Taichiro Tsunoyama

Duodenal injuries are uncommon

Incidence of blunt duodenal injury;0.2%
Penetrating(78%) wounds are more common than
blunt(22%)

Duodenal injuries are both difficult to diagnose and

repair due to its retroperitoneal location
 First portion of the small intestine

From the plyoric ring to the Treitz ligament

25-30 cm in length, Latin word duodeni (twelve each)

Divided into 4 portions

1st: Superior
Pass backword and upward toword the neck of the gallbladder
Most of portion is intraperitoneal

2nd: Descending
Contain the bile and panceatic duct(Ampulaa of Vater)
Entirely retroperitoneal

3rd: Transverse
SMA runs downward over the 3rd portion

4th: Ascending
Short distance(2-3cm), suspensory ligament of Treitz
Derived from the pancreatioduodenal artery
Superior branch; from hepatic artery
Inferior branch; from SMA

Drain into the portal vain and SMV

 Duodenum is the portion of the bowel where the stomach
contents are mixed with biliary and pancreatic secretions for
digestion
Contains food as well as powerful digestive enzymes

About 5L of fluid passes through the duodenum a day

Massive flow volume
gastric juice 2500ml
bile 1000ml
pancreatic juice 800ml
saliva 800 ml
 Most injuries are penetrating in nature
Blunt injuries account for approx 25%
Crush
Occur with a direct force applied to the abdominal wall,
transferred to the duodenum which is pushed posteriorly
against the spinal column
Shear
Occur when the mobile and nonfixed portions of the
organ accelerate and decelerate forward and backward
respectively
Burst
Force is applied to a gas and fluid-filled filled
duodenum against a closed pylorus and acutely flexed
duodenojejunal angle
1st 14.4%
2nd 33.0%
3rd 19.4%
4th 19.0%
Multiple 14.2%

Asensio J management of duodenal injuries

Cur-r Probl Surg, November 1993
Organs most commonly injured in association:
Liver 16.9%
Pancreas 11.6%
Small bowel 11.6%
Colon 11.5%
Venous Injuries 9.8%
Stomach 9.1%
Biliary tree and Gallbladder 6.8%
Arterial Injuries 6.6%

Asensio J management of duodenal injuries

Cur-r Probl Surg, November 1993
 Directly attributable duodenal mortality; 2-5%,6-29%

Morbidity rates;30-63%

Reason for the variability

mechanism of injury
associated injury
time to initial diagnosis
Early death(particularly with penetrating injury)
Exsanguination from associated vascular, liver or spleen

Complication
Anastomotic breakdown
fistula
intra-abdominal abscess
sepsis
MOF
Delay in diagnosis >12hr; 53 % of their patients
Delay in diagnosis >24hr; 28 % of their patients

Mortality
40%; the patients who diagnosed over 24hr
11%; the patients who underwent surgery within 24hr

Lucos C,Ledgerwood A: Factor influencing outcome after blunt duodenal injury. J

Trauma 15(10):839-846,1975
1. Early diagnosis
2. Control of hemorrhage
3. Control of bacterial contamination
 Requires a high index of suspicion
Accurate H&P

More difficult to diagnose in blunt trauma than penetrating

As penetrating injuries tend to necessitate an operative
exploration

No specific diagnostic test found to be accurate all of the time

Abdominal X-rays
UGI
Endoscopy
CT Scan
Often quite subtle

Air collections outlining right kidney

Presence of gas around the right psoas muscle

Upper GI Series
Usually with Gastrograffin or thin barium
May see a leak with fluoroscopy
Consider changing position for oblique or lateral views to
get a 3D picture

Endoscopy
May visualize a intra-luminal blood, a perforation or a
hematoma directly
May be considered in conjunction with UGI or CT
Not usually used acutely due to the possibility of worsening
injury with either the scope or the insufflation
Must be performed with both oral and intravenous
contrast
Best method for visualizing retroperitoneal structures
without an operation
Helpful in evaluating the remaining intra-abdominal
cavity in stable patients
Not always very sensitive
Extravasation of oral contrast from the duodenum with a
retroperitoneal hematoma
Extraluminal gas/fluid around the duodenum
Focal bowel wall thickening
Interruption of progress of the bowel contrast medium
S. Prichayudh et al.
Successful management of large intramural duodenal haematoma causing
obstructive jaundice
10.1016/j.injury.2007.05.025
 Unreliable in detecting isolated duodenal and other
retroperitoneal injuries
But DPL is often helpful because of 40% of patients
have associated intra-abdominal injuries that will result in
a positive DPL
The finding of amylase or bile are more specific
indicators of possible duodenal injury
 Midline incision

