal signs, a supine fi lm of the abdomen discloses free air in less than 50% of cases. In this situation, abdominal CT is more sensitive in identifying free air.

The abdomen is explored through a midline incision. of the stomach Visualization is facilitated by nasogastric tube decompression. Control of hemorrhage is the fi rst priority, followed by control of enteric spill. Gastric wounds may be rapidly initially controlled by a locking running full-thickness closure with absorbable sutures. A lar layer of seromuscu- nonabsorbable sutures is placed later in the operation. This not only affords hemostasis, but also controls further peritoneal contamination by gastric contents. Alternatively a TA-stapler or or Babcock clamp may be used for temporary Allis After control. attention to the more life-threatening injuries, the wound may be addressed. The stomach should fi rst be carefully stomach spected for ecchymosis or hematomas along either the lesser ingreater curvature. Certain areas of the stomach are particularly or fi cult to assess: the gastroesophageal junction, high in the diffundus, gastric the lesser curvature, and the posterior wall. Perixiphoid tension of the midline incision, the use of a self-retaining retractor, exand positioning of the hemodynamically stable patient in the Trendelenburg position may aid in exposure of these reverse areas. The gastroesophageal junction area may also be better exposed problematic

SURGICAL MANAGEMENT

by division of the left triangular ligament and mobilization of lateral segment of the left lobe. The posterior wall of the stomach is the exposed by opening the gastrocolic ligament just outside the gastroepiploic arcade along the greater curvature of the stomach. of the short Division gastric vessels may be necessary to adequately expose the proximal gastric fundus. Occasionally, air insuf ated into the ach via stom- the nasogastric tube with the stomach submerged in may salinehelp identify an occult injury to the stomach. Tangential and/or single perforations of the stomach do occur, but this is a diwounds agnosis of Gastric exclusion. injuries thus identifi ed are treated according to their verity (Table 1, Figure 1). Most intramural hematomas (grades I seII) and are treated by careful evacuation, hemostasis, and closure seromuscular sutures made of nonabsorbable material. Small grade with and I II perforations can be closed in one or two layers. Because of the vascularity of the stomach, I prefer a two-layer closure after hemostasis is achieved.

Table 1: AAST Organ Injury Scale for StomachAAST Grade Injury Characteristics of

I Intramural hematoma 3 cm, partial thickness laceration II Intramural hematoma 3 cm; small ( 3 cm) laceration III Large ( 3 cm) lacerationlaceration involving vessels of greater or IV Large lesser curvature V Extensive ( 50%) rupture; stomach devascularizatio n

AAST American Association for the Surgery of , ModifiTrauma. American Association for the Surgery of Trauma ed from (AAST).

Patient presents with gastric Treat injury according injury tograde after control of hemorrhage

Grade I or II Intramural hematomas: Treat with evacuation, hemostasis, and seromuscular closure. Lacerations: Treat hemostasiswith and one or two layer closure

Grade Treat as III grade I or for IIlacerations, or excise injury with gastrointestin al anastomotic stapler suture inversion of staple line

Grade IV Treatment depends onassociated injuries

Grade V Perform total gastrectom y and Roux en y esophagojejunostom y

Patient has no associated injuries to duodenum, pancreas, or esophaguswith Treat distal gastrectomy and gastroduodenostom y Figure 1 Algorithm for treatment of gastric injury.

Patient has associated injuries to duodenum or pancrea s Treat with distal gastrectomy and gastrojejunostom y, consider feeding jejunostom y

Patient has associated injuries to cardioesophagea l junctio Treat n with proximal gastrectomy andend-to-side esophagogastrectom y and pyloroplasty

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Large (grade III) injuries near the greater curvature can be by closed the same technique or by the use of a GIA stapler. Certain may also defects be closed using a TA stapler. The staple line may be protected with a seromuscular closure using nonabsorbable Care must sutures. be taken to avoid stenosis in the gastroesophageal and pyloric area. A pyloric wound may be converted to a pyloroplasty avoid possible stenosis in this area. Extensive wounds (grade IV) to be mayso destructive that a proximal or distal gastrectomy is Reconstruction with either a Billroth I or II anastomosis is required. by the dictatedpresence or absence of an associated duodenal injury. In cases, rare a total gastrectomy and a Roux-en-Y esophojejunostomy are necessary for severe injuries (grade V). If a diaphragm injury occurs in association with a gastric foration, contamination of pleural cavity with gastric contents perbe canproblematic. 9 Under most circumstances, it is suffi cient to the pleural space clear through the diaphragmatic rent after closure the of gastric perforation. It may be necessary to enlarge the phragmatic injury to achieve complete evacuation of the diacontamination. After surgical repair of the stomach, the pleural phragm injury is closed, and a chest tube is placed. diathe contamination may be so severe, particularly if operation Occasionally, delayed, that a separate thoracotomy to provide adequate drainage is of the pleural space is necessary. Thoracoscopic evacuation of gastric contamination of the pleural space followed by chest the placement is another tube option.

