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Duodenal injuries
E. Degiannis and K. Boffard
Department of Surgery, Medical School, University of the Witwatersrand, 7 York Road, Parktown, 2193 Johannesburg, Republic of South Africa Correspondence to: Dr E. Degiannis

Background: The worldwide increase in road trafc accidents and use of rearms has increased the incidence of duodenal trauma. Methods: The English language literature on duodenal trauma over the period 19701999 was reviewed. Results and conclusion: Upper gastrointestinal radiological studies and computed tomography may lead to the diagnosis of blunt duodenal trauma. Exploratory laparotomy remains the ultimate diagnostic test if a high suspicion of duodenal injury continues in the face of absent or equivocal radiographic signs. The majority of duodenal injuries may be managed by simple repair. More complicated injuries require more sophisticated techniques. High-risk duodenal injuries are followed by a high incidence of suture line dehiscence and they should be treated by duodenal diversion. Pancreaticoduodenectomy should be considered only if no alternative is available. `Damage control' should precede denitive reconstruction.

Paper accepted 14 June 2000

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Duodenal injury can pose a formidable challenge to the surgeon and failure to manage it properly may have devastating results. The total amount of uid passing through the duodenum exceeds 6 l/day and a stula in this area may cause serious uid and electrolyte imbalance. A large amount of activated enzymes liberated into the retroperitoneal space and the peritoneal cavity may be life threatening. A preoperative diagnosis of isolated duodenal injury can be very difcult to make and there is no single method of duodenal repair that completely eliminates the possibility of dehiscence of the duodenal suture line. As a result, the surgeon is confronted with the dilemma of choosing between several preoperative investigations and many surgical procedures. Detailed knowledge of the available operative choices and their correct application is important.

Penetrating trauma is the leading cause of duodenal injury in countries with a high incidence of civilian violence, such as the USA and South Africa; 7580 per cent of this trauma is due to gunshot wounds1. In the more peaceable environment of western Europe, blunt injury is the most likely cause. The retroperitoneal location of the duodenum
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and its close proximity to a number of other viscera and major vascular structures means that isolated penetrating injury of the duodenum itself is rare. The need for abdominal exploration is usually dictated by associated injuries and the diagnosis of duodenal injury is usually made in the operating room. Particularly for gunshot wounds, a trajectory into the abdomen always warrants exploration in the authors' opinion2. Blunt injury of the duodenum is both less common and more difcult to diagnose than penetrating injury, and it may typically occur in isolation or with pancreatic injury. It usually occurs from crushing of the duodenum between spine and steering wheel, handlebar or some other force applied to the anterior aspect of the abdomen. Such injury may be associated with exion/distraction fracture of L1 L2 vertebrae (the Chance fracture). `Stomping' and striking the mid-epigastrium are common. Less commonly, deceleration may produce a tear at the junction of the third and fourth parts of the duodenum, and tears of the rst and second parts have occasionally been reported. These injuries occur at the junction of free (intraperitoneal) parts of the duodenum with xed (retroperitoneal) parts. A high index of suspicion, based on mechanism of injury and physical examination, may lead to further diagnostic studies. The initial clinical changes in isolated duodenal injury may be extremely subtle before severe, life-threatening,
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Duodenal injuries E. Degiannis and K. Boffard

