1. Management of Duodenal Trauma
Dr. Chow Chi Woo Samuel
Department of Surgery, Queen Elizabeth Hospital

2. Introduction Duodenal trauma is uncommon D2 most common (35%)
3-5%
D2 most common (35%)
> D3 > D4 > D1
Penetrating trauma (78%)
Gunshot wounds
Stab wounds
Blunt trauma (22%)
Motor vehicle collisions
Steering wheel
Seatbelt
Bicycle handle (paediatrics)
Duodenal trauma is uncommon
According to literature, it is found in 3-5% of abdominal traumas
D2 is most commonly involved and constitutes 1/3 of the duodenal injuries, followed by D3, D4 and D1 They are most caused by penetrating injuries while blunt injuries are less common
Associated injuries are common, esp those related to the pancreas, bile ducts, liver and bowel (usually 1-4 more organs injured)
Morbidity is up at 40% and the rate of duodenal fistula (one of the most important morbidities) is around 7%
Mortality is as high at 17%

3. Introduction Associated injuries are common High mortality (17%)
Liver
Pancreas
Bowel
Major vessels
High mortality (17%)
High morbidity (40%)
Duodenal fistula (7%)

4. Intra-operative features
Diagnosis
High index of suspicion
Symptoms/signs usually not helpful
Blunt trauma
Radiological Imaging
1. X-ray
2. CT scan
(IV + oral contrast)
3. Fluoroscopy
Penetrating trauma
Intra-operative features
1. Bile staining at retroperitoneum
2. Periduodenal hematoma
3. Periduodenal crepitus
The diagnosis of duodenal trauma remains a challenge and requires a high index of suspicion
Symptoms/signs are usually non-specific/minimal and not helpful
Relevant trauma history, positive radiological findings and positive intra-operative features offer important clues to help diagnose duodenal trauma
For history,
Penetrating injuries are usually a result of gunshot or stab wounds
Blunt injuries are usually found in motor vehicle accidents in which the abdomen collides with the steering wheel or bicycle handle injuries in children
Occasionally, they can also be a result of fist injuries
For imaging, XR, CT and fluroscopy are important investigations for blunt duodenal trauma. CT is the modality of choice, although it can still miss injuries, up to 20% in 1 series
Intra-operative features are the mainstay of evaluation for penetrating trauma and offer the ultimate clue for diagnosis. Positive features include bile staining of the retroperitoneum and the presence of periduodenal hematoma/ entrapped air bubbles

5. These are some CTs taken for patients with duodenal trauma
The left one shows transection of D3
The upper right one shows perforation of the lateral D2 wall with persence of periduodeanl gas
The lower right one shows periduodeanl gas with extravasation of oral contrast

7. Management Patient factors Disease factors 1. Hemodynamic stability
1. Severity of injury
2. Associated injuries
Now that we have an idea of how to diagnose duodenal trauma
how do we manage it
Back to basics
The management of duodenal trauma (like all other conditions) depends on patient factors and disease factors
For patient factors, the hemodynamic status is very important, as I will further elaborate later
For disease factors, the severity of injury and the presence of associated injuries have a signfiicant impact on management

8. Grading of Severity
Duodenum Organ Injury Scale (OIS) according to The American Association for the Surgery of Trauma (AAST)
Grade
Description I
Hematoma
Laceration
1 portion of duodenum
Partial thickness, no perforation II
>1 portion of duodenum
< 50% of circumference
III
50-75% of circumference of D2
50-100% of circumference of D1, 3, 4 IV
>75% of circumference of D2
Involve ampulla or distal CBD V
Vascular
Duodenopancreatic complex
Devascularization of duodenum
With regards to the severity of duodeanl injuries
One of the most commonly used grading systems is the duodenum organ injury scale devised by the American Association for the Surgery of Trauma
There are 5 gradings (I being mildest and V being most severe). The grading system is based on the nature of the duodenal injury, the extent of injury, the location of injury and the presence of invovlement of the biliary/pancreatic system
Another grading system is the duodenal severity scale, which can be divided into and mild and severe and also takes into account the time interval from injury to repair.

