European Journal of Trauma and Emergency Surgery
Duodenal Injuries: A Review
Rao R. Ivatury, Ajai K. Malhotra, Michel B. Aboutanos, Therese M. Duane1
Abstract
Duodenal injuries are uncommon injuries but are
associated with significant morbidity and mortality
from a delayed diagnosis in the case of blunt trauma
and associated major vascular injuries in penetrating
trauma. A simplistic approach with primary repair or
resection and anastomosis is ideal for the vast
majority. Complex procedures such as pyloric exclu-
sion with or without gastrojejunostomy may be indi-
cated for delayed treatment or severe, high-grade
combined pancreato-duodenal injuries. A high index
of suspicion and a judicious treatment plan based on a
careful consideration of all the available options are
crucial for optimal outcome.
Key Words
Duodenal injury Æ Pancreato-duodenal
trauma Æ Duodenal fistula Æ Pyloric exclusion
Eur J Trauma Emerg Surg 2007;33:231–7
DOI 10.1007/s00068-007-7078-5
Introduction
Duodenal injuries are uncommon and are found in
only 3.7% of all laparotomies for trauma [1, 2]. The
duodenum is retroperitoneal, in close proximity to vital
biliary and vascular structures that increase the com-
plexity of duodenal trauma. The diagnosis after blunt
abdominal trauma may be delayed because of subtle
signs and symptoms with a resultant increase in mor-
bidity and mortality. The management of penetrating
trauma is challenging because of associated injury to
major vessels of the upper abdomen [1–8]. In either
type of trauma, it is essential to make an early diag-
nosis and apply judicious surgical principles for optimal
outcomes. This review will focus on the diagnosis and
treatment options for duodenal trauma.
1
Division of Trauma, Critical Care and Emergency Surgery, Virginia
Commonwealth University Medical Center, Richmond, VA, USA.
Received: May 21, 2007; revision accepted: May 30, 2007;
Published Online: June 6, 2007
Eur J Trauma Emerg Surg 2007 Æ No. 3 ! URBAN & VOGEL
Focus on Pancreatic and Duodenal Injuries
Incidence
Penetrating trauma is the most common cause of
duodenal injuries, since the organ has a protected
location in the retroperitoneum from blunt forces.
Blunt trauma, however, continues to predominate in
rural areas. The reported incidence of duodenal injury
ranged from 3.7 to 5% in the literature [1, 2]. In a
review of 17 series with 1,513 cases of duodenal inju-
ries, Asensio et al. [1] reported an incidence of 77.7%
occurring as the result of penetrating trauma and
22.3% from blunt trauma. Blunt injury causes duode-
nal disruption by a crushing force against the vertebral
column or by shearing forces as in falls. The second
portion of the duodenum (DII) is injured most com-
monly, in 35% of the cases, followed by the third
(DIII), fourth (DIV), and first (DI) parts in that order.
Diagnosis
Duodenal injuries from blunt trauma continue to pose
a diagnostic challenge. The organ’s retroperitoneal
location may only produce minimal and vague symp-
toms such as abdominal, back, or flank pain. The key to
diagnosis is a high index of suspicion based on a con-
sideration of the injury mechanism (Figure 1). Routine
laboratory tests are not helpful in the preoperative
diagnosis of duodenal rupture. Serum amylase and li-
pase levels have a high false-positive and false-negative
rates for duodenal trauma [1–8].