peritonitis develops. In the vast majority of retroperitoneal perforations there is at rst only mild upper abdominal tenderness with a progressive rise in temperature, tachycardia and occasionally vomiting. After several hours the duodenal contents extravasate into the peritoneal cavity with the development of peritonitis. If these contents spill into the lesser sac they are usually `walled off' and localized, although occasionally they may leak into the general peritoneal cavity via the foramen of Winslow, with resultant generalized peritonitis3. Diagnostic difculties do not arise in those patients in whom blunt injury causes intraperitoneal perforation. Theoretically, duodenal perforation should be associated with a leak of amylase and other digestive enzymes, and it has been suggested that determination of the serum amylase concentration may be helpful in diagnosis4,5. The test lacks sensitivity6,7. The duodenum is retroperitoneal, the concentration of amylase in the uid that leaks is variable, and amylase concentrations often take hours to days to increase after injury. Although serial determination of serum amylase is better than a single, isolated assay on admission, sensitivity is still poor and serial determination involves necessary delay in treatment. If the serum amylase level is raised on admission, a diligent search for duodenal rupture is warranted. The presence of a normal amylase level, however, does not exclude duodenal injury8. Although virtually all patients with blunt duodenal injury will eventually have an increased white blood cell count and amylase level in diagnostic peritoneal lavage uid, such lavage has a low sensitivity for diagnosis of duodenal perforation9,10. Radiological studies may be helpful in the diagnosis. Plain radiographs of the abdomen are useful when gas bubbles are present in the retroperitoneum adjacent to the right psoas muscle, around the right kidney, or anterior to the upper lumbar spine. They may also show free intraperitoneal gas and, although rarely seen, gas in the biliary tree has also been described11. Obliteration of the right psoas muscle shadow or fractures of the transverse processes of the lumbar vertebrae are indicative of forceful retroperitoneal trauma and serve as a predictor of duodenal injury5,12. An upper gastrointestinal series using water-soluble contrast material provides positive results in 50 per cent of patients with duodenal perforations13. Meglumine (Gastrogran; Schering, Berlin, Germany) should be infused via a nasogastric tube rather than swallowed, and the study should be done under uoroscopic control with the patient in the right lateral position. If no leak is observed, the investigation continues with the patient in the supine and then in the left lateral position. If the Gastrogran study is negative, it should be followed by
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administration of barium contrast agent since it allows detection of small perforations more readily3. Upper gastrointestinal studies with contrast media are also indicated in patients with a suspected haematoma of the duodenum, because they may demonstrate the classic `coiled spring' appearance of complete obstruction by the haematoma8,14. Computed tomography (CT) has been added to the diagnostic armamentarium for subtle duodenal injury. It is very sensitive to the presence of small amounts of retroperitoneal air, blood or contrast agent extravasated from the injured duodenum, especially in children15,16. Its reliability in adults is more controversial15,17. The presence of periduodenal wall thickening or haematoma without extravasation of contrast material should be investigated with a gastrointestinal study with Gastrogran. If normal, it should be followed by a barium contrast study if the patient's condition allows this3. Diagnostic laparoscopy does not confer any improvement over more traditional methods in the investigation of the duodenum. Because of its anatomical position, diagnostic laparoscopy is a poor modality for determining organ injury18. Exploratory laparotomy remains the ultimate diagnostic test if a high degree of suspicion of duodenal injury continues in the face of absent or equivocal radiographic signs. All patients undergoing a laparotomy for abdominal trauma should be explored through a long midline incision. Upper midline retroperitoneal haematomas should be explored to rule out underlying duodenal, pancreatic or vascular injury. It is wise to ensure that proximal and distal control of the aorta, and distal control of the inferior vena cava, are readily available before the haematoma is explored. Mobilization of the whole duodenum is mandatory for exclusion of duodenal injury. Initially the Kocher manoeuvre is performed by dividing the lateral peritoneal attachment of the duodenum and mobilizing both the second and third parts medially with a combination of sharp and blunt dissection. Entry into the lesser sac by way of the gastrocolic ligament provides exposure of the posterior aspect of the proximal portion of the rst part of the duodenum and the medial aspect of the second part. Better inspection of the third part and inspection of the fourth part of the duodenum may be achieved by mobilizing the ligament of Treitz, and performing the Cattell and Braasch manoeuvre. This manoeuvre requires mobilization of the right colon (including the hepatic exure) from right to left so that the right colon and small intestine may be elevated. The small bowel mobilization is undertaken by sharply incising its retroperitoneal attachments from the lower right quadrant to the ligament of Treitz. It is important to replace the small intestine in the abdominal cavity with
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E. Degiannis and K. Boffard Duodenal injuries 1475

great care at the conclusion of the operation. Iatrogenic volvulus of the mobilized bowel is possible if this is not done. Severe oedema, crepitation or bile staining of the periduodenal tissues implies a duodenal injury until proven otherwise. If the exploration of the duodenum is negative but there is still a strong suspicion of duodenal injury, Brotman et al.19 recommend instillation of methylene blue through a nasogastric tube. Rapid staining of periduodenal tissues is unmistakable evidence of an intestinal leak in this area, and the lack of staining, in their hands, has proven reliable in ruling out full-thickness duodenal injury.
Surgical management of duodenal injury