9. Temporary abdominal closure
Damage control
Control hemorrhage
Provisional repair
Temporary abdominal closure
ICU resuscitation
Unstable
Operative
Hemodynamic stability is one of the most important parameters in guiding management
Unstable patients (shock), should be brough to the operating theatre as soon as possible and damage control surgery should be done.
After stabilization, delayed repair should follow
Delayed repair

10. Stable 1. Hemorrhage control 2. Decontamination 3. Repair
In stable patients, the story is completely different
For penetrating injuries, they should be brought to the operating theatre for hemorrhage control, decontamination and repair
For blunt injuries, they should get a CT scan. If the CT scan shows an intramural hematoma, non-operative treatment should be established with NG tube suction and TPN, However, if the CT scan shows findings suggestive of a perforation, operative treatment should be adopted.
If the CT scan shows equivocal findings, operative treatment or re-evaluation CT should be done, depending on degree of suspicion
----- Meeting Notes (21/4/16 14:26) -----
colour scheme
Perforation
1. Hemorrhage control
2. Decontamination
3. Repair
* Associated injuries
Penetrating
Operative

11. Intramural hematoma Non-operative Blunt CT scan Equivocal Perforation
Stable
In stable patients, the story is completely different
For penetrating injuries, they should be brought to the operating theatre for hemorrhage control, decontamination and repair
For blunt injuries, they should get a CT scan. If the CT scan shows an intramural hematoma, non-operative treatment should be established with NG tube suction and TPN, However, if the CT scan shows findings suggestive of a perforation, operative treatment should be adopted.
If the CT scan shows equivocal findings, operative treatment or re-evaluation CT should be done, depending on degree of suspicion
----- Meeting Notes (21/4/16 14:26) -----
colour scheme
Perforation
1. Hemorrhage control
2. Decontamination
3. Repair
* Associated injuries
Operative

12. Repair Simple Complex Aim Always ascertain location of ampulla (D2)
Close the defect
Restore continuity
Always ascertain location of ampulla (D2)
Options
Duodenorrhaphy
Duodenorrhaphy + diversion
Duodenal resection + anastomosis
Jejunal serosal patch
Pedicled graft
Whipple operation
Simple
The aim of repair for duodenal trauma is to close the defect and restore intestinal continuity
Options from simple to complex includes duodenorrhaphy, duodenorrhpahy with diversion, duodenal resection and anastomosis, jejunal serosal patch in which the serosa of the jejunum is used to buttress the defect, pedicled graft in which a mesenteric border of a segment of jejunum with a vascular pedicle is use to patch up the defect, and Whipple operation, which is the last resort for severe duodenopancratic injuries and carries a very high mortality.
Complex

13. Duodenorrhaphy 75-85% of duodenal injuries Debride non-viable tissue
Tension-free repair
Single/double layer closure
Transverse closure
< 50% of circumference
Duodenorrhaphy is used to manage up to 85% of all duodenal injuries
It comprises adequate debridement of non-viable followed by tension free repair.
The defect is closed in single/double layer and ideally transversely to avoid stricture
Also, its best when the injuries are < 50% circumference
This cartoon shows how a longitudinal laceration is repaired in a transverse manner

15. Duodenorrhaphy + Diversion
Indication
High risk of suture line dehiscence
Delayed injury
Large defect
Combined injury
Aim
Divert gastric secretions
Promote healing
Options
Tube decompression
Pyloric exclusion
Duodenal diverticulization
Duodenorrhpahy with diversion is often used for to lesions at risk of suture line dehiscence
These include high grade injuries with large defects/combined duodenopancreatic injuries, as well as delayed injuries
The aim of diversion to exclude the duodenum from the passage of gastric contents rich in bile juice and pancreatic juice, thereby buying time for the duodenum to heal and to prevent suture line dehiscence
Options of diversion from simple to complex would include tube decompression, pyloric exlcusion and duodenal diverticulization
Simple
Complex

16. Tube decompression External diversion
Tube decompression is placement of an intraluminal tube for external diversion of gastric secretions
It can be primary in the duodenum as shown in the diagram, or antegrade in the stomach proximal to the repair, or retrograde in the jejunum distal to the repair
Triple ostomy technique is shown in the cartoon on the right, which shows a diversion gastrostomy, a diversion jejunostomy and a feeding jejunostomy. This technique was first described by stone and fabian in 1970s,

