1. Niqui Kiffin, M.D. Operative Skills Conference 17 November 2009
Duodenal Injuries
Niqui Kiffin, M.D.
Operative Skills Conference
17 November 2009

2. Introduction
Duodenal injuries are both difficult to diagnose and repair due to its retroperitoneal location, close association with the biliary tract and pancreas, as well as its marginal blood supply
Injuries are fairly uncommon – approx 3-5% incidence
Almost always occur with associated injuries to vascular structures or nearby organs
Injury must be suspected and acted upon early due to significantly increased morbidity and mortality with delayed diagnosis

3. Duodenal Anatomy Small, thin-walled organ
Constitutes the beginning of the SB
Approx 21cm
Starts just distal to the pylorus

4. Duodenal Anatomy Divided into 4 portions:
1st: Superior – Ranges from the pyloric vein of Mayo to the CBD
2nd: Descending – Extends from the CBD and the GDA to the Ampulla of Vater
3rd: Transverse – Extends from the Ampulla of Vater to the mesenteric vessels
4th: Ascending – Extends from the mesenteric vessels to the ligament of Treitz
Entry is closed by the pyloric sphincter
Exit is suspended by the ligament of Treitz
Organ is almost entirely retroperitoneal
With the exception of the 1st portion and the convergence of the 3rd to the 4th portion

5. Blood Supply Shares the blood supply with the pancreas
Arterial supply includes the GDA, retroduodenal artery, supraduodenal artery, the superior pancreaticoduodenal artery, the SMA and the inferior pancreaticoduodenal artery
Multiple variations are common in this region

6. Surrounding Anatomy
Portions of the duodenum lie directly over the spine (1st,distal 3rd, and 4th)
Psoas muscles, aorta, IVC, and R kidney form the posterior boundaries
Anterior organs include liver, hepatic flexure of colon, R transverse colon, mesocolon, and stomach
Gallbladder is located laterally and the pancreas is found medially

7. Additional Anatomy
CBD enters the posterior aspect of the pancreas after it passes underneath the duodenum (83%).
It enters the gland, courses within the pancreatic tissue, and enters the duodenal lumen at the junction between the 2nd and 3rd portion.

8. Physiology
Duodenum is the portion of the bowel where the stomach contents are mixed with biliary and pancreatic secretions for digestion, therefore it contains food as well as powerful digestive enzymes
Approx 10L of fluid passes through the duodenum a day
The high volume, as well as the caustic nature of the secretions, combine to cause the disastrous complications associated with duodenal injury.

9. Mechanism of Injury Most injuries are penetrating in nature
GSW SW
Shotgun
Blunt injuries account for approx 25%
MVC
Steering wheel
Bicycle handlebars (pediatrics)
Fall

10. Mechanism of Injury Blunt Injury (con’t) 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
“Closed-loop” effect is established periodically throughout the day as the pylorus is closed approximately 1/3 of the day

11. Associated Injuries Organs most commonly injured in association: Liver
Pancreas SB
Colon
Venous Injuries
Stomach
Arterial Injuries

12. 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

13. Diagnosis History & Physical History Physical Mechanism of injury
Deceleration injury (fall, head-on MVC, right-sided impact)
Details from the field
Vital signs
Crushed steering wheel
Impact to the epigastrium
Physical
Peritoneal signs usually not present unless retroperitoneum violated
May be characterized by minimal findings
Unless diagnosis delayed

14. Abdominal X-Ray Air collections outlining R kidney
Presence of gas around the R psoas muscle
Usually do not present with free intraperitoneal air

15. Diagnosis Upper GI Series Endoscopy
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

16. Diagnosis
CT Scan
Best method for visualizing retroperitoneal structures without an operation
Also very 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 – OR
Extraluminal gas/fluid around the duodenum/focal bowel wall thickening/interruption of progress of the bowel contrast medium –May be inconclusive
May be combined with UGI, endoscopy, or OR for conclusive diagnosis

17. CT Abdomen/Pelvis

18. Surgical Exposure

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

20. 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

21. 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

22. Kocher Maneuver
Incise the lateral peritoneal attachments of the duodenum
Sweep the 2nd and 3rd portions medially using blunt and sharp dissection
Use gentle traction
Be mindful not to cause iatrogenic injury to the duodenum

23. Kocher Maneuver
Surgeon should be able to palpate the head of the pancreas to the level of the mesenteric vessels
Surgeon will 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
Be mindful of the R gonad vessel

24. Kocher Maneuver

25. Transection of the Ligament of Treitz
Transect the ligament of Treitz to visualize the 4th portion of the duodenum
Use sharp dissection
ID and preserve the inferior mesenteric vein
Rotate the duodenum laterally from right to left
Can visualize the 3rd (anteriorly) and 4th portion
Can palpate the 3rd portion posteriorly

26. Cattell & Braasch Maneuver
Incise the avascular line of Toldt
Mobilize the R colon and the hepatic flexure
Sharply incise the retroperitoneal attachments of the SB from the RLQ to the duodenojejunal junction
Reflect the SB out of the abdominal cavity
Gives excellent exposure, however it is a somewhat complex maneuver that may not be required

27. Cattell & Braasch Maneuver

28. Techniques for
Duodenal Repair

29. Duodenum Organ Injury Scale

30. Duodenal Repair Options
Duodenorrhaphy
Duodenorrhaphy with external drainage
Duodenorrhaphy with tube duodenostomy
Primary
Antegrade
Retrograde
Triple ostomy technique
Jejunal serosal patch
Pedicled Graft
Duodenal Resection
Duodenal Diverticulization
Pyloric exclusion
Whipple procedure