the duodenum are densely adherent and dependent for their blood supply on the head of the pancreas, so diagnosis and management of any injury is complex, and resection, unless involving the entire C loop and pancreatic head, is impossible. The lower portion may generally be treated like small bowel; diagnosis and management is relatively simple, including debridement, closure, resection and reanastomosis1. Intramural haematoma This is a rare injury of the duodenum that is specic to patients with blunt trauma. It is most common in children after isolated force to the upper abdomen, possibly because of the relatively exible and pliable musculature of the child's abdominal wall; half of the cases can be attributed to child abuse21. The haematoma develops in the submucosal or subserosal layers of the duodenum, which is not perforated. Such a haematoma may lead to obstruction. The symptoms of gastric outlet obstruction may take up to 48 h to present as gradual increase in size of the haematoma occurs owing to breakdown of the haemoglobin rendering it hyperosmotic with resultant uid shifts into it. The diagnosis may be made by double-contrast CT or upper gastrointestinal contrast studies that show the `coiled spring' or `stacked coin' sign15. The injury is usually considered non-surgical and best results are obtained by conservative treatment, if associated injuries can be ruled out16,23. After 3 weeks of conservative management with nasogastric aspiration and total parenteral nutrition, the patient is re-evaluated. If there is no improvement he or she undergoes laparotomy to rule out the presence of duodenal perforation or injury of the head of the pancreas that may be an alternative cause of duodenal obstruction. The treatment of an intramural haematoma found at early laparotomy is controversial1. One option is to open the serosa, evacuate the haematoma without violation of the mucosa, and carefully repair the wall of the bowel. The concern is that this may convert a partial tear to a fullthickness tear of the duodenal wall. Another option is carefully to explore the duodenum to exclude a perforation, leaving the intramural haematoma intact, with postoperative nasogastric decompression planned1. Duodenal perforation The great majority of duodenal perforations may be managed with simple surgical procedures. This is particularly true of penetrating injuries where the time interval between injury and operation is usually short. On the other hand, a minority of cases comprises high-risk lesions with an increased likelihood of dehiscence of the British Journal of Surgery 2000, 87, 14731479

Grading systems have been devised to characterize duodenal injuries (Table 1). Although useful for research purposes, the specics of the grading systems are less important than several simple aspects of the duodenal injuries: (a) the anatomical relation to the ampulla of Vater; (b) the characteristics of the injury (simple laceration versus destruction of duodenal wall); (c) the involved circumference of the duodenum; and (d) associated injury to the biliary tract, pancreas, or major vascular injury21,22. Timing of the operation is also important as the mortality rate rises from 11 to 40 per cent if the time interval between injury and operation is more than 24 h18. From a practical point of view the duodenum may be divided into an upper portion that includes the rst and second part, and a lower portion that includes the third and fourth part1. The upper portion has complex anatomical structures within it (common bile duct and sphincter) and the pylorus. It requires distinct manoeuvres to diagnose injury (cholangiogram, direct visual inspection) and complex techniques to repair them. The rst and second parts of
Table 1

Duodenal injury severity according to the American Association for the Surgery of Trauma
Grade Injury I II III Haematoma Laceration Haematoma Laceration Laceration Description Single portion of duodenum Partial thickness only Involving more than one portion Disruption < 50 per cent circumference Disruption 5075 per cent circumference of D2 Disruption 50100 per cent circumference of D1, D3, D4 Disruption > 75 per cent circumference of D2 Involving ampulla or distal common duct Massive disruption of duodenopancreatic complex Devascularization of duodenum


Laceration Laceration

D1, D2, D3, D4: first, second, third, and fourth portions of the duodenum. For multiple injuries, the grade is advanced by one20.