17. Pyloric exclusion Internal diversion
Pyloric exlcusion was first described by Jordan in 1970s
Operative steps include creating a gastrostomy, closing the pylorus via the gastrostomy with sutures/staple, and finally using the gastrostomy to build a side-to-side GJ
94% of the pylorus restores patency by 3 weeks time
It is a type of internal diversion in which gastric secretions are diverted through a GJ and the suture line is protected via a closed pylorus

18. Duodenal Resection + Anastomosis
Large duodenal defects (near-circumferential)
Duodenal transections
Segmental resection with end-to-end duodenostomy
Adequate mobilization, tension-free
Duodenal resection and anastomosis is suitable for large near-circumferential duodenal defects and duodenal transections
The specific type of repair depends on the location and the resultant tension of the suture ends
As a thumb of rule, if the duodenum can be mobilize adequately and the sutures ends are tension free, segmental resection with end to end duodenostomy can be done as shown in the cartoon on the upper right corner. This type of repair is applicable to lesions in D1, D3, D4
If the duodenum cannot be mobilized adequately and the sutures ends are at tension, the distal duodenum should be oversewn and the proximal duodenum should be used to form a Roux-en-Y end-to-end duodenojejunostomy as shown in the cartoon on the lower right corner. Alternatively a roux-en-Y side to side duodenojejunostomy can be done. This type of repair is applicable to lesions at D2, in which mobilization can be difficult and dangerous due to close proximity to the biliary/pancreatic system, thereby minimizing disruption of the biliary/pancreatic system

19. Closure of duodenal stump + end-to-end duodenojejunostomy
Antrectomy + closure of duodenal stump + side-to-side gastrojejunostomy
Inadequate mobilization
Proximal to ampulla
Closure of duodenal stump + end-to-end duodenojejunostomy
Distal to ampulla

20. Which repair is the best?
Now that we have a whole list of different types of repair
The question is which repair is the best?

21. Which repair is the best?
Low grade injuries
For the low grade injuries (Grade 1 and 2)
Duodenorrhaphy is a well-accepted safe modality of repair with low complication
Duodenorrhaphy

22. Which repair is the best?
High grade injuries
1. Involve CBD/pancreas
2. Devascularization
Repairable
Non-repairable
For high grade injuries
the picture is more complicatied
for repairable lesions, duodenorrhaphy with diversion or duodenorrhaphy can be done
for non-repairable lesions, duodenal resection with anastomosis, jejunosal serosal patch or pedicled graft can be done
for those lesions involving biliary/pancreatic system or devasculization injury, treatment is often very complicated. Possible options include duodenorrhaphy with diversion and wide drainage, reimplantation of CBD, reconstruction with HJ or in extreme cases whipple operation
1. Damage Control Surgery + delayed reconstruction
2. Duodenorrhaphy + diversion + wide drainage
Delayed reconstruction
1. Reimplantation of CBD
2. Hepaticojejunostomy
3. Whipple operation
1. Duodenorrhaphy + diversion
2. Duodenorrhaphy
1. Duodenal Resection + anastomosis
2. Jejunal serosal patch
3. Pedicled graft

