Mx duod injuries curr probl surg (1)

MANAGEMENT OF DUODENAL INJURIES

IN BRIEF

With most of the duodenum protected deep within the anatomic confines of the retroperitoneum, injuries to this organ are uncommon but not rare. These injuries represent approximately 4% of all abdominal injuries. However, because of difficulties with initial assessment, establishment of the diagnosis, and, occasionally, management, the morbidity and mortality rates associated with injuries of the duodenum approach 65% and 20%, respectively.

The first successful repair of a duodenal injury after blunt trauma was reported by Herczel in 1896. It was 1901 before Moynihan repaired a penetrating duodenal injury; he performed a gastrojejunostomy in a patient who lived for 104 days. With subsequent improvements in anesthesia, antibiotic therapy, and surgical techniques, significant decreases in operative morbidity and mortality rates have been reported.

The experiences of American military surgeons from the American Civil War through the Korean and Vietnam conflicts have contributed to our understanding of duodenal injuries. World Wars I and II, in particular, provided surgeons the opportunity to improve the care of many battlefield casualties.

The incidence of duodenal injuries is related to the geographic setting of the traumatic incident (i.e., urban or rural). Penetrating trauma accounts for 78% of all duodenal injuries, whereas blunt trauma accounts for 22%. Retroperitoneal duodenal ruptures caused by blunt trauma occur only rarely.

The morbidity and mortality associated with duodenal injuries are increased with associated injuries of the liver, pancreas, small bowel, and colon. The most commonly injured vascular structures are the inferior vena cava and the abdominal aorta. These associated injuries result in particularly high mortality from the resulting exsangui- nating hemorrhage.

The second portion of the duodenum is injured more often than any other portion and poses greater technical difficulties for surgical management. Injuries affecting multiple portions of the duodenum

1026 Curr Probl Surg, November 1993

occur with a frequency of 14%, resulting in greater technical challenges to the surgeon.

Successful diagnosis of a duodenal injury requires a high index of suspicion. The mechanism of injury represents important information that can be obtained from close communication with personnel from emergency medical services (EMS). Information such as the presence of a bent steering wheel and related data on the velocity, direction, and impact of the motor vehicular accident often yield important clues that alert the surgeon to the possibility of duodenal injury.

Duodenal injury is often overlooked because of seemingly more dramatic and life-threatening injuries, particularly those causing life- threatening hemorrhage. The history and physical examination ini- tiates the diagnostic process. The use of laboratory studies, in general, are not helpful. Radiographic studies such as plain abdominal films are helpful but only if positive. Important abnormal findings such as unexplained fluid collections surrounding the duodenum and retroperitoneal free air, particularly that outlining the upper pole of the right kidney, strongly suggest a duodenal injury.

No studies, either retrospective or prospective, have compared the use of upper gastrointestinal contrast study with the computed to- mographic scan. The upper gastrointestinal contrast study is performed initially by the ingestion or administration of a water-soluble medium and should confirm or exclude the presence of a leak. If negative, this initial study should be followed by a thin solution of barium to provide better definition of the duodenal anatomy. Posi- tive computed tomography scan findings include extravasation from the lumen, perimural and intramural duodenal hematomas, and free retroperitoneal air. The computed tomography scan also provides information that helps to diagnose other associated injuries. Magnetic resonance imaging is not yet a useful diagnostic tool in this setting.

Diagnostic peritoneal lavage is not useful in detecting retroperitoneal injuries. It is positive in approximately 50% of all cases resulting from the multiple associated intraabdominal injuries. The definitive diagnostic tool remains a meticulous exploratory laparotomy and ret-+ roperitoneal exploration.

Surgical management of duodenal injuries begins with the basic principles of initial assessment and resuscitation recommended by the Advanced Trauma Life Support course of the American College of Surgeons, including early control of the airway and adequate volume resuscitation. When a decision has been made to operate, ap- propriate broad-spectrum antibiotics are administered. The abdomen is entered through a generous midline incision extending from xiphoid to pubis. A meticulous exploratory laparotomy and retroperitoneal exploration should avoid the severe consequences of overlooked injuries.

Curr Probl SW,, November 1993 1027

When a duodenal injury is detected intraoperatively, the surgeon must be aware of factors that increase the morbidity and mortality of the injury, including the presence of associated biliary and pancreatic injuries. We recommend intraoperative grading of all duodenal injuries by the Penetrating Abdominal Trauma Index. Injuries of lesser grade should be treated by simpler surgical techniques, and injuries of greater severity should be treated by more complex techniques. The American Association for the Surgery of Trauma has also devised a scoring system to grade these injuries and establish a uni- form reporting standard.

Surgeons who treat patients with traumatic injuries to the duodenum must be able to use an armamentarium of surgical procedures to repair these injuries. Approximately 75% to 80% of all duodenal injuries can be repaired safely by simple surgical techniques such as debridement to viable tissue, primary repair by double-layer duodenorrhaphy, and drainage using a closed system. The role of tube duodenostomy as an adjunct to management and as a means of decompression and protection of the suture line is controversial. Complex surgical procedures such as the jejunal serosal patch, duodenal resection with Roux-en-Y duodenojejunostomy, duodenal resection with end-to-end duodenoduodenostomy, pedicled grafts, duodenal diverticularization, pyloric exclusion, and pancreatoduodenectomy are each useful in selected patients.