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duodenal repair, with increased morbidity and, sometimes, mortality rates. These high-risk injuries are related to associated pancreatic injury, blunt or missile injury, involvement of more than 75 per cent of the duodenal wall, injury of the rst or second part of the duodenum, time interval between injury and repair of more than 24 h, and associated common bile duct injury1. For such injuries several adjunctive operative procedures have been proposed in an attempt to reduce the incidence of dehiscence of the duodenal suture line. Methods of repair of the duodenal injury and supportive procedures against dehiscence are described below. Repair of the perforation Most injuries of the duodenum may be repaired by primary closure in one or two layers. The closure should be orientated transversely, if possible, to avoid luminal compromise. Excessive inversion should be avoided. Longitudinal duodenotomies may usually be closed transversely if the length of the duodenal injury is less than 50 per cent of the circumference of the duodenum1. If primary closure would compromise the lumen of the duodenum, several options have been recommended. Pedicled mucosal graft, using a segment of jejunum or a gastric island ap from the body of the stomach, has been suggested as a method of closing large duodenal defects24,25. Another possibility is the use of a jejunal serosal patch to close the duodenal defect26,27. The serosa of the loop of jejunum is sutured to the edges of the duodenal defect. Although encouraging in experimental studies, the clinical application of both of these methods is limited and suture line leaks have been reported28. Laying a loop of jejunum on to the area of the injury such that the serosa of the jejunum buttresses the duodenal repair has also been suggested29. No benecial results have been reported from this technique30,31. In complete transection of the duodenum, the preferred method of repair is primary anastomosis of the two ends after appropriate debridement and mobilization11. It is frequently the case with injuries of the rst, third and fourth part of the duodenum that mobilization is technically not difcult. However, if a large amount of tissue is lost, approximation of the duodenal ends may not be possible without producing undue tension on the suture line. If this is the case and complete transection occurs in the rst part of the duodenum, antrectomy should be performed with closure of the duodenal stump and a Bilroth II gastrojejunostomy. When such injury occurs distal to the ampulla of Vater, closure of the distal duodenum and Roux-en-Y duodenojejunal anastomosis is appropriate32. Mobilization of the second part of the duodenum is limited by its shared
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blood supply with the head of the pancreas. A direct anastomosis to a Roux-en-Y loop sutured over the duodenal defect in an end-to-side fashion is the procedure of choice. This may also be applied as an alternative method of operative management of extensive defects of the other parts of the duodenum when primary anastomosis is not feasible. External drainage should always be provided because it affords early detection and control of duodenal stula. The drain is preferably a simple, soft silicone rubber, closed system placed adjacent to the repair32. Duodenal diversion In high-risk duodenal injury, repair is followed by a high incidence of suture line dehiscence. To protect the repair, the gastrointestinal contents with their proteolytic enzymes may be diverted, a practice that also makes the management of a duodenal stula easier. Tube decompression was the earliest technique used for decompression of the duodenum and diversion of its contents in an attempt to preserve the integrity of the duodenorrhaphy. It was rst described in 1954 as a method of management of a precarious closure of the duodenal stump after a gastrectomy33. The technique was introduced for trauma by Stone and Garoni as a triple ostomy34. This consists of a gastrostomy tube to decompress the stomach, a retrograde jejunostomy to decompress the duodenum, and an antegrade jejunostomy to feed the patient. The initially favourable reports on the ability of this technique to decrease the incidence of dehiscence of the duodenorrhaphy have not been supported by more recent work11,31,35. The drawbacks of the technique include several new perforations being made in the gastrointestinal tract, the inefciency of the jejunostomy tube in decompressing properly the duodenum, and the common scenario of the drains falling out or being removed by the patient3. The fashioning of a feeding jejunostomy at the initial laparotomy in patients with duodenal injury and extensive abdominal trauma (Abdominal Trauma Index greater than 25) is highly recommended11. Duodenal diverticulation, as originally described, includes a distal Billroth II gastrectomy, closure of the duodenal wound, placement of a decompressive catheter into the duodenum and generous drainage of the duodenal repair36. Truncal vagotomy and biliary drainage might be added. The disadvantage of duodenal diverticulation is that it is an extensive procedure that is totally inappropriate for the haemodynamically unstable trauma patient or the patient with multiple injuries. Resection of a normal distal stomach cannot be benecial and should not be considered unless there is a large amount of destruction and tissue loss, and no other course is possible.
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Pyloric exclusion was devised as an alternative to the above extensive procedure to shorten the operative time and make the procedure reversible. After primary repair of the duodenum, a gastrotomy is made at the antrum along the greater curvature. The pyloric ring is grasped and invaginated outside the stomach through the gastrotomy, and is closed with a large running suture or by stapling. The closed pyloric ring is returned into the stomach and a gastrojejunostomy is fashioned at the gastrotomy site (Fig. 1). The closure of the pylorus breaks down after several weeks and gastrointestinal continuity is re-established. This occurs regardless of whether the pylorus is closed with absorbable suture, non-absorbable suture or stapler37. Concern has been expressed about the ulcerogenic potential of the pyloric exclusion, as marginal ulceration has been reported in up to 10 per cent of cases37,38. The long-term incidence of marginal ulceration in patients who underwent pyloric exclusion is probably underestimated; it is notoriously difcult to achieve adequate long-term follow-up in the trauma population. In line with others, the authors do not practice vagotomy with pyloric exclusion39. Ginzburg et al.40 question the need to perform routine gastrojejunostomy after pyloric exclusion, taking into consideration that continuity of the gastrointestinal tract will be re-established in 90 per cent of patients within 3 weeks. A duodenal stula may still occur with pyloric exclusion, and there is concern that spontaneous opening of the pyloric sphincter will negatively inuence closure of the stula. This has been shown not to be a clinically relevant problem41. Pyloric exclusion is a technically easier, less radical and quicker operation than diverticulation of the duodenum, and appears to be equally effective in the protection of a duodenal repair4245. An interesting technique of controlled reopening of the pyloric exclusion is reported by Fang et al.46. The use of octreotide in protection of the suture line in pancreaticojejunostomy after pancreaticoduodenectomy has been shown to be benecial47,48. Its application following duodenal trauma