23. High grade repairable injuries
Optimal repair remains debatable
Duodenorrhaphy + pyloric exclusion
Classically recommended (Vaughan, Degiannis, Cogbill)
Problems
Increased operative time and hospital stay, extra anastomosis, suture line ulcers
Role downplayed (Seamon)
Duodenorrhaphy + tube decompression
Controversial (Stone, Hasson, Ivatury, Girgin)
Increased hospital stay, dislodgement, obstruction
Duodenorrhaphy
Gaining popularity (DuBose, Velmahos, Siboni)
Concept of “less is better”
Duodenorrhaphy
Pyloric exclusion
For high grade repairable injuries
the optimal repair for high grade repairable injuries is a debatable topic
Duodenorrhaphy + pyloric exclusion is classically recommended by many authors including Vaughan who showed a low fistula rate (5%) in 75 patients treated with pyloric exclusion, Degiannis who showed a lower fistula rate in pyloric exclusion compared to primary repair in a total of 31 patients with severe duodenal trauma, cogbill who showed a low mortality rate with the use of pyloric exclusion in 27 patients.
However it has been criticized for its increased OT time and hospital stay, the formation of an extra anastomosis and the risk of suture line ulcers
Duodenorrhaphy + tube decompression has always been controversial. While authors like stone (237 patients, 0.5% fistula rate vs 19.3%) and hasson (9% mortality and 2.3% fistual rate vs 19.4% and 11.8%) have supported tube compression by showing lower mortality rate and fistula rate when comparing with those without decompression, others like Ivatury (60 patients, comparing primary repair with tube duodenostomy) and Girgin (67 patients, comparing primary repair and tube duodenostomy) questioned its role. Ivatury showed increased mortality and morbidity while Girgin showed no benefit in outcome with increased hospital stay. Problems of an additional tube would include increased hospital stay, tube dislodgement and obstruction
Duodenorrhaphy was never a popular choice for high grade injuries in the past. However, in recent years it has gained popularity with the introduction of the concept of less is better
Duodenorrhaphy
Mainstay for low grade injuries
Emerging role for high grade injuries
Siboni et al. 2015
2220 patients with isolated blunt duodenal injuries
No difference in mortality and sepsis (PR vs GE)
Shorter hospital stay
Pyloric exclusion
Mainstay for high grade injuries
Role downplayed
Seamon et al.
Greater complication rate, pancreatic fistula rate and increased hospital stay in PE group
Velmahos et al.
No difference in morbdiity/mortality/ICU/hospital stay (PE vs PR)
DuBose et al.
PE contribute to longer hospital stay and confers no survival/outcome benefit

24. What else…… Feeding jejunostomy Periduodenal drains
Early enteral nutrition
Periduodenal drains
Closed suction drain
Controlled fistula
No level I evidence
Surgeon preference
So what else can we do intra-operatively
Feeding jejunostomy can be done to ensure early enteral nutrition, esp for patients who are anticipated to fast for a longer period of time
this is esp important for trauma patients who are in a severe catabolic state and require good nutrititional support for recovery
Periduodenal drains if placed, should be closed suction drains. By far, there is no level I evidence to support or refute its use
The benefit of it is it can act as a controlled fistula in case of leakage. Ultimately, its use depends on surgeon preference

25. Summary
Duodenal trauma is DEADLY and requires a HIGH INDEX OF SUSPICION for diagnosis
Management depends on HEMODYNAMICS, INJURY SEVERITY and ASSOCIATED INJURIES
DUODENORRHAPHY is good enough for most injuries – keep it simple, but consider DIVERSION when in doubt
Never forget DAMAGE CONTROL
To conclude my presentation
I hope that you can bring with you these few take home messages
First, management of duodenal trauma is challenging. Diagnosis is not easy, most decisions are made on table, morbidity and mortality are high, operation is technically demanding.
Second, surgical treatments are diverse with no gold standard. The complexity of treatments are highly variable
Third, unstable patients require damage control surgery. This is important, bearing in mind saving the patient is more important than doing a perfect repair
Fourth, most injuries can be managed with duodenorrhaphy. with its well-documented role in low grade injuries and emerging role in high grade injuries,
Fifth, the management of high grade injuries sometimes require complex repair, including pyloric exclusion, resection and anastomoses or even whipple
Last but not least, treatment must be individualized and catered to the patient’s best interest.
----- Meeting Notes (21/4/16 14:26) -----
Outline
Summary
Background
Seat belt