Computerized tomography (CT) scan of the
abdomen with intraluminal and intravenous contrast
has become the mainstay for the evaluation of blunt
abdominal trauma. It has a high degree of accuracy in
diagnosing retroperitoneal injuries and is sensitive in
the detection of small amounts of retroperitoneal air,
blood, or extravasated contrast from the injured duo-
denum. The presence of free fluid in the absence of
solid organ injury may be a sign of blunt small bowel
231
Ivatury RR, et al. Duodenal Injuries
Figure 1. Severe blunt duodenal injury in a crash. The pylorus was
completely detached from the duodenum. Treated with pyloric
exclusion and gastro-jejunostomy.
injury and should lead to additional investigation. Al-
len et al. [9] reported their experience with 35 patients
with blunt duodenal injury. Seven were diagnosed
correctly only after 6 h. Six of the seven were evalu-
ated initially with CT scans, and five (83%) did show
findings suggestive of BDI. Deterioration on physical
signs, however, prompted follow-up CT scans in six and
the scans were diagnostic for BDI in all cases. This
delayed diagnosis was associated with increased
abdominal complications. The authors make the
important recommendation that patients with persis-
tent abdominal complaints and equivocal CT or DPL
findings should undergo laparotomy or repeat CT scan
evaluations. Ballard et al. [10] reviewed a statewide
experience in Pennsylvania and identified duodenal
injury in 206 (0.2%) patients. Only 30 of these had full-
thickness rupture of the duodenum. Twenty-five pre-
sented with either abdominal pain, tenderness, or
guarding on physical examination. Extravasation of
contrast was noted in only 2 of the 18 cases, which had
CT scans. Four studies were interpreted as normal, and
seven patients had delayed diagnosis beyond 12 h after
admission. Two deaths were caused by duodenal in-
jury-related sepsis. The authors emphasized that CT
findings were non-specific and that delay in diagnosis
was common. Laparoscopy is yet another diagnostic
option but the ultimate diagnostic test, if a high degree
of suspicion of duodenal injury continues in the face of
absent or equivocal radiographic signs, is surgical
exploration [7, 9, 10–12].
Early diagnosis is easier after penetrating trauma,
since exploratory laparotomy for peritoneal signs will
232
lead to the correct diagnosis [1–8]. Even at celiotomy,
small wounds of the duodenum may be easily over-
looked. One needs to look for bile staining of the
retroperitoneum, small bubbles of entrapped air in the
periduodenal tissues, and small periduodenal hemato-
mas. Kocherization (mobilization of the C-loop of the
duodenum from its retroperitoneal attachment) is the
next step. This facilitates inspection of DI, DII and a
portion of DIII. This maneuver will also allow an
evaluation of the pancreatic head, periampullary area
and distal CBD. The Cattell and Braasch maneuver
consists of mobilization of the hepatic flexure of the
colon, sharp dissection of the small bowel attachment
from the ligament of Treitz to the right lower quadrant,
and cephalad displacement of the small bowel. This
brings D III into view along with the body of the
pancreas. DIV may be evaluated by mobilizing the
ligament of Treitz [5–6].
Grading Duodenal Injury Severity
The organ injury scaling (OIS) for the duodenum and
the pancreas, as defined by the American Asscoiation
for the Surgery of Trauma (AAST), ranges from sim-
ple (Grade I) to the most severe (Grade V) [13].
Grades III to V are complex duodenal injuries, as are
combined pancreatoduodenal injuries and injuries
involving the distal common duct and the periampul-
lary area. Even minor lacerations of the duodenum,
when diagnosed in a delayed fashion, must also be
considered complex injuries because of the presence of
tissue edema and reaction.
Management
The surgical management of the duodenal injuries
would depend on hemodynamic stability, severity of
duodenal injury, and the presence and severity of
associated pancreatic injury [1–8, 12].
In the hemodynamically unstable patient, the
optimal treatment is an abbreviated laparotomy [1, 7].
The priorities are control of hemorrhage and restora-
tion of the deranged physiology. Gastrointestinal per-
forations and lacerations are sealed by rapid,
provisional methods such as suture, stapling, rapid
resection without establishing continuity, temporary
abdominal closure, and intensive care unit resuscita-
tion: the so-called damage control approach. Restora-
tion of gastrointestinal tract integrity is accomplished
at a second operation. Because it is a delayed closure,
the duodenal repair may not be as easy as when done
primarily. The techniques for delayed treatment are
described below.
