TRAUMA

Review Article
Trauma
2017, Vol. 19(2) 94–102

Duodenal trauma ! The Author(s) 2017

Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1460408616684866
journals.sagepub.com/home/tra
Luke R Johnston1,2, Gary Wind1 and Matthew J Bradley1,2,3

Abstract
Duodenal trauma represents a unique challenge to the surgeon due to its relative rarity, anatomic location, and often the
difficulty in diagnosing and managing these injuries. Despite these challenges, significant advances have been made over
the previous century, and mortality has fallen to as low as 17%. The CT scan is the primary modality for diagnosis in the
blunt trauma patient, and thorough surgical exploration at laparotomy is the mainstay for penetrating injuries.
Management is guided by the grade of injury, with low-grade hematomas managed by observation, intermediate grade
injuries by primary repair, and high-grade injuries with a damage control surgery approach. While pyloric exclusion
remains the most common technique to augment primary repair in intermediate and higher grade injuries, the utility of
this procedure has come into question in current literature, and an overall ‘less-is-more’ surgical approach has been
advocated in recent publications. Complications following duodenal trauma are common and include fistulae, duodenal
obstruction, and infectious complications. However, the overall morbidity and mortality have improved with these
injuries. Future investigation is needed to determine the optimal management approach for these challenging patients.

Keywords
Duodenum, trauma, injury, review

Introduction in only 0.1% of patients suffering blunt injury and 0.4%

Care for patients with duodenal trauma presents
numerous challenges. The relative rarity of these inju-
ries, anatomic location, difficulties in diagnosis and
management, likelihood of concomitant injuries, fre-
quent complications, and high mortality, all contribute
to the complexity of these patients. Over time, advances
in early diagnosis and evolving strategies in manage-
ment have brought about significant improvements in
mortality from the earliest series of traumatic duodenal
injury in early 1900s reporting 100% mortality1 to
today where mortality has fallen to an average of
17%.2 However, this mortality rate has remained stag-
nant over the last four decades, reflecting the complex
nature of these patients and the frequently associated
additional injuries.3–10 This article reviews the epidemi-
ology, diagnosis, definitive management, and complica-
tions associated with duodenal trauma.
Epidemiology
of patients suffering blunt abdominal trauma specific-
ally.11 Even centers reporting large case series of over
100 patients still only see 10–20 cases annually.2 In
exploratory laparotomy performed for trauma, duodenal
injury is discovered in 3.7–5% of patients.12 A majority
of traumatic duodenal injuries are due to a penetrating
mechanism of injury in 62–92% of patients.3–5,7–9,13
Anatomically, the second portion of the duodenum is
most commonly injured location (15–65%) with a vari-
ably reported distribution among the remaining seg-
ments.13,14 Associated abdominal injuries are the
rule rather than the exception with 87% of patients
with duodenal injury having at least one associated
1
Uniformed Services University of the Health Sciences and Walter Reed
National Military Medical Center, Bethesda, MD, USA
2
Naval Medical Research Center, Silver Spring, MD, USA
3
Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA

Overall, duodenal trauma remains uncommon. In an Corresponding author:

Luke R Johnston, Uniformed Services University of the Health Sciences
EAST (Eastern Association for the Surgery in Trauma) and Walter Reed National Military Medical Center, 8901 Wisconsin Ave.,
multi-institutional retrospective review of over 275,000 Bethesda, MD 20889, USA.
blunt trauma admissions, duodenal trauma was identified Email: luke.r.johnston.mil@mail.mil
Johnston et al.