26. References
Vaughan GD, Frazier OH, Graham DY, et al.. The use of pyloric exclusion in the management of severe duodenal injuries. Am J Surg. 1977;134(6):
Degiannis E, Krawczykowski D, Velmahos GC, et al. Pyloric exclusion in severe penetrating injuries of the duodenum. World J Surg. 1993;17(6):751-4
Cogbill T H, Moore E E, Feliciano D V. et al. Conservative management of duodenal trauma: a multicenter perspective. J Trauma. (1990);30:1469–1475.
Seamon MJ, Pieri PG, Fisher CA, et al. A ten-year retrospective review: does pyloric exclusion improve clinical outcome after penetrating duodenal and combined pancreaticoduodenal injuries? J Trauma. 2007;62(4): Stone HH, Fabian TC. Management of duodenal wounds. J Trauma 1979;19:334-9
Hasson JE, Stern D, Moss GS. Penetrating duodenal trauma. J Trauma Jun;24(6):471–474.
Ivatury RR, Gaudino J, Ascer E, et al. Treatment of penetrating duodenal injuries: primary repair vs. repair with decompressive enter- ostomy/serosal patch. J Trauma 1985;25:337-41
Girgin S, Gedik E, Yağmur Y, et al. Management of duodenal injury: our experience and the value of tube duodenostomy. Ulus Travma Acil Cerrahi Derg. 2009;15:
Siboni S, Benjamin E, Haltmeier T, et al. Isolated Blunt Duodenal Trauma: Simple Repair, Low Mortality. Am Surg Oct;81(10)961-4
Velmahos GC,Constantinou C,Kasotakis G. Safety of repair for severe duodenal injuries. World J Surg 2008;32:7-12.
DuBose JJ, Inaba K, Teixeira PG, et al. Pyloric exclusion in the treatment of severe duodenal injuries: results from the National Trauma Data Bank. Am Surg. 2008;74:925–9.
Ivatury RR, Malhotra AK, Aboutanos MB, et al. Duodenal Injuries: A Review. Eur J Trauma Emerg Surg 2007;33:231-7
Ordoñez C, García A, Parra MW, et al. Complex penetrating duodenal injuries: less is better. J Trauma Acute Care Surg. 2014;76(5):
Am Surg Oct;81(10):961-4.
Isolated Blunt Duodenal Trauma: Simple Repair, Low Mortality.
Siboni S1, Benjamin E, Haltmeier T, Inaba K, Demetriades D.

27. Question Time

28. Radiological Imaging in abdominal xray
we may see retroperitoneal gas or free gas under diaphragm
Both of the XRs are taken in patients with duodenal trauma
For the XR on the right, the red arrow illustates the presence of retroperitoneal gas, which outlines the right psoas muscle whereas
For the XR on the left, thewhite arrow delineates the retroperitoneal gas, which outlines the right kidney

29. Less is better Damage control approach
Duodenorrhaphy is advocated for high grade injuries
Siboni et al. 2015
2220 patients with isolated blunt duodenal injuries
No difference in mortality and sepsis
Shorter hospital stay
Velmahos et al. 2008
50 patients with severe duodenal injuries
No difference in morbidity/mortality/ICU/hospital stay
DuBose et al. 2008
147 patients with severe duodenal injuries
No difference in survival/outcome
Role of pyloric exclusion downplayed
Seamon et al. 2007
29 patients with duodenal injuries ≥ II
Greater complication rate, pancreatic fistula rate and increased hospital stay
What is less is better?
In short, it means doing less may be more beneficial
This is in line with the damage control approach
Duodenorrhaphy is advocated for high grade injuries as shown in recent literature
Siboni has shown that there is no difference in mortality and sepsis in 2000 patients with isolated blunt duodenal injuries when treated with duodenorrhaphy compared with the addition of a gastroenterostomy. Hospital stay was also shorter. These findings are echoed by Velhamos and DuBose
On the contrary, the role of pyloric exclusion is downplayed
Seamon demonstrated greater complcation rate, pancreatic fistula rate and increased hospital stay in 29 patients with severe duodenal injuries comparing duodenorrhpahy and pyloric exxlusion
Seemingly, recent studies have demonstrated a shift in the paradigm from duodenpharrhphy with pyloric exlcusion to duodenorrphay alone as the repair of choice for high grade duodenal injuries
Schroeppel TJ et al 2016
Penetrating duodenal trauma: A 19-year experience
Primary suture repair should be the initial approach considered for most injuries
Siboni et al 2015
Isolated blunt duodenal trauma: Simple Repair, Low Mortality
Retro study Siboni on 3798 patients, database 2015 paper (2220 with isolated duodenal injury)
Compare primary repair and GE patients
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
Fraga
Pyloric exclusion was associated with multiple complictions and a high mortality rate
Ivatury Duodenal injury review
Sriussadaporn Management of blunt duodenal injuries
Jansen
Duodenal injuries: Surgical management adapted to circumstances
Degiannis E et al.
Pyloric exclusion in severe penetrating injuries of the duodenum
Cogbill
Conservative management of duodenal trauma: a multicenter perspective
Martin TD Severe duodenal injuries. Treatment with pyloric exlcusion and gastrojejunostomy
Controversial
Stone and Fabian
Lower rate of duodenal fistula
0.4% vs 18% (tube duodenostomy vs no tube duodenostomy)
Ivatury et al
Higher rate of duodenal fistula
27.3% vs 1.6% (tube duodenostomy vs no tube duodenostomy)
Cogbill et al
Tube duodenostomy unnecessary and ineffective in preventing post-op complications