Eur J Trauma Emerg Surg 2007 Æ No. 3 ! URBAN & VOGEL
Ivatury RR, et al. Duodenal Injuries
Figure 2. Primary repair of duodenal laceration.
In hemodynamically stable patients, lower grade
lesions of the duodenum and pancreas, low velocity
penetrating wounds as in civilian injuries when there
was no delay in diagnosis and treatment, the vast
majority of duodenal injuries may be managed by
simple procedures. Adequate debridement of the
duodenal wall around the laceration back to bleeding
tissue, careful repair employing standard surgical
techniques, e.g., one to two layers, transverse closure of
longitudinal wounds, converting adjacent wounds into
one wound closure, etc., will provide excellent results
(Figure 2). If the duodenal injury has caused a large
defect in the wall (more than 3 cm in diameter), pri-
mary closure of the defect may narrow the lumen of
the bowel or result in undue tension and subsequent
suture line breakdown. Segmental resection and pri-
mary end-to-end duodenoduodenostomy are usually
feasible when dealing with injuries to DI, DIII, or DIV
[1–8] (Figure 3).
Mckenney et al. [14] reviewed 40 consecutive pe-
netrating duodenal injuries. Sixteen patients with
minor duodenal injuries were treated by primary repair
alone. In this group, none of the 11 patients without a
combined pancreaticoduodenal injury that developed a
leak. Ivatury et al. [3–7] also emphasized good results
with repair/resection for the vast majority of duodenal
injuries. In their retrospective analysis of 100 patients
[4] with penetrating duodenal injuries, primary repair
or resection anastomosis was noted in 62 patients,
including 22 with stab wounds and 40 with gunshot
Eur J Trauma Emerg Surg 2007 Æ No. 3 ! URBAN & VOGEL
Figure 3. Side-to-side duodenojejunostomy. Useful for injuries of
DII, DIII.
wounds. Only one developed a duodenal fistula, as
opposed to 3 of the 11 patients (27.3%) when treated
with repair and duodenostomy. In a subsequent pro-
spective study [8], these findings were confirmed. Fifty-
six patients had primary repair, with two duodenal
leaks, both with associated injury to the head of the
pancreas. Duodenum related mortality in this series
was 1.7%. Repair or resection and anastomosis were
also recommended for low-velocity gunshot wounds by
others [15–17].
Complex duodenal injuries, delayed treatment:
Only a small number of duodenal injuries are complex,
as defined above [7, 17–19]. These have a real potential
for duodenal fistulization and increased morbidity.
This has prompted surgeons to add a variety of
adjunctive operative procedures to protect the duode-
nal suture line in an attempt to prevent this compli-
cation.
Stone & Fabian [20] introduced the concept of
‘‘triple ostomy,’’ (gastrostomy, duodenostomy, and
jejunostomy), based on their experience with 237 pa-
tients. These authors observed only one duodenal fis-
tula when tube decompression was used, whereas 8 of
the 44 patients without the decompression developed
this complication. This technique is particularly valu-
able when dealing with high-grade lesions in the diffi-
cult region of DII. The tube decompression can be
achieved either antegrade, proximal to the injury site
or retrograde, via a jejunostomy. Currently, most
trauma centers adopt, not the triple ostomy technique
but some variant of tube duodenostomy to protect
the suture line in the duodenum. There are detractors
of this technique; however, Snyder et al. [12], Ivatury
233
Ivatury RR, et al. Duodenal Injuries
Figures 4a to 4c. a) Patient with a GSW of abdomen managed by
damage-control surgery. The debrided liver is evident as well as a
large amount of bile collection in the right upper quadrant. Further
exploration reveals a large laceration in the pyloric region, missed at
the initial exploration. b) The pylorus is grasped with a Babcock
forceps, ready for closure. c) The pylorus is closed shut with inter-
rupted 2–0 prolene sutures. Gastro-jejunostomy is used to restore GI
continuity.