intra-abdominal organ injury. The liver and pancreas
are the most commonly associated injured organs.12
Presentation and diagnosis
The initial evaluation and management of the patient
presenting with abdominal trauma are guided by the
current American College of Surgeons Advanced
Trauma Life Support course. As the majority of duo-
denal injuries are the result of penetrating abdominal
trauma, the initial diagnosis is usually made at the time
of exploratory laparotomy. In general, the hemo-
dynamically unstable penetrating trauma patient is
best managed in the operating room, omitting any pre-
operative imaging evaluation. However, in a patient
with a gunshot wound (GSW), and especially multiple
GSWs, whose clinical presentation allows for it, pre-
operative plain X-rays of the chest, abdomen, and
pelvis can aid in raising the clinical suspicion for duo-
denal injury, help track bullet(s) trajectory, and assist in
selecting which cavity to explore.2 If any pre-operative
findings suggest a possible duodenal injury, a thorough
intraoperative evaluation is mandatory. Intraoperative
findings to suggest a possible duodenal injury include
the presence of retroperitoneal hematoma, retroperi-
toneal bile staining, peritoneal fat saponification or
necrosis, and lesser sac or peripancreatic edema.15
Meticulous intraoperative evaluation of the duode-
num is accomplished by performing a right medial vis-
ceral rotation of the hepatic flexure and a Kocher
maneuver to provide anterior and posterior exposure
of the second and third portions of the duodenum and
head of the pancreas.15 To further visualize the fourth
portion of the duodenum, and for a full evaluation of the
pancreas, the gastrocolic ligament is taken down and the
lesser sack entered.2 Alternatively, the Ligament of
Treitz (LOT) can be mobilized to expose the distal duo-
denum following medial visceral rotation.16
Evaluation for duodenal injury in patients with
blunt abdominal trauma can present a greater chal-
lenge. Despite the relatively high energy required to
cause blunt duodenal injury, the majority of these
patients on initial presentation are normotensive, with-
out significant alteration in mental status, and lack
external evidence of abdominal trauma such as ecchym-
osis or abrasions.16 Findings in the secondary survey
associated with duodenal injury include abdominal,
back or flank pain, and abdominal distension.
However, these are non-specific and not universally
present, with abdominal pain or tenderness being the
most commonly reported finding, and yet still absent in
8% of patients with duodenal injury.16–19
While hemodynamic instability and/or peritonitis
require operative exploration, the mainstay in evaluation
of blunt abdominal injury in the hemodynamically stable
95
patient without peritonitis is the abdominal computed
tomography (CT) scan with intravenous contrast admin-
istration. Some debate regarding the role for oral con-
trast exists and its use is mostly dependent on the center,
with some arguing that the lack of contrast reduces sen-
sitivity for perforation and others that oral contrast can
obscure subtle signs of injury to the duodenal wall.20
Abdominal CT has a diagnostic sensitivity of 84–100%
in the blunt abdominal trauma patient population for
hollow viscus injury.19–23 The variability in these sensi-
tivities stems from the wide range of criteria used to
classify a CT scan as having positive findings. Some
studies classify the presence of any intra-abdominal-
free fluid as a positive finding22 and others require
3 mm or greater bowel wall thickening, free air, contrast
extravasation, or larger amounts of free fluid.20,21,23
However, multiple studies have documented 13–14%
of patients with completely normal CT scans having a
hollow viscus organ injury found in the operating room
at a later time.19,23
In evaluating the duodenum, direct evidence of perfor-
ating injury on a CT scan, such as pneumoperitoneum or
contrast extravasation, is the most unambiguous finding
and mandates proceeding to laparotomy. Indirect evi-
dence of duodenal trauma such as periduodenal hema-
tomas or fluid have not been found to be closely
associated with duodenal injury and carry a positive pre-
dictive value of only 21%.24
In the patient without definitive findings on CT scan,
but whose presentation remains suspicious for duo-
denal injury, little help can be gained from other pre-
operative evaluation. Timaran et al.25 retrospectively
evaluated duodenography (oral contrast-enhanced
fluoroscopic evaluation) for blunt and penetrating duo-
denal trauma in patients with an equivocal CT scan, yet
found it to only have a sensitivity of 25% for blunt
duodenal injury overall and 54% for blunt duodenal
injuries requiring repair.
No laboratory test has been found to accurately iden-
tify patients with duodenal injury or other hollow viscus
injury.10,24 Elevated serum amylase has been used as a
marker for hollow viscus organ injury with mixed
results. In the largest study to date by Fahkry and col-
leagues in 2003, significant differences were found in the
average serum amylase level of those patients with a
perforated hollow viscus injury compared to those with
non-perforated hollow viscus injury.19 However, the
authors noted that there was no cutoff value, where a
patient with a perforation could be reliably distinguished
from those without a perforation.
For patients with a normal CT scan or with only
non-specific findings such as free fluid within the abdo-
men, observation with serial abdominal examination
and planned interval abdominal CT imaging is a safe
option with reservation of operative exploration for
96 Trauma 19(2)

unremitting abdominal pain or clinical deterioration. is made pre-operatively with CT scan or at the time of
While delays in diagnosis have been shown to increase laparotomy.