contribute to the development of intra-abdominal abscess Intra-abdominal contamination is often signifi cantly greater formation. blunt after gastric After injury. penetrating trauma, the incidence of intra-abdominal abscess formation and surgical site infection is similarly low for both gastric isolatedand colonic injury. The low incidence of intra-abdominal scess ab- formation with either isolated stomach or colon injury dramatically when concomitant injuries to the liver, kidney, increases or duodenum are present. 10 ,1 1 There is even a greater synergistic effect pancreas, on intra-abdominal abscess formation with combined stomach colon and injuries. The risk of empyema increases signifi cantly when is a therediaphragm injury in association with penetrating injuries to stomach. Bleeding can occur from the surgical site or gastric the line, suture and may require reoperation. Occasionally suture line may be bleeding controlled using endoscopic techniques. In the rare of gastric injuries that require resection and anastomosis, instances stenosis require anastomotic may revision.

CONCLUSIONMost gastric injuries require debridement and closure. On rare currences more complex procedures, including gastric resection ocanastomosis, are required. Shock and associated injuries dictate and all overoutcome.

MORTALITYMortality after gastric injury is related to the mechanism of and the injury presence of shock and transfusion requirements, as well as the number of associated injuries. The mortality associated blunt with gastric rupture has been reported to range from 0% to 66% and averages around 30%. 4 8 Associated intra- and extra-abdominal injuries are usually present. The intra-abdominal organs most quently injured include the spleen, liver, small bowel, and freThe most frequent extra-abdominal injuries include chest, pancreas. and head. extremity, Hemorrhagic shock and complications related to the sociated injuries account for the vast majority of asdeaths. overall mortality rate for penetrating gastric injuries The 14%20%.1 3 Early deaths are related to irreversible is shock from associated injuries. Mortality increases dramatically hemorrhagic the with number of organs injured. The most common associated include injuries the liver, diaphragm, colon, lung, and small bowel. Injuries the to spleen, pancreas, and major blood vessels in the abdomen are also common. Mortality after either penetrating or blunt gastric rarely injury is the result of injury to the stomach. When it occurs, it is lated re- to anastomotic dehiscence, abscess or fi stula formation, and subsequent organ failure.

RE F E R E N

C ES

Major morbidity after gastric injury includes intra-abdominal formation, abscess bleeding, anastomotic breakdown, and empyema formation 3 ,6 The severity of gastric injury and degree of . contamination

MORBIDIT Y

1. Nicholas JM, Parker Rix E, Esley KA, et al: Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the J Trauma55:10951110, 2003. same. 2. Durham RM, Olson S, Weigelt JA: Penetrating injuries to the stomach. Gynecol Obstet 172:298302, 1991. Surg 3. Coimbra R, Pinto MCC, Aguir JR, Rasslan S: Factors related to the occurrence of postoperative complications following penetrating gastric inju- Injury26:463466, 1995. ries 4. . Watts DD, Fakry SM: EAST Multi-Institutional Hollow Viscus Injury Re- Group. Incidence of hollow viscus injury in blunt trauma: an search analysis from 275,557 trauma admissions from the EAST multiinstitutional trial J Trauma54:289294, 2003. . 5. Shinkawa H, Yasuhara H, Nika S, et al: Characteristic features of bdominal organ injuries associated with gastric rupture in blunt abdominal Am J187:394397, 2004. trauma. Surg 6. Bruscagin V, Coimbra R, Rasslan S, et al: Blunt gastric injury: a multicentre Injury 32:761764, 2001. experience. 7. Nanji SA, Mock C: Gastric rupture resulting from blunt abdominal trauma and requiring gastric J Trauma47:410412, 1999. 8. resection. RR, Simon RJ, Stahl WM: A critical evaluation of Ivatury laparoscopy in penetrating abdominal J Trauma34:827828, 1993. trauma. 9. Zellweger R, Navsaria PH, Hess F, Omoshoro-Jones J, Kahn D, Nicol A: Transdiaphragmatic pleural lavage in penetrating thoracoabdominal trauma. Br J Surg91:16191623, 2004. 10. Croce MA, Fabian TC, Patton JH, et al: Impact of stomach and colon injuries on intraabdominal abscess and the synergistic effect of hemor- and rhage associated J Trauma45:649655, 1998. 11. injury. PA, Kirton OC, Dresner LS, Tortella B, Kestner MM: ONeill Analysis colon injuries in patients with penetrating abdominal trauma: 162 of concomitant stomach injury results in a higher rate of J Trauma infection. 56:304313, 2004.

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