et al. [3, 4, 8], and Cogbill et al. [16] argued against
‘‘routine’’ tube duodenostomy and even suggested that
indiscriminate tube duodenostomy may increase the
234
incidence of complications. Other techniques were
sometimes mentioned in the literature based on animal
experiments or theoretical attractiveness. Examples
include serosal patch and pedicled mucosal grafts. Se-
rosal patch is the use of serosa of a loop of jejunum to
buttress the duodenal repair. An alternative to the use
of a serosal patch for large duodenal defects is the use
of a pedicled mucosal graft. Such grafts may be taken
from the jejunum or the stomach [1, 3, 8]. These
techniques have been used infrequently and are not
supported by large data. Our preferred option when
dealing with large duodenal defects is resection and
end-to-end duodenoduodenostomy. In the second part
of duodenum such resections are not feasible. The
other options are to perform either side-to-end or end-
to-end Roux-en-Y duodenojejunostomy [8] (Figure 5)
or a side-to-side duodenojejunostomy. These complex
procedures are seldom used in large series of duodenal
injuries. Duodenal repair and exclusion appears to be
the favored approach in these difficult situations [4–8,
16–19, 21] (Figures 4a–4c).
The objective of duodenal exclusion is to divert
gastric secretions away from the duodenal repair and
allow time for adequate healing of repair. Duodenal
diverticulization, first described by Berne and associ-
ates in 1968 [22], consisted of suture closure of the
duodenal injury, gastric antrectomy with end-to-side
gastrojejunostomy, tube duodenostomy, and generous
drainage in the region of the duodenal repair. This
procedure is now replaced by the pyloric exclusion
procedure, a lesser operation which avoids antral
resection. Popularized by Jordan in the early 1970s
[23], it consists of primary repair of the duodenal
wound followed by closure with non-absorbable su-
tures of the pylorus, accomplished through a gastrot-
omy incision on the greater curvature of the antrum.
Alternatively, a staple line may be placed across the
pylorus. A gastrojejunostomy is then performed at the
gastrotomy site. The first large series of this procedure
was reported by Vaughan et al. [23] from Ben Taub
Hospital. In 1983, a 12-year experience with pyloric
exclusion was reported from the same institution. In
total, 128 of the 313 (41%) patients with duodenal
injuries [17] underwent this procedure, with a duodenal
fistula rate of 5.5%. Interestingly, 94% had restoration
of the patency of the pylorus when examined 3 weeks
or more after the operation. Pyloric exclusion is also
reported in children with duodenal injuries [24]. While
a majority of authors recommend pyloric exclusion for
complex pancreatico-duodenal injuries [6–8, 17–19],
there have been no controlled studies to establish the
superiority of pyloric exclusion. At least one recent
Eur J Trauma Emerg Surg 2007 Æ No. 3 ! URBAN & VOGEL
Ivatury RR, et al. Duodenal Injuries
series downplayed its role. In this report [25], 15 of the
29 patients were managed without pyloric exclusion
and 14 with exclusion. Both groups were similar with
respect to age, sex, mechanism, injury grade, ISS, he-
modynamic stability, the presence of vascular injury,
associated abdominal injuries, and mortality rates. A
trend toward a higher overall complication rate (71%
vs. 33%), pancreatic fistula rate (40% vs. 0%), and
length of hospital stay (24.3 vs. 13.5 days) was evident
in the pyloric exclusion group. Variations of the pyloric
exclusion procedure have been described: pyloric
exclusion without gastrojejunostomy [26]; a ‘‘con-
trolled reopen suture technique’’ of the pylorus that
enables manual reopening of the pylorus after the
duodenum has healed [27]. Pyloric exclusion is cer-
tainly a good option for patients with a delayed diag-
nosis and treatment of duodenal trauma. Fang et al.
[27] analyzed 18 patients with delayed diagnosis.
Twelve patients were treated by pyloric exclusion with
no deaths and four complications (one duodenal fistula
and three retroperitoneal abscesses.