morbidities, no increase in mortality or hospital length of
stay has been found in recent series with this strategy.10,26
Grade I and II injuries
Diagnostic laparoscopy has a growing role in the
evaluation of penetrating abdominal trauma and is For grade I and II intramural hematomas diagnosed by
being advocated in the evaluation of blunt abdominal CT scan, initial management consists of a trial of non-
trauma as well.27 However, laparoscopy has not been operative therapy. Many of these patients will have gas-
studied for the evaluation of duodenal injury specific- tric outlet obstruction that is accompanied by nausea
ally. The duodenum’s anatomic relation to surrounding with or without bilious emesis. Treatment involves
viscera and the retroperitoneal location of segments proximal decompression by placing a nasogastric tube
two and three, at least theoretically, increase the risk and provision of parenteral nutrition; with this strat-
of a missed injury. Ultimately, in the patient with diag- egy, most intramural hematomas resolve within three
nostic uncertainty and equivocal imaging, the definitive weeks. Some advocate repeat abdominal imaging with
evaluation is laparotomy, which should not be delayed CT scan and operative evacuation of the hematoma for
in the patient who is not quickly improving.2,10,16 patients who still have complete obstruction after seven
to 10 days of decompression.15,29 Non-operative man-
agement has a success rate of 89% for these low-grade
Classification isolated blunt duodenal injuries with failures caused by
The grading of duodenal injuries is defined by the Organ persistent obstruction and worsening abdominal pain.10
Injury Scaling produced by the American Association for Successful CT-guided percutaneous drainage of duo-
the Surgery of Trauma.28 This system breaks down duo- denal hematomas causing persistent obstruction has
denal injury from grades I to V based on the presence of been reported on a case report basis but is not generally
hematoma or laceration and degree of involvement of the recommended.30,31 More commonly, surgical decom-
duodenal circumference (Table 1). pression is performed laparoscopically or with an
open approach to drain the hematoma. Operative
drainage provides the advantage of allowing examin-
Management
ation of the surrounding anatomy for any evidence of
The overall management of duodenal injuries is deter- additional injury but remains controversial due to the
mined by both the grade of the injury and, to a lesser risk of converting a closed injury to a full thickness
extent for the low grade injuries, whether the diagnosis perforation of the duodenum.2
Duodenal hematomas that are discovered during
operative exploration should be managed based on
the degree of mass effect and luminal compromise.
Table 1. Duodenum organ injury scaling, reproduced from Larger hematomas, with >50% luminal compromise,
Moore et al.28
should be incised and evacuated, while smaller hema-
Grade Description tomas should be left undisturbed. When incision and
evacuation are performed, meticulous hemostasis is
I Hematoma Involving single portion of
essential followed by closure of the duodenal serosal
duodenum
defect. In all cases, the establishment of enteral feeding
Laceration Partial thickness, no perforation
access should be strongly considered prior to closure of
II Hematoma Involving more than one portion the abdomen. Primary options include the placement of
Laceration Disruption of <50% of a nasoenteral feeding tube past the area of injury, or a
circumference surgical jejunostomy/gastrojejunostomy feeding tube.2,15
III Laceration Disruption of 50–75% circum- The majority of duodenal injuries are the result of
ference of second portion, or penetrating trauma and are discovered at the time
disruption 50–100% of first,
of exploratory laparotomy. Grade I and II injuries
third, or fourth portions
make up to 92–96% of isolated duodenal trauma3,32
IV Laceration Disruption of >75% circumfer-
(Figure 1). There is good consensus that these either
ence of second portion,
partial thickness lacerations or <50% circumference
involving ampulla or distal
common bile duct full thickness injuries can be repaired primarily as
long as there is no question regarding the adequacy
V Laceration Massive disruption of duodeno-
pancreatic complex of blood supply. While most agree that a primary trans-
verse repair is appropriate to prevent stricture forma-
Vascular Devascularization of duodenum
tion, the technique for performing this is debated.
Johnston et al.
Figure 1. A grade II duodenal injury.
The use of one versus two layers, monofilament or
braided and permanent or absorbable suture, with or
without buttressing with omentum has been contem-
plated but no published data support one method
over another specifically when focusing on the duode-
num.2,15,33 Extraluminal closed-suction, intra-abdom-
inal drains are often placed around the repair to assist
with diagnosis and control of a leak should it occur.
However, some have suggested that drain placement
for these low-grade injuries is not required and have
even suggested that drains may contribute to duodenal
leak and fistula formation.34 Nevertheless, the common
association of a pancreatic or other organ injury often
requires drain placement to manage a comorbid
condition.32
Grade III injuries
The management of grade III injuries requires a degree
of clinical judgment and individualization of surgical
decision making. Numerous options for repair are
available, and significant debate exists regarding the
best option for repair or resection with primary anas-
tomosis as well as the role for additional procedures to
protect the repair or limit the consequences of failure.
