Duodenal Trauma

Scott Williams, MD
The Operative Review of Surgery. 2023; 1:11-16.

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Table of Contents

General Information
Presentation & Diagnosis
Treatment
Paraduodenal Hematoma

References

General Information

General

  • Difficult Due to Complex Anatomical & Physiologic Relationships 1
  • Delay in Diagnosis is a Significant Factor in Morbidity & Mortality
    • Mortality Risk 4x if Diagnosis Delayed by Over 24-Hours 2
  • Morbidity Rate: 22-27% 1
  • Mortality Rate: 5-30% 1
    • Grade I: 8.3%
    • Grade II: 18.7%
    • Grade III: 27.6%
    • Grade IV: 30.8%
    • Grade V: 58.8%

Etiology

  • Rare: Only 3.7-5% of All Abdominal Injuries 3
  • Penetrating Trauma Most Common (77.7%) 4
    • 81% Gunshot Wounds 1
    • 19% Stab Wounds 1
  • Blunt Trauma (22.3%) 4
    • 85% Motor Vehicle Collisions 1
    • Other Blunt Causes: Assault & Falls

Mechanism of Injury

Location of Injury 1

  • First Portion: 13%
  • Second Portion: 36% – Most Common
  • Third Portion: 18%
  • Fourth Portion: 15%
  • *18% Affect Multiple Portions

Duodenal D1 Transection 5

Presentation & Diagnosis

Presentation 6

  • Mostly Nonspecific
  • Abdominal Pain, Can Radiate to the Back
  • Chest Pain
  • Nausea & Vomiting
  • Hematemesis
  • Rarely Associated with Severe Testicular Pain & Priapism I
    • Due to Sympathetic Stimulation Along the Gonadal Vessels

Diagnosis

  • Difficult Due to Complex Anatomical & Physiologic Relationships 1
  • Requires a High Index of Suspicion
  • Stable Patients May Be Diagnosed on CT
  • May Be Diagnosed Intraoperatively

AAST Duodenum Injury Scale

Associated Injuries 1

  • Liver (17%)
  • Colon (13%)
  • Pancreas (12%)
  • Other Small Bowel (11%)
  • Stomach (9%)
  • *Rarely Occurs in Isolation

Complications 6

  • Duodenal Leak/Fistula – Major Source of Morbidity
    • Initial Treatment: Conservative (NPO/NGT/TPN) & Octreotide
  • Missed Injury
  • Intraabdominal Abscess
  • Duodenal Obstruction
  • Recurrent Pancreatitis
  • Bleeding

Treatment

Surgical Access

  • Kocher Maneuver: Access D1, D2 & Proximal D3
  • Cattel-Braasch Maneuver: Access Entire Duodenum (Including Distal D3 & D4)

Primary Repair

  • Primary Repair is Generally the Preferred Treatment for Most Duodenal Injuries 7
  • Successful for 70-85% of Injuries (Even with Full Transection) 8
  • Requires: Little Tissue Loss with No Tension & No Involvement of the Ampulla
  • Considerations:
    • Nasogastric Tube to Protect Repair
    • Extraluminal Drain – Use is Debated with No Level I Evidence
      • Possible Increased Risk for Duodenal Leak 6
  • Severe or Concurrent Pancreatic Injury: Pyloric Exclusion with Gastrojejunostomy 9
    • Pyloric Exclusion (PEX) – Gastrotomy & Closure of the Pylorus Using Absorbable Suture (Vicryl or PDS) 11
    • After 4-12 Weeks Gastrojejunostomy Closes and Pylorus Reopens
    • Risk for Marginal Ulcer (Some Add Truncal Vagotomy, Most Manage Medically)

If Primary Repair Not Feasible

  • Under Tension or Involves Ampulla: Roux-en-Y Duodenojejunostomy (DJ) 12
    • Jejunal Limb Anastomosis to the Proximal Duodenum & Oversewing of Distal Duodenum
  • Massive Injury Involving Head of Pancreas: Pancreaticoduodenectomy (Whipple Procedure) 13
    • Never Done in an Emergent Setting
    • Requires Wide Drainage at Index Operation & Definitive Repair Upon Medical Stabilization

