1. Duodenal Injuries
Taichiro Tsunoyama

2. Introduction Duodenal injuries are uncommon
Incidence of blunt duodenal injury;0.2%
Penetrating(78%) wounds are more common than
blunt(22%)
Duodenal injuries are both difficult to diagnose and
repair due to its retroperitoneal location

3. Duodenal Anatomy First portion of the small intestine
From the plyoric ring to the Treitz ligament
25-30 cm in length, Latin word duodeni (twelve each)
Divided into 4 portions

4. Divided into 4 portions 1st: Superior 2nd: Descending 3rd: Transverse
Pass backword and upward toword the neck of the gallbladder
Most of portion is intraperitoneal
2nd: Descending
Contain the bile and panceatic duct(Ampulaa of Vater)
Entirely retroperitoneal
3rd: Transverse
SMA runs downward over the 3rd portion
4th: Ascending
Short distance(2-3cm), suspensory ligament of Treitz

6. Blood Supply Derived from the pancreatioduodenal artery
Superior branch; from hepatic artery
Inferior branch; from SMA
Drain into the portal vain and SMV

9. Physiology
Duodenum is the portion of the bowel where the stomach contents are mixed with biliary and pancreatic secretions for digestion
Contains food as well as powerful digestive enzymes
About 5L of fluid passes through the duodenum a day
Massive flow volume
gastric juice ml
bile ml
pancreatic juice 800ml
saliva ml

10. Mechanism of Injury Most injuries are penetrating in nature
Blunt injuries account for approx 25%

11. Blunt Injury Crush Shear Burst
Occur with a direct force applied to the abdominal wall, transferred to the duodenum which is pushed posteriorly against the spinal column
Shear
Occur when the mobile and nonfixed portions of the organ accelerate and decelerate forward and backward respectively
Burst
Force is applied to a gas and fluid-filled filled duodenum against a closed pylorus and acutely flexed duodenojejunal angle
Blunt Injury

12. Anatomic location of duodenal injury (blunt and penetrating)
1st %
2nd %
3rd %
4th %
Multiple 14.2%
Asensio J management of duodenal injuries
Cur-r Probl Surg, November 1993

13. Associated Injuries Organs most commonly injured in association:
Liver %
Pancreas %
Small bowel %
Colon %
Venous Injuries 9.8%
Stomach %
Biliary tree and Gallbladder 6.8%
Arterial Injuries 6.6%
Asensio J management of duodenal injuries
Cur-r Probl Surg, November 1993

14. Outcome Directly attributable duodenal mortality; 2-5%,6-29%
Morbidity rates;30-63%
Reason for the variability
mechanism of injury
associated injury
time to initial diagnosis

15. Outcome Early death(particularly with penetrating injury)
Exsanguination from associated vascular, liver or spleen
Complication
Anastomotic breakdown
fistula
intra-abdominal abscess
sepsis
MOF

16. Time from injury to the definitive treatment
Delay in diagnosis >12hr; 53 % of their patients
Delay in diagnosis >24hr; 28 % of their patients
Mortality
40%; the patients who diagnosed over 24hr
11%; the patients who underwent surgery within 24hr
Lucos C,Ledgerwood A: Factor influencing outcome after blunt duodenal injury. J Trauma 15(10): ,1975

17. Important steps for duodenal injury
Early diagnosis
Control of hemorrhage
Control of bacterial contamination

18. Diagnosis Requires a high index of suspicion Accurate H&P
More difficult to diagnose in blunt trauma than penetrating
As penetrating injuries tend to necessitate an operative exploration
No specific diagnostic test found to be accurate all of the time
Abdominal X-rays
UGI
Endoscopy
CT Scan

19. Abdominal X-Ray Often quite subtle
Air collections outlining right kidney
Presence of gas around the right psoas muscle

20. Diagnosis Upper GI Series Usually with Gastrograffin or thin barium
May see a leak with fluoroscopy
Consider changing position for oblique or lateral views to get a 3D picture
Endoscopy
May visualize a intra-luminal blood, a perforation or a hematoma directly
May be considered in conjunction with UGI or CT
Not usually used acutely due to the possibility of worsening injury with either the scope or the insufflation

21. CT Scan Must be performed with both oral and intravenous contrast
Best method for visualizing retroperitoneal structures without an operation
Helpful in evaluating the remaining intra-abdominal cavity in stable patients
Not always very sensitive
Extravasation of oral contrast from the duodenum with a retroperitoneal hematoma
Extraluminal gas/fluid around the duodenum
Focal bowel wall thickening
Interruption of progress of the bowel contrast medium

23. S. Prichayudh et al. Successful management of large intramural duodenal haematoma causing obstructive jaundice /j.injury

24. DPL
Unreliable in detecting isolated duodenal and other retroperitoneal injuries
But DPL is often helpful because of 40% of patients have associated intra-abdominal injuries that will result in a positive DPL
The finding of amylase or bile are more specific indicators of possible duodenal injury

25. Exploratory Laparotomy
Midline incision
Immediate control of life-threatening hemorrhage
Control of GI contamination
Thorough exploration of the abdominal cavity and retroperitoneum

26. Operative Exposure of Duodenal Injuries
Intra-op findings that require exploration
Crepitus along the duodenal sweep
Bile staining of paraduodenal or adjacent tissues
Documented bile leak
Right-sided retroperitoneal or periduodenal hematoma

27. Operative Exposure of Duodenal Injuries
Thorough exploration requires evaluation of all 4 portions
Kocher Maneuver
Transection of the ligament of Treitz
Cattell and Braasch maneuver