The initial determination in a stable patient at the index
operation is to determine whether a primary repair of
the duodenum is feasible. The surgeon needs to
consider the degree of the circumference and extent of
devitalized tissue when deciding on the appropriate
operation. Lacerations up to 75% of duodenal circum-
ference can be safely repaired primarily depending
on their location, ability to close the defect without
tension, and presence of adequate perfusion. Risk fac-
tors for complications include injuries to the second
portion of the duodenum, delay in surgical treatment,
97
Figure 2. Duodenal diverticulularization with extraluminal
drainage, intraluminal duodenal drainage and t-tube decompres-
sion of the biliary tree.
blunt injuries or injuries resulting from a projectile as
compared to a stab, shock, and presence of additional
organ injuries.5,9 When a primary repair cannot be per-
formed, options for management include resection with
reanastomosis via a duodenoduodenostomy or end-to-
end duodenojejunostomy with either roux-en-Y recon-
struction or as part of pyloric exclusion procedure with
the addition of a gastrojejunostomy.2
Most grade III injuries are still amenable to primary
repair.13,16,35 However, even if this can be accom-
plished, many authors advocate an additional proced-
ure to protect the repair in order to reduce the risk or
severity of complications in patient with the more
severe end of grade III injuries or in those with add-
itional organ injuries, especially the pancreas.3–8
Numerous operations have been described to accom-
plish this goal. In the early 1970s, Berne et al.45 first
published on ‘‘duodenal diverticulization’’ where they
performed a gastric antrectomy, tube duodenostomy
of the remaining duodenal diverticulum, and gastroje-
junostomy with the placement of intra-abdominal
drains. Stone and Fabian4 reported their results on a
technique utilizing triple tube decompression using a
draining tube gastrostomy and two jejunostomy tubes
projecting both proximally and distally for decompres-
sion and feeding, respectively (Figure 2). Both of these
surgeries have since fallen out of favor for lack of effi-
cacy and potential detriment to the patient.
The technique most utilized today, likely due to its
relative simplicity and comparatively large amount
of literature to support its use, is pyloric exclusion
(Figure 3). This technique, first described for
by Vaughan et al.,3 involves primary repair of the duo-
denal defect, followed by sutured closured of the
pylorus though a gastrostomy made on the greater
98
Figure 3. Duodenoduodenostomy with sutured pyloric exclu-
sion and gastrojejunostomy.
curvature of the stomach, and finally a side-to-side gas-
trojejunostomy using the previously made gastrostomy
and a loop of jejunum brought up to the stomach.
Modifications to this initial technique have included
the use of different suture materials; while the initial
procedure utilized chromic gut, other authors describe
the use of both longer lasting absorbable or non-
absorbable suture,15 or alternatively using a linear
non-cutting stapler to close the pylorus.36 Regardless
of the technique or suture used, closure is temporary
as the lumen of the pylorus recannulates over a period
of 3–12 weeks with the main variable in time to recan-
nulation being the type suture used for closure.3,36,37
Pyloric exclusion without gastrojejunostomy has been
performed successfully with the addition of a gastros-
tomy tube and feeding jejunostomy tube for proximal
decompression and distal enteral feeding.38 Several
studies have ascribed a benefit to pyloric exclusion in
reducing complications, but no randomized study has
been conducted.8,1238,
Interestingly, authors in several more recent studies
have argued against the use of pyloric exclusion, favor-
ing a simple primary repair without additional proced-
ures whenever possible. These articles cite pyloric
exclusion as being associated with an increased hospital
length of stay without improvements in mortality, post-
operative sepsis, or the rate of development of a duo-
denal fistula when compared to similar injures managed
without a pyloric exclusion.13,32,33 While these studies
try to correct for injury severity, comorbid injuries and
other confounding variables, they are all limited by
their retrospective design. Again, to date, no rando-
mized data are available to evaluate the role of pyloric
exclusion or any other diverting procedures. As Dubose
et al.35 review of the management of duodenal injuries
Trauma 19(2)
Figure 4. Duodenal resection with duodenoduodenostomy
and roux-en-Y reconstruction.
in the national trauma databank, there is a notable and
problematic lack of data comparing the use of pyloric
exclusion versus primary repair alone in higher grade
duodenal injuries. If a role for pyloric exclusion exists,
it likely resides in, and offers the most theoretical bene-
fit for, these higher grade injuries.
Grade III injuries distal to the ampulla of Vater,
where loss of tissue precludes a primary repair or
where the duodenum has been damaged to the point
of needing resection, require reconstruction via either
duodenoduodenostomy or roux-en-Y duodenojejunost-
omy for definitive repair. The short mesentery of
the duodenum makes adequate mobilization for a duo-
denoduodenostomy difficult and is blamed for the
increased rate of fistula formation with this procedure.