Pancreatico-duodenectomy is the ultimate option
for extensive injuries causing uncontrollable peripan-
creatic hemorrhage, distal bile duct, and proximal pan-
creatic duct or ampullary injuries with extensive tissue
destruction, and combined devascularizing injuries to
the duodenum and head of the pancreas [1–8, 12, 16–19].
Among 247 patients with duodenal injuries, pancreati-
coduodenectomy was performed for seven patients, an
incidence of only 3% [19]. The overall reported mor-
tality rate for this operation was 33%. This high mor-
tality is related primarily to associated vascular injuries.
Abbreviated laparotomy on unstable patients with
staged reconstruction should make this rare operation
for trauma a better option than that in the past. Defin-
itive reconstruction is performed at the second opera-
tion when the patient’s physiology is less deranged and
is actually facilitated by the dilatation of the common
bile and pancreatic ducts that were ligated at the initial
operation. Gentilello et al. [28] have suggested that
ligation of pancreatic duct without pancreatico-jejunal
anastomosis is a viable option in carefully selected pa-
tients undergoing pancreatico-duodenectomy.
Combined pancreaticoduodenal injuries: based on
an analysis of 129 patients with combined pancreati-
coduodenal injuries, Feliciano et al. [18] put forth these
recommendations for optimal results. (1) Primary re-
pair and drainage are used for simple duodenal injuries
with nonductal pancreatic injury (Grades I and II). (2)
More extensive duodenal injuries combined with pan-
creatic injuries not involving the duct to the right of
superior mesenteric vessels are best treated with repair
Eur J Trauma Emerg Surg 2007 Æ No. 3 ! URBAN & VOGEL
or resection of duodenum, pyloric exclusion, gastro-
jejunostomy, and drainage. (3) Lacerations in the head
of the pancreas with ductal involvement, devascular-
izing lesions of the duodenum, or duodenal lacerations
with destruction of the ampulla and distal common
duct (Grade V injuries of these structures in any
combination) are best treated by a one-stage or two-
stage pancreaticoduodenectomy, as discussed above.
More recent reports suggest a highly conservative,
simpler approach that avoids major resections and
pancreatico-enteric anastomosis, emphasizing duode-
nal repair, pyloric exclusion and wide drainage of the
pancreatic head [6, 8, 16–18].
Delay in surgical treatment is another situation
causing a complex duodenal injury. At the time of
exploration, the tissues may be so inflamed that
suturing of perforations and lacerations or resection
may be technically difficult and ill-advised. In addition,
there may be extensive retroperitoneal abscess for-
mation. Under these circumstances, one can only rely
on pyloric exclusion, if at all possible, and drainage of
the abscess. The objective is to establish a controlled
fistula, eradicate the abscess and hope for future
reconstruction. Feeding jejunostomy is established in
normal small bowel, away from the site of the potential
fistula. We have found that an aggressive approach
with an open abdomen, repeated surgical intervention
to drain the abscess and maintenance of feeding has
many advantages in helping to establish a controlled
fistula. Pyloric exclusion is sometimes added as an
adjunctive procedure [29, 30]. Fang et al. [31] advocate
a ‘‘retroperitoneal laparostomy’’ for the treatment of
retroperitoneal abscess with continuous soiling. They
reported on 11 patients who developed extensive ret-
roperitoneal abscesses, and were treated with anterior
laparotomy initially. Five patients recovered after this
procedure. Six patients continued to have retroperito-
neal abscesses and were under septic status. Retro-
peritoneal laparostomy was performed for these six
patients. After retroperitoneal laparostomy, daily
wound care, and antibiotic treatment, all six patients
recovered. Figure 5 describes an algorithm for the
management of complex duodenal injuries.