28. Kocher Maneuver
Should be able to palpate the head of the pancreas to the level of the mesenteric vessels
Be able to visualize the anterior and posterior aspects of the 2nd and 3rd portions of the duodenum, the head of the pancreas and the infrarenal IVC

29. Kocher Maneuver

30. Cattell & Braasch Maneuver
Technique for exposure of 3rd and 4th portion of the duodenum
Incise the avascular line of Toldt
Mobilize the asending colon and the hepatic flexure
Sharply incise the retroperitoneal attachments of the Small bowel from the RLQ to the duodenojejunal junction
Reflect the Small bowel out of the abdominal cavity
Gives excellent exposure, however it is a somewhat complex maneuver that may not be required

31. Cattell & Braasch Maneuver

32. Divide ligament of Treitz
Exposure of the entire fourth portion of the duodenum and the duodenojejunal junction

33. Duodenum Organ Injury Scale

34. Non operative NG tube Surgical evacuation and seromuscular repair
Grade 1 or 2 hematoma
Non operative
NG tube
Surgical evacuation and seromuscular repair

35. Grade 1 or 2 laceration
Duodenorrhaphy

36. Duodenorrhaphy Used to repair approximately 75-85% of all injuries
Debride nonviable tissue
Double layer closure
Close longitudinal injuries transversely if less than 50% of the duodenal circumference to avoid duodenal narrowing
Consider placing omentum over your repair

37. Duodenorrhaphy

38. Grade 3 or 4 laceration Primary repair(with Tube Duodenostomy)
Resection anastomosis
Roux-en-Y duodenojejunostomy
Pyloric Exclusion

39. Synder Duodenal severity scale
Mild
Severe
Agent
Stab
Blunt or missile
Size
<75%wall
≥75%wall
Duodenal site
3,4
1,2
Injury repair interval
<24
≥24
Adjacent injury
No CBD
CBD
No pancreatic injury
Pancreatic injury
Protection of the duodenalrepair is not necessary in the mild group

40. Duodenorrhaphy with Tube Duodenostomy
“protecting the repair” with decompression maneuvers
1. Primary
Tube is placed through a separate stab incision in the duodenum
2. Antegrade
Duodenum is decompressed by passage of a tube through the pylorus
3. Retrograde
Tube is passed retrograde from insertion in the jejunum

41. Duodenorrhaphy with Tube Duodenostomy

42. Pyloric Exclusion
An alternative to duodenal diverticulization
Secures exclusion of the duodenal suture line and diversion of the gastric contents
Through the gastrotomy, the pylorus is closed using absorbable suture
Alternative method includes using a stapler across the pylorus (TA-50)

43. Pyloric Exclusion

44. Seamon MJ
A ten-year retrospective review: does pyloric exclusion improve clinical outcome after penetrating duodenal and combined pancreaticoduodenal injuries?
J Trauma Apr;62(4):
Barone JE,
Pyloric exclusion leads to a trend toward more complications, a higher pancreatic fistula rate, and a longer hospital length of stay.
J Trauma Sep;63(3):720
DuBose JJ, Demetriades D
Pyloric exclusion in the treatment of severe duodenal injuries: results from the National Trauma Data Bank.
Am Surg Oct;74(10):925-9

45. Jejunal Serosal Patch
The serosa of a loop of jejunum is sutured to the edge of the duodenal defect
The serosa exposed to the duodenal lumen rapidly undergoes complete mucosal resurfacing.

46. Jejunal Serosal Patch

47. Duodenal Resection
If nearly the entire circumference of the duodenum is devitalized, a segmental resection with an end-to-end duodenostomy may be performed
If it is not possible to mobilize the duodenum without tension, a Roux-en-Y duodenojejunostomy can be performed with the distal duodenum oversewn.

48. Duodenal Resection

49. Duodenal Diverticulization
Originally described by Berne in 1968
The concept is to completely divert both gastric and biliary contents
antrectomy,
debridement and repair of the duodenum
tube duodenostomy
vagotomy
biliary tract drainage(T-tube)
feeding jejunostomy tube
Procedure is very time-consuming and may or may not require all of the steps

50. Duodenal Diverticulization

51. Grade 5 duodenal injury Duodenal devascularization Whipple for Trauma
Massive disruption of duodeopancreatic complex
Duodenal devascularization
Whipple for Trauma

52. Whipple for Trauma Performed as a staged procedure
Control of hemorrhage, resection debridement in the initial laparotomy
stapler resection of the duodenal sweep and pancreatic head,
ligation of the common bile duct at pancreatic head
Resuscitation in the ICU
Gastrointestinal reconstruction with pancreatic remnant anastomosis and choledochojejunal anastomosis

53. Pancreaticoduodenectomy: A Rare Procedure for the Management of ComplexPancreaticoduodenal Injuries Juan A Asensio, MD
18 patients (retrospective 126-month study)
17 penetrating (94%) / 1 blunt (6%)
Indications
massive uncontrollable retropancreatic hemorrhage
13 patients (72%)
massive unreconstructable injury to
the head of thepancreas/main pancreatic duct intrapancreatic
portion/distal common bile duct
18 patients (100%)
Overall survival was 67% (12 of 18 patients)

54. Pancresaticojejunosotmy
Nonabsorbable interrupted sutures should be used to sew the mucosa of the jejunum to the pancreatic capsule
A second layer of nonabsorbable sutures is added