Consequently, for the patient who is not hypotensive,
hypothermic, or acidotic and does not otherwise have
indications for a damage control approach, a roux-
en-Y reconstruction offers the more feasible approach39
(Figure 4). In this procedure, the duodenum is divided
with oversewing of the distal duodenum. The jejunum is
divided distally (20 cm from the LOT) and the distal
limb is brought retrocolic through the transverse meso-
colon to fashion an end-to-end anastomosis with the
proximal duodenum. A distal jejunojejunostomy must
then be created to form the Y limb and restore intes-
tinal continuity.2
Grades IV and V
High-grade injuries involve either significant devascu-
larization of the duodenum or disruption of the
ampulla of Vater and duodenopancreatic complex.
Johnston et al.
Patients who present with this degree of trauma usually
present either in shock or with concomitant severe inju-
ries to other organs.33 These patients are best served
with a damage control strategy, focusing on hemor-
rhage control, debriding devitalized tissue, containing
gross contamination, and using liberal external drain-
age in an effort to minimize operative time and maxi-
mize time in the intensive care unit for ongoing
resuscitation and correction of the lethal triad.40
The role for pancreaticoduodenectomy in the
management of duodenal and combined pancreatic–
duodenal trauma is disputed. Over 45 years ago, Foley
et al.41 published the still largely agreed upon criteria for
pancreaticoduodenectomy in trauma which include (1)
damage to the head of the pancreas with the presence of
significant devitalized tissue with or with damage to the
main pancreatic duct, (2) uncontrollable bleeding in
the head of the pancreas, and (3) combined injuries to
the duodenum and pancreas with inability to restore
intestinal continuity without resection. Where the main
debate lies is whether it is appropriate to undertake this
surgical endeavor at the index operation or if a delayed
reconstruction is the more appropriate decision. While
several recent retrospective series have reported success
with pancreaticoduodenectomy and reconstruction at
the index procedure, a trend towards delayed reconstruc-
tion or delay of resection and reconstruction is evident.
However, with the exception of Krige et al.’s recent pub-
lication showing a mortality of only 14% for patients
undergoing pancreaticoduodenectomy with delayed
reconstruction, other recent studies have not shown
improvement since Asensio et al. published an average
mortality of 33% in a series of traumatic pancreatico-
duodenectomies from 1964 to 1990.12,42–44 Consistent
with damage control principles, though, delayed recon-
struction after traumatic pancreatiticoduodenal resec-
tion seems prudent in these critically injured patients.
Complications
Morbidities are common in patients with duodenal
trauma with many series documenting a majority of
patients suffering a complication following a duodenal
injury. Published series report complication rates ranging
from 7 to 125% with the overall injury severity score,
grade of duodenal injury, and associated organ injuries
among the factors that are associated most strongly with
complications.8–10,17,45 Complications unique to the duo-
denum include duodenal fistulas, duodenal obstruction,
intra-abdominal abscess, and bile duct fistulas.10,12
In all published series through 1993, Arsensio et al.12
reported a rate for the development duodenal fistulas of
6.6%. During that time period, studies reported a range
of 0–17%, with variance in these rates depending on the
grading of injury reported and the definition of fistula
99
versus repair breakdown that was used. When looking
at grades III to V injuries alone, duodenal fistulas
develop in as many as 33% of patients.33 These fistulas
develop from the breakdown of the suture line of a
primary duodenal repair or at the site of anastomosis.
If intra-abdominal extra-luminal drains were placed at
the time of repair, bilious drainage is the initial indica-
tor that a fistula has developed. If no extraluminal
drains were placed, the presentation is usually marked
by the development of post-operative sepsis. While
most trauma surgeons are partial to the placement of
extra-luminal drains and it is considered standard ther-
apy to preemptively monitor for and reduce the mor-
bidity of a duodenal leak, two separate studies have
noted an association with the placement of extralum-
inal drains at the time of the initial procedure and the
development of duodenal fistulas.33,34
Pyloric exclusion has not been shown in recent lit-
erature to reduce frequency of this complication; how-
ever, one benefit is that if a fistula develops in a patient
who has undergone pyloric exclusion, the fistula is an
end fistula and is usually lower output compared to a
lateral fistula that develops in a patient without pyloric
exclusion.2 Dubose et al. noted that all patients treated
with pyloric exclusion who developed duodenal fistulas
had this complication resolve without operative inter-
vention using only conservative measures. They add-
itionally used pyloric exclusion to manage duodenal
fistulas that developed in patients who underwent pri-
mary repair alone initially and were successful with this
strategy. Alternatively placing closed suction drains to
control effluent, or the combination of diversion and
drain placement are described for the management of
duodenal fistula that are not draining externally.33,34
Intra-abdominal abscesses and surgical site infections
are reported to occur in up to 17–18% and 18%, respect-
ively, of patients following a full thickness perforation.