for protection of the duodenal repair has been suggested by Mullins et al.49. The principle is attractive, but further experience is required before sound conclusions can be drawn. Pancreaticoduodenectomy This is a major procedure that should only be practised in the trauma situation if no alternative is available. Damage control, with control of bleeding and bowel contamination, and ligation of the common bile and pancreatic ducts, should be the rule50. Reconstruction should take place within the next 48 h when the patient is stable. Indications for considering pancreaticoduodenectomy are massive disruption of the pancreaticoduodenal complex, devascularization of the duodenum and, sometimes, extensive injury to the second part of the duodenum involving the ampulla or distal common bile duct3,5052. The role of pancreaticoduodenectomy in trauma is best summarized by Walt53: `Finally, to Whipple or not to Whipple, that is the question. In the massively destructive lesions involving the pancreas, duodenum and common bile duct, the decision to do a pancreaticoduodenectomy is unavoidable; and, in fact, much of the dissection may have been done by the wounding force. In a few patients, when the call is of necessity close, the overall physiologic status of the patient and the extent of damage become the determining factors in the decision. Though few in gross numbers, more patients are eventually salvaged by drainage, total parenteral nutrition and meticulous overall care than by a desperate pancreaticoduodenectomy in a marginal patient'. Specic injuries Simple combined injuries of the pancreas and duodenum should be managed separately. More severe injuries require more complex procedures. Feliciano et al.54 have reported by far the largest experience of combined pancreaticoduodenal injuries and suggest that (a) simple duodenal injury with no ductal pancreatic injury (grades I and II) should be managed with primary repair and drainage (Table 2); (b) grade III duodenal and pancreatic injuries are best treated with repair or resection of both organs as indicated, pyloric exclusion, gastrojejunostomy and closure; and (c) grade IV and V duodenal and pancreatic injuries are best treated by pancreaticoduodenectomy. Extensive local damage of the intraduodenal or intrapancreatic bile duct frequently necessitates a staged pancreaticoduodenectomy. Less extensive local injuries may be managed by intraluminal stenting, sphincteroplasty or reimplantation of the ampulla of Vater11,5557. British Journal of Surgery 2000, 87, 14731479

Fig. 1 Pyloric exclusion

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Duodenal injuries E. Degiannis and K. Boffard

Table 2

Pancreatic injury severity according to the American Association for the Surgery of Trauma
Grade Injury description I II III IV V Minor contusions or superficial lacerations, no ductal injury Major contusions or lacerations, no ductal injury, no tissue loss Distal transection of the pancreas or a parenchymal injury involving the duct Proximal transection (to the right of the superior mesenteric vessels) or a parenchymal injury involving the ampulla Massive disruption of the pancreatic head

For multiple injuries, the grade is advanced by one20.


Upper gastrointestinal radiological studies and CT may lead to the diagnosis of blunt duodenal trauma, but exploratory laparotomy remains the ultimate diagnostic test if a high suspicion of duodenal injury continues in the face of absent or equivocal radiographic signs. Most duodenal injuries can be managed successfully by simple repair. More complicated injury requires more sophisticated techniques. High-risk duodenal injury is followed by a high incidence of suture line dehiscence and treatment should involve duodenal diversion. Pancreaticoduodenectomy should be practised only if no alternative is available. Damage control should precede denitive reconstruction. Detailed knowledge of available operative choices and when to use them is important for good overall results.
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2000 Blackwell Science Ltd

British Journal of Surgery 2000, 87, 14731479