30. Duodenum 25-30cm (12 fingerbreaths) 4 parts Retroperitoneal
1st (Superior)
2nd (Descending)
Bile/pancreatic duct opening
3rd (Transverse)
Mesenteric vessels
4th (Ascending)
Retroperitoneal
Exception: 1st part 2cm
Complex anatomical relations
25-30cm (12 fingerbreaths)

31. Blood supply Physiology Arterial Venous
Pancreaticoduodenal artery
Superior (GDA)
Inferior (SMA)
Retroduodenal artery
Supraduodenal artery
Venous
Posterosuperior arcade  portal vein
Anteroinferior arcade  SMV
Physiology
Conduit for mixing of gastric juice/bile/pancreatic secretions
10L/day

32. Fluoroscopic studies Gastrograffin/barium follow through Features
Leakage of contrast
“Stacked coin sign” (intramural hematoma)
Limitation
Timaran CH et al.
Sensitivity 54%, specificity 98%
Difficult to interpret
Series of 96 patients with CT findings suspicious of duodenal injury

33. Delayed treatment Complex duodenal injury Drainage of abscess
Inflammed and unhealthy tissue
Retroperitoneal abscess
Drainage of abscess
Retroperitoneal laparostomy
Pyloric exclusion + duodenostomy
Controlled fistula
Feeding jejunostomy

34. Intramural hematoma
Non-operative
Stable
CT scan
Perforation
Operative
Reconstruction
Blunt Injury
Unstable
Operative
Damage control

35. Management Algorithm
These are two management algorithms for duodenal trauma
The right one is proposed by Moore while the left one is prposed by the western trauma association
As you can see, there are differences between the two
I will not go into details for each algorithm
I just want to illustrate that by now, there is no standardized treatment for duodenal trauma
This is one of the management algorithms proposed by Moore
For patients with unstable hemodynamics or peritonitis, laparotomy should be done
For patients, which are stable and can undergo further workup, CT/contrast studies should be done
If findings suggestive of perforation, laparotomy should be done while if duodenal hematoma is found, non-operative treatment with NG suction and TPN can be done
Following laparotomy
Duodenal injuries can be graded
For grade I and II lesions,
hematomas can either be managed conservatively and evaucated if large
lacerations are repaired by duodenorrhaphy
For grade III lesions,
duodenrrhaphy and pyloric exclusion or roux-en-Y jejunoduodenostomy should be performed
For grade IV and V lesions,
these patients are often unstable and damage control surgery should be done first, they should then be reassesed later for reconstruction or whipple
It is noteworthy that that author is in favour of the use of jejunostomy to ensure early enteral nutrition

36. Intramural hematoma More common in children
Obstruction within 48 hours
“Coiled spring/stacked coin sign”
NG tube suction + TPN
Desai et al
Success rate 89%
Czyrko et al
Success rate 83%
Failed conservative (2-3 weeks)  exploration
Involves serosa/subserosa

37. Intramural hematoma If detected intra-operatively
Evacuate hematoma and repair wall
Partial tear  full thickness tear
Explore and exclude perforation, leave hematoma intact, nasogastric tube suction

38. Morbidity Asensio et al. Duodenal fistula Intra-abdominal abscess7%
Intra-abdominal abscess
11-18%
Pancreatitis
3-15%
Duodenal obstruction
1-2%
Bile duct fistula 1%
Review of 15 series with 1408 patients with duodenal injuries