32. Duodenorrhaphy Used to repair approximately 75-85% of all injuries
Debride nonviable tissue
Meticulous double layer closure
Closely reapproximate the mucosal layer with absorbable suture
Interrupted seromuscular layer with nonabsorbable suture – Lembert sutures
Close longitudinal injuries transversely if less than 50% of the duodenal circumference to avoid duodenal narrowing
Consider placing omentum over your repair
External drainage is surgeon’s prerogative
Do not place directly over the repair

33. Duodenorrhaphy

34. Duodenorrhaphy with Tube Duodenostomy
With more complex injuries, some surgeons have advocated “protecting the repair” with decompression maneuvers
Primary
Tube is placed through a separate stab incision in the duodenum
Antegrade
Duodenum is decompressed by passage of a tube through the pylorus
Retrograde
Tube is passed retrograde from insertion in the jejunum

35. Duodenorrhaphy with Tube Duodenostomy
The use of tube duodenostomy is very controversial
Studies have shown conflicting results
Some advocate decompression of duodenum, however many surgeons are not comfortable placing additional holes in the GI tract

36. Duodenorrhaphy with Tube Duodenostomy

37. Jejunal Serosal Patch Described by Kobbold and Thal
Resected areas of duodenal wall in dogs (1.5 x 3cm)
Injuries were repaired by sewing the serosa of a loop of jejunum to the edges of the duodenal defect
After the animals were sacrificed, a histologic study showed mucosal resurfacing of the jejunal serosa
Since then, this technique has been used on human patients using a patch from a Roux-en-Y limb.
Some surgeons have criticized the idea of making an additional suture line

38. Jejunal Serosal Patch

39. Pedicled Graft
First described by Jones and Joergenson, later modified by DeShazo
Patch is constructed by using a proximal segment of jejunum, which is carried up in a retrocolic location on its vascular pedicle.
Antimesenteric border is then split longitudinally and anastomosed using a double-layer technique to the duodenal defect.
This technique has also been described using pedicle flaps from stomach (gastric island flaps) or the ileum. Blood supply is based on the gastroepiploic vessels.

40. Pedicled Graft

41. Duodenal Resection
If nearly the entire circumference of the duodenum is devitalized, a segmental resection with an end-to-end duodenostomy may be performed
Rate-limiting step may be mobilization of the 2nd portion of the duodenum
In cases where the injury is adjacent to the ampulla of Vater, extreme care must be taken
Consider performing a choledochostomy with passage of a probe in order to be certain of the exact location of the ampulla
Cases have been documented where re-implantation of the ampulla or the CBD were necessary
If it is not possible to mobilize the duodenum without tension, a Roux-en-Y duodenojejunostomy can be performed with the distal duodenum oversewn.

42. Duodenal Resection

43. Grade III/IV Injuries
Certain injuries are severe enough to require an extended repair
Grade III or IV duodenal injuries
Compromised blood supply to the duodenum
Associated pancreatic injury without injury to the main pancreatic duct
Delayed diagnosis
Injury to 1st or 2nd portion
The following procedures exclude the duodenum from the passage of gastric contents to allow time for the duodenum to heal and to prevent suture line dehiscence
Duodenal diverticulization
Pyloric Exclusion
Should be noted that these procedures can only be performed if the injury is amenable to primary repair

44. Duodenal Diverticulization
Originally described by Berne in 1968
Concept had first been described in 1907, however this technique did not include the entire process
Technique was prompted by the unacceptably high complication rate associated with combined duodenal/pancreatic injuries
Procedure includes antrectomy, debridement and repair of the duodenum, tube duodenostomy, vagotomy, biliary tract drainage, and a feeding jejunostomy tube
Procedure is very time-consuming and may or may not require all of the steps

45. Duodenal Diverticulization

46. Pyloric Exclusion An alternative to duodenal diverticulization
Secures exclusion of the duodenal suture line and diversion of the gastric contents
Procedure entails a duodenorrhaphy plus a gastrotomy
Through the gastrotomy the pylorus is closed using absorbable suture
Ideally the suture breaks down over a few weeks and the pylorus opens up
Then a gastrojejunostomy is performed using the gastrotomy site
Alternative method includes using a stapler across the pylorus

47. Pyloric Exclusion

48. Whipple Procedure
Whipple Procedure aka Pancreaticoduodenectomy may be required for severe duodenal injuries that involve the main pancreatic duct and the CBD or ampulla
Indications include:
Massive, uncontrollable bleeding from the HOP or adjacent vascular structures
Massive and unreconstructable injury to the main pancreatic duct in the head
Combined unreconstructable injuries of:
Duodenum and HOP
Duodenum, HOP, and CBD
Almost never performed during the 1st operation
Approximately 30-40% mortality rate with patients that require trauma Whipple

49. Whipple Procedure

50. Conclusion
Duodenal injuries are fairly uncommon, however they may be devastating when they occur
Average mortality is 17%
Increases with delayed diagnosis
Most duodenal injuries can be repaired with simple repair, however all trauma surgeons should have a few techniques in their armamentarium for more severe injuries

51. References…
Asensio JA, Demetriades D, Berne JD, et al. A Unified Approach to the Surgical Exposure of the Pancreatic and Duodenal Injuries. The American journal of Surgery Vol 174: 1997;
Asensio JA, Feliciano DV, Britt LD, et al. Management of Duodenal Injuries. Current Problems in Surgery Vol 30, No 11: 1993;
Britt, LD. Duodenal Primary repair, Diversion, and Exclusion. Operative Techniques in General Surgery Vol 2, No 3: 2000;
Feliciano DV, Mattox KL, Moore EE, et al. Duodenum and Pancreas. Trauma 6th ed: 2008; CH 35.