Abscesses are generally managed with percutaneous
drainage and antibiotics, while surgical site infections
may require wound exploration plus antibiotics.12,46
Duodenal obstruction from large duodenal hema-
tomas is not uncommon. However, small bowel obstruc-
tion following duodenorrhaphy with or without pyloric
exclusion can occur as well in 1–6% of patients. Reported
management of post-operative bowel obstructions
ranges from complete success with proximal decompres-
sion and non-operative management to the need for
resection and re-anastomosis in the majority of
patients.5,10,12
Outcomes
Overall, mortality in patients with duodenal injuries
follows the same general trend of mortality in patients
sustaining major trauma, where 73–80% of deaths are
100
seen in the first 48 h and are not related directly to the
duodenal injury but instead related to hemorrhage or
traumatic brain injury. Death after 48 h is attributable
most commonly to sepsis and multisystem organ fail-
ure.8,9 Mortality directly attributable to duodenal inju-
ries is variably reported but ranges from 1 to 4%.4,5,34
In most of these cases, the mortality is due to sep-
sis developing from an uncontrollable fistula or duo-
denal leak.
Two major reviews have evaluated prognostic
factors that predict morbidity and mortality after sus-
taining duodenal trauma. Timaran et al.46 identified
preoperative or intraoperative shock, and comorbid
pancreatic, superior mesenteric vessel or colonic
injury as being independently associated with an
increase in septic complications, duodenal fistula for-
mation and late mortality. Similarly, Blocksom et al.9
found that patients’ having a thoracotomy, associated
pancreatic, splenic, thoracic or abdominal vascular
injury, an injury severity score of >25, an intraopera-
tive core temperature of <35 C, and >5 units of blood
transfusion to all be predictors of mortality.
As further suggested by Siboni et al. more recently
described finding of a mortality of only 0.9% in all iso-
lated blunt duodenal trauma, the predominant cause of
death in patients with duodenal trauma is related to
associated injuries that are far more commonly present
than not.
Conclusion
Duodenal injury is an uncommon event where the man-
agement is made especially challenging due to the com-
plexity of making an accurate and timely diagnosis,
anatomic location complicating exposure for evalu-
ation and repair, the commonly associated additional
injuries, and what is often a lack of significant experi-
ence in the individual surgeon due to the overall rarity
of the problem. Despite these challenges, there is an
overall trend towards a less-is-more approach with
documented safety of non-operative management of
low-grade injuries, arguments for a simplified operative
repair for intermediate grade injuries, and a damage
control strategy for severe injuries. Despite a large
numbers of publications, most are limited to a small
cohort and a retrospective evaluation leaving the field
open for further study of the optimal management of
these complex injuries.
Disclaimers and Copyright statements
1. The opinions or assertions contained herein are the
private ones of the author/speaker and are not to be
construed as official or reflecting the views of the
Trauma 19(2)
Department of Defense, the Uniformed Services
University of the Health Sciences or any other
agency of the U.S. Government.
2. The views expressed in this article are those of the
authors and do not necessarily reflect the official
policy or position of the Department of the Navy,
Department of Defense, nor the U.S. Government.
3. Authors Luke Johnston and Matthew Bradley are
military service members (or employees of the U.S.
Government). This work was prepared as part of our
official duties. Title 17 U.S.C. §105 provides that
‘Copyright protection under this title is not available
for any work of the United States Government.’
Title 17 U.S.C. §101 defines a U.S. Government
work as a work prepared by a military service
member or employee of the U.S. Government as
part of that person’s official duties.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Provenance and peer review
Commissioned, externally peer reviewed.
References
1. Berry J and Giuseppi PL. Traumatic rupture of the intes-
tine, with a case of recovery after operation and an ana-
lysis of the 132 cases that have occurred in Ten London
Hospitals during the last fifteen years. (1893–1907). Proc
Roy Soc Med 1909; ii(Surg Sect): 1–65.
2. Biffl WL. Duodenum and pancreas. In: Mattox KL,
Moore EE and Feliciano DV (eds) Trauma, 7th ed. New
York: McGraw-Hill, 2013, pp. 603–619.