Immediate control of life-threatening hemorrhage

Control of GI contamination

Thorough exploration of the abdominal cavity and

retroperitoneum
Intra-op findings that require exploration
Crepitus along the duodenal sweep
Bile staining of paraduodenal or adjacent tissues
Documented bile leak
Right-sided retroperitoneal or periduodenal hematoma
Thorough exploration requires evaluation of all 4 portions
Kocher Maneuver
Transection of the ligament of Treitz
Cattell and Braasch maneuver
 Should be able to palpate the head of the pancreas to the
level of the mesenteric vessels

Be able to visualize the anterior and posterior aspects of

the 2nd and 3rd portions of the duodenum, the head of the
pancreas and the infrarenal IVC
Technique for exposure of 3rd and 4th portion of the duodenum
1. Incise the avascular line of Toldt

2. Mobilize the asending colon and the hepatic flexure

3. Sharply incise the retroperitoneal attachments of the Small

bowel from the RLQ to the duodenojejunal junction

4. Reflect the Small bowel out of the abdominal cavity

Gives excellent exposure, however it is a somewhat complex
maneuver that may not be required
Exposure of the entire fourth portion of the duodenum and
the duodenojejunal junction
Non operative
NG tube
Surgical evacuation and seromuscular repair
Duodenorrhaphy
 Used to repair approximately 75-85% of all injuries

Debride nonviable tissue

Double layer closure

Close longitudinal injuries transversely if less than 50% of

the duodenal circumference to avoid duodenal narrowing

Consider placing omentum over your repair

Duodenorrhaphy
Primary repair(with Tube Duodenostomy)
Resection anastomosis
Roux-en-Y duodenojejunostomy
Pyloric Exclusion
 Mild Severe
Agent Stab Blunt or missile
Size <75%wall 75%wall
Duodenal site 3,4 1,2
Injury repair <24 24
interval
Adjacent injury No CBD CBD
No pancreatic injury Pancreatic injury

Protection of the duodenalrepair is not necessary in the

mild group
protecting the repair with decompression maneuvers

1. Primary
Tube is placed through a separate stab incision in the
duodenum
2. Antegrade
Duodenum is decompressed by passage of a tube through
the pylorus
3. Retrograde
Tube is passed retrograde from insertion in the jejunum
Duodenorrhaphy with Tube
Duodenostomy
 An alternative to duodenal diverticulization

Secures exclusion of the duodenal suture line and diversion

of the gastric contents

Through the gastrotomy, the pylorus is closed using

absorbable suture

Alternative method includes using a stapler across the

pylorus (TA-50)
Pyloric Exclusion
Seamon MJ
A ten-year retrospective review: does pyloric exclusion
improve clinical outcome after penetrating duodenal and
combined pancreaticoduodenal injuries?
J Trauma. 2007 Apr;62(4):829-33.

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. 2007 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. 2008 Oct;74(10):925-9
 The serosa of a loop of jejunum is sutured to the edge of
the duodenal defect

The serosa exposed to the duodenal lumen rapidly

undergoes complete mucosal resurfacing.
Jejunal Serosal Patch
 If nearly the entire circumference of the duodenum is
devitalized, a segmental resection with an end-to-end
duodenostomy may be performed

If it is not possible to mobilize the duodenum without

tension, a Roux-en-Y duodenojejunostomy can be performed
with the distal duodenum oversewn.
Duodenal Resection
 Originally described by Berne in 1968
The concept is to completely divert both gastric and
biliary contents
antrectomy,
debridement and repair of the duodenum
tube duodenostomy
vagotomy
biliary tract drainage(T-tube)
feeding jejunostomy tube
Procedure is very time-consuming and may or may
not require all of the steps
Duodenal Diverticulization
 Massive disruption of duodeopancreatic complex

Duodenal devascularization

Whipple for Trauma

 Performed as a staged procedure
Control of hemorrhage, resection debridement in the initial
laparotomy
stapler resection of the duodenal sweep and pancreatic head,
ligation of the common bile duct at pancreatic head

Resuscitation in the ICU

Gastrointestinal reconstruction with pancreatic remnant
anastomosis and choledochojejunal anastomosis
18 patients (retrospective 126-month study)
17 penetrating (94%) / 1 blunt (6%)
Indications
massive uncontrollable retropancreatic hemorrhage
13 patients (72%)
massive unreconstructable injury to
the head of thepancreas/main pancreatic duct intrapancreatic
portion/distal common bile duct
18 patients (100%)
Overall survival was 67% (12 of 18 patients)
 Nonabsorbable interrupted sutures should be used to
sew the mucosa of the jejunum to the pancreatic capsule
A second layer of nonabsorbable sutures is added