39. Mortality Overall Disease-specific Risk factors 17% 6.5-12.5%
Delayed diagnosis
Associated injuries
Disease specific related to duodenal fistula, sepsis, MOF, abscess
Associated with fistula (0-3.9%)
Delayed diagnosis
Cogbill 14.4% blunt trauma, penetrating trauma 3.6%
Early dieath: Exsanguination from associated vascular/liver/spleen injuries
late death 1-2 weeks, MOF sepsis
Time to diagnosis
Roman and colleagues
Delay > 24 hours
4/10 died
3/10 duodenal fistulas
Lucas and Ledgerwood
Mortality 40%
Delay < 24 hours
Mortality 11%
Snyder and coworkers
Delay
2/4 died
2/4 duodenal fistulas

40. Pedicled graft Jejunal Serosal Patch
Buttress duodenal defect with serosa of jejunum
Large defects
Unproven efficacy
Graft
Jejunum
Vascular pedicle
Large defects
Unproven efficacy
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.

41. Grading of Severity Duodenal Severity Scale Mild Severe
Determinants of injury severity
Agent
Stab
Blunt/Missile
Size
<75% wall
≥75% wall
Duodenal site
3, 4
1, 2
Injury-repair interval (hr)
<24
≥24
Adjacent Injury
No CBD
No pancreatic injury
CBD
Pancreatic injury
Outcome
Mortality 0% 6%
Morbidity 2%
10%
Mild : low mortality and morbidity
Snyder

42. Plain radiograph Retroperitoneal gas Free gas under diaphragm
Obliteration of right psoas muscle

43. Computerized Tomography
Contrast extravasation
Pneumoperitoneum
Retroperitoneal hematoma
Unusual bowel morphology
Unexplained periduodenal fluid

44. Computerized Tomography
Mainstay of evaluation for blunt trauma
Limitations
Allen et al.
Diagnostic delay in 20%
Ballard et al
Diagnostic delay in 27%
Importance of re-evaluation CT or exploration

45. Operative Exposure Laparotomy Cattel and Braasch Maneuver
Kocher Maneuver
Transection of Ligament of Treitz
Laparotomy
Kocher Maneuver
D1, D2, D3
Pancreatic head
Periampullary area
Distal CBD
Cattel and Braasch Maneuver D3
Body of pancreas
Transection of the ligament of Treitz D4
Kocher: Incise lateral attachments
Sweep D2/3 medially using sharp/blunt dissection
Visualize anterior/posterior D2/D3, head of pancreas, infrarenal IVC
Cattel and Braasch maneuver
Incise avascular line of Toldt
Mobilize right colon and hepatic flexure
Incise retroperitoneal attachments of SB from the RLQ to DJ junction
Reflect SB out of abdominal cavity
Visualize D4
Preserve IMV
Rotate right to left to visualize anterior D3 and D4

46. Whipple procedure Pancreatico-duodenectomy Indications
Uncontrolled peripancreatic hemorrhage
Extensive injury to proximal pancreatic duct, distal common bile duct and ampulla
Combined devascularizing injuries to duodenum and head of pancreas
High mortality rate
Velmahos et al
33%
2-stage vs 1-stage
247 patients
PD for 7 patients
Mortality due to vascular injuries
Feliciano
Simple duodenal injuries with nonductal pancreatic injury  primary repair and drainage
Extensive duodenal injuries combined with pancreatic injuries not involving duct to the right of SM vessels  repair or resection, pyloric exclusion, GJ, drainage
Lacerations in HOP with ductal involvement, devascularizing lesions of duodenum, duodenal lacerations with destruction of ampulla nad CBD  PD (1 stage or 2 stage, duodeanl repair, pyloric exlcusion and wide drainage)

47. Jejunal Serosal Patch Pedicled graft 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.

48. Duodenal diverticulization
Berne 1968
Procedure
Duodenorrhaphy
Gastric antrectomy
Vagotomy
Tube duodenostomy
T-tube common bile duct drainage
End-to-side gastrojejunostomy
Complicated
Out-of-date

49. Damage control Hemorrhage control Provisional repair
closure of perforation
resection without anastomosis
Temporary abdominal closure
Intensive care unit resuscitation
Damage control is an important concept, especially in trauma
It includes hemorrhage control by means of plication of bleeders and packing, provisional repair aiming at closing up perforation with sutures/staples or resection without establish continuity, temporary abdominal closure and ICU resuscitation
The aim is to achieve rapid surgery with temporary control, while minimizing physiological disturbance, thereby reversing and preventing the progression of the lethal triad of trauma.