Historical Options Fallen Out of Favor

  • Jejunal Serosal Patch 14
    • Less Desirable than Roux-en-Y
  • Retrograde Jejunostomy
    • For Duodenal Decompression
  • Duodenal Diverticularization 15
    • Procedure: Primary Repair, Antrectomy & Gastrojejunostomy
    • Creates a Permanent Bypass of the Repair
    • May Add Tube Duodenostomy for Decompression
  • Triple-Ostomy Repair 16
    • Procedure: Gastrostomy, Duodenostomy (Or Retrograde Jejunostomy) & Feeding Jejunostomy
  • Triple-Tube Repair 16
    • Procedure: Primary Repair with NG Tube, Feeding Jejunostomy & Retrograde Jejunostomy

Pyloric Exclusion 10

Paraduodenal Hematoma

Causes

  • Most Common in Peds After Play (Bicycle Handlebars or Sports) or Abuse 18
  • Can Be Spontaneous Due to Hemophilia
  • May Be Associated with Anticoagulation in Older Patients 19
  • *Duodenum is the Most Common Site of Intramural Hematoma Among the GI Tract (27.5%) 20

Presentation 19

  • Mostly Nonspecific
  • Primary Concern is Progression Causing Luminal Obstruction
  • Abdominal Pain
  • Nausea & Vomiting
  • Hematemesis
  • Ampullary Obstruction Can Cause Cholestasis or Pancreatitis 21-23

Diagnosis

  • Often Difficult to Diagnose & Requires a High Index of Suspicion
  • Primarily Diagnosed by CT or UGI 19
    • May Also Be Seen on MRI
  • US Often Used in Peds to Avoid Radiation 19
  • “Stacked Coins” or “Coiled Spring” Sign on UGI – Due to Partial Intussusception of the Bowel Wall Distal to the Hematoma 24

Treatment (If Found on Imaging)

  • Conservative Treatment (NPO & Serial Exams)
    • Most (60-85%) Improve Within a Short Period (2-3 Weeks) 19
    • Complete Resolution of Symptoms Often Takes Months (Average 13 Months) 19
  • If Obstructs: NGT, TPN, & UGI Every 5-7 Days
  • If Persists > 2-3 Weeks: Operative Evacuation 17

Treatment (If Found Intraoperatively)

  • Mostly Conservative Treatment
  • Kocher & Thoroughly Inspect for Perforation
  • Indications for Hematoma Evacuation: 6
    • High Suspicion for Full-Thickness Injury
    • > 50% Luminal Narrowing

Duodenal Hematoma 17

Duodenal Hematoma 17

References

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  3. Malhotra A, Biffl WL, Moore EE, Schreiber M, Albrecht RA, Cohen M, Croce M, Karmy-Jones R, Namias N, Rowell S, Shatz DV, Brasel KJ. Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of duodenal injuries. Journal of Trauma and Acute Care Surgery. 2015;79(6):1096-1101.
  4. Poyrazoglu Y, Duman K, Harlak A. Review of pancreaticoduodenal trauma with a case report. Indian Journal of Surgery. 2016;78(3):209-213.
  5. Smiley K, Wright T, Skinner S, Iocono JA, Draus JM. Primary Closure without Diversion in Management of Operative Blunt Duodenal Trauma in Children. ISRN Pediatr. 2012;2012:298753. (License: CC BY-3.0)
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  8. Fraga GP, Biazotto G, Bortoto JB, Andreollo NA, Mantovani M. The use of pyloric exclusion for treating duodenal trauma: case series. Sao Paulo Med J. 2008 Nov;126(6):337-41.
  9. Degiannis E, Krawczykowski D, Velmahos GC, Levy RD, Souter I, Saadia R. Pyloric exclusion in severe penetrating injuries of the duodenum. World J Surg. 1993 Nov-Dec;17(6):751-4.
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