3. Vaughan GD III, Frazier OH, Graham DR, et al. The use
of pyloric exclusion in the management of severe duodenal
injuries. AM J Surg 1977; 134: 785–790.
4. Stone HH and Fabian TC. Management of duodenal
wounds. J Trauma 1979; 19: 334–339.
5. Snyder WH III, Weigelt JA, Watkins WL, et al. The sur-
gical management of duodenal trauma. Arch Surg 1980;
115: 422–429.
6. Ivatury RR, Nallathambi M, Gaudino J, et al. Penetrating
duodenal injuries: analysis of 100 consecutive cases. Ann
Surg 1985; 202: 153–158.
7. Shorr RM, Greaney GC and Donovan AJ. Injuries of the
duodenum. Am J Surg 1987; 154: 93–98.
8. Cogbill TH, Moore EE, Feliciano DV, et al. Conservative
management of duodenal trauma: a multicenter perspective.
[Clinical Trial. Multicenter Study. Research Support, Non-
U.S. Gov’t]. J Trauma 1990; 30: 1469–1475.
Johnston et al.
9. Blocksom JM, Tyburski JG, Sohn RL, et al. Prognostic
determinants in duodenal injuries. Am Surg 2004; 70:
248–255.
10. Velmahos GC, Tabbara M, Gross R, et al. Blunt pan-
creatoduodenal injury: a multicenter study of the
Research Consortium of New England Centers for
Trauma (ReCONECT). Arch Surg 2009; 144: 413–419.
11. Watts DD and Fakhry SM. Incidence of hollow viscus
injury in blunt trauma: an analysis from 275,557 trauma
admissions from the EAST multi-institutional trial.
J Trauma 2003; 54: 289–295.
12. Asensio JA, Feliciano DV, Britt LD, et al. Management
of duodenal injuries. Curr Probl Surg 1993; 30:
1023–1093.
13. Seamon MJ, Paola GP, Fisher CA, et al. A ten-year
retrospective review: does pyloric exclusion improve clin-
ical outcome after penetrating duodenal and combined
pancreaticoduodenal injuries. J Trauma 2007; 62:
829–833.
14. Flint LM, McCoy M, Richardson JD, et al. Duodenal
injury: analysis of common misconceptions in diagnosis
and treatment. Ann Surg 1980; 191: 697–702.
15. Fang R. Pancreas and duodenum In: Scalea TM (ed.) The
shock trauma manual of operative techniques. New York:
Springer Science þBusiness Media, 2015, pp.243–263.
16. Ivatury RR, Malhotra AK, Aboutanos MB, et al.
Duodenal injuries: a review. Eur J Trauma Emerg Surg
2007; 33: 231–237.
17. Ballard RB, Badellino MM and Eynon CA. Blunt duo-
denal rupture: a 6-year statewide experience. J Trauma
1997; 43: 229–233.
18. Rodriguez A, DuPriest RW Jr and Shatney CH.
Recognition of intra-abdominal injury in blunt trauma
victims. A prospective study comparing physical examin-
ation with peritoneal lavage. Am Surg 1982; 48: 457–459.
19. Fakhry SM, Watts DD and Luchette FA EAST Multi-
Institutional Hollow Viscus Injury Research Group.
Current diagnostic approaches lack sensitivity in the
diagnosis of perforated blunt small bowel injury: analysis
from 275,557 trauma admissions from the EAST multi-
institutional HVI trial. J Trauma 2003; 54: 295–306.
20. Miller LA and Shanmuganathan K. Multidetector CT
evaluation of abdominal trauma. Radiol Clin North Am
2005; 43: 1079–1095.
21. Killeen KL, Shanmuganathan K, Poletti PA, et al.
Helical computed tomography of bowel and mesenteric
injuries. J Trauma 2001; 51: 26–36.
22. Petrosoniak A, Engels PT, Hamilton P, et al. Detection
of significant bowel and mesenteric injuries in blunt
abdominal trauma with 64-slice computed tomography.
J Trauma 2013; 74: 1081–1086.
23. Ekeh AP, Sace J, Walusimbi M, et al. Diagnosis of blunt
intestinal and mesenteric injury in the era of multidetec-
tor CT technology – are results better? J Trauma 2008;
65: 354–359.
24. Bradley M, Bonds B, Dreizin D, et al. Indirect signs of
blunt duodenal injury on computed tomography: is non-
operative management safe? Injury 2016; 47: 53–58.
101
25. Timaran CH, Daley BJ and Enderson BL. Role of duo-
denography in the diagnosis of blunt duodenal injuries. J
Trauma 2001; 51: 648–651.