Morbidity and Mortality
The most serious complication following the treatment
of duodenal injury is the development of a duodenal
fistula from suture line dehiscence. In a collective re-
view of 15 series with 1,408 patients with duodenal
injuries, Asensio et al. [1, 2] noted a 0 to 17% incidence
of duodenal fistula, with an average rate of 6.6%. Other
235
Ivatury RR, et al. Duodenal Injuries
Complex duodenal injury
Hemodynamic stability
A. Isolated duodenal injury
Primary closure after debridement
or resection and EEA
Duodeno-duodenostomy/jejunostomy
for large defects
B. Combined pancreatoduodenal injuries
Grades I & II : repair of duodenum, drainage of pancreas
Grade III duodenal and pancreatic injuries :
Duodenal repair/ resection and EEA, distal
pancreatectomy, pyloric exclusion
Grades IV,V duodenal and pancreatic injuries:
Pancreatico-duodenectomy (one or two stage)
complications reported with duodenal trauma (may or
may not be directly related to the duodenal injury itself)
include (1) intra-abdominal abscess, 10.9 to 18.4%; (2)
pancreatitis, 2.5 to 14.9%; (3) duodenal obstruction, 1.1
to 1.8%; and (4) bile duct fistula, 1.3%. As outlined
above, the management of a duodenal fistula consists of
extensive drainage; nutritional support by intravenous
hyperalimentation or, preferably, by enteral feeding
through a jejunostomy; drainage of all associated intra-
abdominal abscesses; and antibiotic therapy.
The overall mortality rate of duodenal injuries
continues to be significant, up to an average of 17%.
This mortality, however, is related more to the extent
of associated vascular injuries and injury to the adja-
cent head of the pancreas. When early death from
exsanguination is excluded, the mortality rate attrib-
uted to the duodenal injury itself ranges from 6.5 to
12.5% and is related to duodenal fistulization, intra-
abdominal abscess, sepsis, and multiorgan failure. The
mortality rate attributed exclusively to fistula forma-
tion ranges from 0 to 3.9% [1, 2]. In the multicenter
report by Cogbill et al. [16], the mortality rate for blunt
trauma was 14.4%. The rate was only 3.6% for pene-
trating trauma, a difference attributed mostly to a de-
layed diagnosis of blunt duodenal injury. In a
retrospective review of 222 consecutive patients with
duodenal injuries at a Level 1 Trauma Center with a
predominance of penetrating injuries, the mortality
rate was 22.5% [32]. Multivariate analysis revealed the
performance of a thoracotomy, initial emergency
department (ED) systolic blood pressure (SBP)
< 90 mmHg, final operating room (OR) core body
temperature less than 35"C, and presence of a splenic
236
Hemodynamic instability
Damage Control
Hemorrhage control
Packing
Rapid closure of GI perforations
ICU resuscitation
Definitive reconstruction at repeat laparotomy
Figure 5. Algorithm for the management of complex
duodenal injuries.
injury to be the most important predictors of mortality,
emphasizing the role of associated physiologic injury.
Huerta et al. identified 52 patients [blunt (62%), gun
shot wound (GSW) (27%), and stab wound (SW)
(11%)] with a mortality rate of 15.4% (n = 8). Multi-
variate regression analysis revealed age, initial lowest
pH, and Glasgow Coma Score to be independent pre-
dictors of mortality. The delayed diagnosis of blunt
injury and physiologic derangement from associated
injuries, therefore, appear to determine the outcome.
Summary
Duodenal trauma, with early diagnosis and prompt
treatment, can be managed effectively by simple sur-
gical techniques. Complex duodenal injuries, those
diagnosed and treated late, and those associated with
major destruction of adjacent structures (the pancre-
aticobiliary complex or abdominal vessels) require a
more thoughtful strategy that incorporates a careful
consideration of the physiologic stability of the patient,
the severity of injury, extent of local inflammation and
the experience of the surgeon. Such a careful approach
will yield optimal outcome even in this difficult area.
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Address for Correspondence
Rao R. Ivatury, MD
1200 East Broad Street
W15E Rihmond
VA 23298
USA
Phone (+1/804) 827-1207
Fax -0285
e-mail: rivatury@hsc.vcu.edu
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