Trauma: Duodenum Trauma

Duodenum Trauma

General

  • Difficult Due to Complex Anatomical & Physiologic Relationships
  • Delay in Diagnosis is a Significant Factor in Morbidity & Mortality (4x Risk)
  • Morbidity Rate: 22-27%
  • Mortality Rate: 5-30%

Etiology

  • Rare: Only 3.7-5% of All Abdominal Injuries
  • Penetrating Trauma Most Common (77.7%)
    • 81% Gunshot Wounds
    • 19% Stab Wounds
  • Blunt Trauma (22.3%)
    • 85% Motor Vehicle Collisions

Presentation

  • Mostly Nonspecific
  • Abdominal Pain, Can Radiate to the Back
  • Chest Pain
  • Nausea & Vomiting
  • Hematemesis

Location

  • First Portion: 13%
  • Second Portion: 36% – Most Common
  • Third Portion: 18%
  • Fourth Portion: 15%
  • Multiple Portions: 18%

Duodenum D1 Transection 1

AAST Duodenum Injury Scale

Complications

  • Duodenal Leak/Fistula – Major Source of Morbidity
    • Tx: Conservative (NPO/NGT/TPN) & Octreotide
  • Missed Injury
  • Intraabdominal Abscess
  • Duodenal Obstruction
  • Recurrent Pancreatitis
  • Bleeding

Duodenum Trauma – Treatment

Surgical Access

  • Kocher Maneuver: Access D1, D2 & Proximal D3
  • Cattel-Braasch Maneuver: Access Entire Duodenum (Including Distal D3 & D4)

Primary Repair

  • Primary Repair is Generally the Preferred Treatment for Most Duodenal Injuries
  • Successful for 70-85% of Injuries (Even with Full Transection)
  • Requires: Little Tissue Loss with No Tension & No Involvement of Ampulla
  • Considerations:
    • Nasogastric Tube to Protect Repair
    • Extraluminal Drain – Use is Debated with No Level I Evidence
      • Possible Increased Risk for Duodenal Leak
  • Severe or Concurrent Pancreatic Injury: Pyloric Exclusion with Gastrojejunostomy
    • Pyloric Exclusion (PEX) – Gastrotomy & Closure of the Pylorus Using Absorbable Suture (Vicryl or PDS)
    • After 4-12 Weeks Gastrojejunostomy Closes and Pylorus Reopens
    • Risk for Marginal Ulcer (Some Add Truncal Vagotomy, Most Manage Medically)

Pyloric Exclusion 2

If Primary Repair Not Feasible

  • Under Tension or Involves Ampulla: Roux-en-Y Duodeno-Jejunostomy
    • Jejunal Limb Anastomosis to the Proximal Duodenum & Oversewing of Distal Duodenum
  • Massive Injury Involving Head of Pancreas: Pancreaticoduodenectomy (Whipple Procedure)
    • Not Done in an Emergent Setting
    • Wide Drainage at Index Operation & Definitive Repair Upon Medical Stabilization

Historical Options Fallen Out of Favor

  • Jejunal Serosal Patch
    • Less Desirable than Roux-en-Y
  • Retrograde Jejunostomy
    • For Duodenal Decompression
  • Duodenal Diverticularization
    • Procedure: Primary Repair, Antrectomy & Gastrojejunostomy
    • Creates a Permanent Bypass of the Repair
    • May Add Tube Duodenostomy for Decompression
  • Triple-Ostomy Repair
    • Procedure: Gastrostomy, Duodenostomy & Feeding Jejunostomy
  • Triple-Tube Repair
    • Procedure: Primary Repair with NG Tube, Feeding Jejunostomy & Retrograde Jejunostomy

Paraduodenal Hematoma

Presentation

  • Most Common in Peds After Play or Abuse
    • Can Be Spontaneous with Hemophilia
  • Can Cause Obstruction

Diagnosis

  • Dx: CT or UGI
  • “Stacked Coins” or “Coiled Spring” Sign

Treatment

  • On CT: Conservative (NPO & Serial Exams)
    • If Obstructs: NGT, TPN & UGI Every 5-7 Days
    • If > 2-3 Weeks: Operative Evacuation
  • Intra-Op: Mostly Conservative
    • Kocher & Thoroughly Inspect for Perforation
    • Hematoma Evacuation Indications:
      • High Suspicion for Full-Thickness Injury
      • > 50% Luminal Narrowing

Duodenal Hematoma 3

Duodenal Hematoma 3

References

  1. Smiley K, Wright T, Skinner S, Iocono JA, Draus JM. Primary Closure without Diversion in Management of Operative Blunt Duodenal Trauma in Children. ISRN Pediatr. 2012;2012:298753. (License: CC BY-3.0)
  2. Pierro AC, Mantovani M, Reis NS, Morandin RC, Fraga GP. Tratamento do trauma duodenal complexo: comparação entre sutura simples e sutura associada à exclusão pilórica e gastrojejunostomia em cães. Acta Cir Bras. [serial online] 2005 Jan- Fev;20(1). (License: CC BY-4.0)
  3. Nolan GJ, Bendinelli C, Gani J. Laparoscopic drainage of an intramural duodenal haematoma: a novel technique and review of the literature. World J Emerg Surg. 2011 Dec 20;6(1):42. (License: CC BY-2.0)