26. Allen GS, Moore FA, Cox CS Jr, et al. Delayed diagnosis
of blunt duodenal injury: an avoidable complication. J
Am Coll Surg 1998; 187: 393–399.
27. Johnson JJ, Garwe T, Raines AR, et al. The use of lapar-
oscopy in the diagnosis and treatment of blunt and pene-
trating abdominal injuries: 10-year experience at a level 1
trauma center. Am J Surg 2013; 205: 317–321.
28. Moore EE, Cogbill TH, Malangoni MA, et al. Organ
injury scaling. II. Pancreas, duodenum, small bowel,
colon and rectum. J Trauma 1990; 30: 1427–1429.
29. Carrillo EH, Richardson JD and Miller FB. Evolution in
the management of duodenal injuries. J Trauma 1996; 40:
1037–1046.
30. Kortbeek JB, Brown M and Steed B. Percutaneous drain-
age of a duodenal haematoma. Injury 1997; 28: 419–420.
31. Gulotto C and Paulson EK. CT-guided percutaneous
drainage of a duodenal hematoma. AJR 2005; 184:
231–233.
32. Siboni S, Benjamin E, Haltmeier T, et al. Isolated blunt
duodenal trauma: simple repair, low mortality. Am Surg
2015; 81: 961–964.
33. Ordoñez C, Garcia A, Parra MW, et al. Complex pene-
trating duodenal injuries: less is Better. J Trauma 2014;
75: 1177–1183.
34. Schroeppel TJ, Saleem K, Shaoe JP, et al. Penetrating
duodenal trauma: a 19-year experience. J Trauma 2016;
80: 461–465.
35. Dubose JJ, Inaba K, Teixeira PGR, et al. Pyloric exclu-
sion in the treatment of severe duodenal injuries: results
from the national trauma data bank. Am Surg 2008; 74:
925–929.
36. Martin TD, Feliciano DV, Mattox KL, et al. Severe duo-
denal injuries. Treatment with pyloric exclusion and gas-
trojejunostomy. Arch Surg 1983; 118: 631–635.
37. DeSantis M, Devereux DF and Thompson D. Pyloric
exclusion, suture material of choice. Am Surg 1987; 53:
711–714.
38. Ginzburg E, Carrillo EH, Sosa JL, et al. Pyloric exclusion
in the management of duodenal trauma: is concomitant
gastrojejunostomy necessary? Am Surg 1997; 63:
944–946.
39. Kashuk JL, Moore EE and Cogbill TH. Management of
the intermediate severity duodenal injury. Surgery 1982;
92: 758–764.
40. Moore EE, Burch JM, Granciose RJ, et al. Staged
physiologic restoration and damage control surgery.
World J Surg 1998; 22: 1184–1191.
41. Foley WJ, Gaines RD and Fry WJ.
Pancreaticoduodenectomy for severe trauma to the
head of the pancreas and the associated structures:
report of three cases. Ann Surg 1969; 170: 759–765.
42. Krige JE, Kotze UK, Setshed M, et al. Surgical manage-
ment and outcomes of combined pancreaticoduodenal
injuries: analysis of 75 consecutive cases. J Am Coll
Surg 2016; 222: 737–749.
102
43. Thompson CA, Shalhub S, Deboard ZM, et al. Revisiting
the pancreaticoduodenectomy for trauma: a single insti-
tution’s experience. J Trauma 2013; 75: 225–228.
44. Asensio JA, Petrone P, Roldán G, et al.
Pancreaticoduodenectomy: a rare procedure for the man-
agement of complex pancreaticoduodenal injuries. J Am
Coll Surg 2003; 197: 937–942.
45. Berne CJ, Donovan AJ and White EJ. Duodenal
‘‘Diverticulization’’ for duodenal and pancreatic injury.
Am J Surg 1974; 127: 503–507.
46. Timaran CH, Martinez O and Ospina JA. Prognostic
factors and management of civilian penetrating duodenal
trauma. J Trauma 1999; 47: 330–335.
Trauma 19(2)
47. Rotundo MF, Schwab CW, McGonigal MD, et al.
‘‘Damage Control’’: an approach for improved survival
in exsanguinating penetrating abdominal injury.
J Trauma 1993; 35: 375–384.
48. Roberts DJ, Bobrovitz N, Zygun DA, et al. Indications
for use of damage control surgery and damage control
interventions in civilian trauma patients: a scoping
review. J Trauma 2015; 78: 1187–1196.
49. Velmahos GC, Constantinou C and Kasotakis G. Safety
of repair for severe duodenal injuries. World J Surg 2008;
32: 7–12.