Duodenal injuries are uncommon in the trauma patient, and thus many general surgeons do not develop the expertise necessary to manage patients with this unique and challenging clinical problem. The potential for morbidity and mortality is ample and is related to the accuracy and timing of diagnosis as well as to the skill of the surgeon.

1028 Cur-r Probl Surg, November 1993

Juan A. Asensio, MD, graduated with a BS degree from the University of Illinois. He received his MD degree from Rush Medical College and completed his surgical residency at Northwestern University in Chicago and the Medical CoZ- lege of Ohio at Toledo and then completed fellowships in trauma surgery and surgical critical care at the University of Tezas Health Sciences Center, Dallas/Southwestern Medical School, and Parkland Memorial Hospital. He is CUF-

rently Associate Professor of Surgery and Chief of the Di- vision of Trauma Surgery and Surgical Critical Care at Hah- nemann University, where he also serves in the capacity as medical director of the Air Evacuation Service/MEDEVAC and medical director of the Trauma Center. Dr. Asensio has been instrumental in organizing trauma centers in both Central and South America. ilr. Asensio’s interests include exsanguination; penetrating neck injuries, cardiovascular system injuries, pancreas, and duodenum; and surgical critical care.

David V. Feliciano, MD, received his BS and MD degrees from Georgetown University, He completed internship and residency training in general surgery at the Mayo Clinic after active duty in the U.S. Navy. He furthered his training in trauma surgery at Detroit General Hospital during residency and a fellowship in vascular surgery at the Baylor, College of Medicine. Dr. Feliciano is currently Chief of Sur- gery at Grady Memorial Hospital, attending surgeon at Crawford Long Hospital, Professor of Surgery at Emory Uni- versity, and Clinical Professor of Surgery at the Uniformed Services University of Health Sciences. He is immediate Past President of the Southwestern Surgical Corigress, the President of the Western Trauma Association and the Priestley Society (Mayo surgeons), and a member of the Ex- ecutive Committee of the Committee on Trauma of the American College of Surgeons. His interests include abdominal and vascular trauma, endocrine and general SUF-

gery, and surgical critical care.

Curr Probl Surg, November 1993 1029

L. Delano Britt, MD, received his BA degree from the Uni- versity of Virginia, his MD degree from the Harvard Medi- cal School, and his MPH degree from the Harvard School of Public Health. Dr. Britt is currently Chief of the Division of Trauma and Critical Care at the Eastern Virginia Medi- cal School and medical director of the Shock Trauma Cen- ter at Sentara Norjiolk General Hospital.

Morris D. Kerstein, MD, completed his surgical training on the First (Tufts) Surgical Service of the Boston City Hospi- tal in 1971 afrer serving a research fellowship at Sahlgren- ska Hospital in Goteborg, Sweden, from 1968 to 1969. After serving on the faculty of the Yale University School of Medi- cine, the University of Chicago, and the Tulane University School of Medicine, Dr. Kerstein was appointed as the Edgar J. Deissler Professor and Chairman of the Depart- ment of Surgery at Hahnemann University School of Medi- cine. His interest in trauma began with an active-duty tour from 2965 to 1967 with the U.S. Navy during the Vietnam conflict. His continued interest in trauma and the Navy contributed to his appointments as Rear Admiral, U.S. Navy, at the Bureau of Medicine and Surgery and Assistant to the Deputy Surgeon General of the Navy for Reserve Matters. Dr. Kerstein’s research interests have focused on vascular surgery problems, prostaglandin metabolism in the vascu- lature, and trauma.

Curr Probl Surg, November 1993

MANAGEMENT OF DUODENAL INJURIES

INTRODUCTION

The duodenum is the epitome of an organ poorly designed to with- stand the ravages of trauma. Located in the inaccessible and dark reaches of the retroperitoneum, injuries to the duodenum usually are not suspected or are diagnosed rather late while more apparent injuries to other organs are addressed. The small, thin-walled duodenum possesses a marginal blood supply shared with the pancreas. Therefore this organ is not amenable to sound technical closure, and parts of it are very difficult to resect. Lying against the vertebral column, the duodenum is highly susceptible to severe crushing injuries. It is also fixed at two separate points-the portal triad and the ligament of Treitz- thereby subjecting it to decelerating injuries. Fur- thermore, it is subject to “blow-out” injury by being, at times, closed at its portals of entrance (the pylorus) and exit (the duodenojejunal junction).

The duodenum is surrounded by many vital structures, including the aorta, inferior vena cava, superior mesenteric vessels, portal vessels, right renovascular pedicle, and the biliary tree. When injured, these structures produce large amounts of blood and bile that may obscure injuries of the duodenal wall. Finally, its matrimony of con- venience to the pancreas (by virtue of its shared blood supply) is easily disrupted at the time of injury by the action of the pancreatic en- zpes released frequently during combined pancreatic and duodenal injuries.

Given these considerations, it is no wonder that duodenal injuries remain one of the most complex challenges for modern-day trauma surgeons. The objectives of this monograph are (1) to familiarize the reader with duodenal anatomy as it relates to trauma surgery, (2) to provide an in-depth analysis of the incidence and mortality rate of duodenal injuries, and (3) to provide a concise approach to diagnosis, surgical management, and treatment of complications of duodenal trauma.

Curr Probl Surg November 1993 1031

HISTORIC PERSPECTIVE

There is a scarcity of well-documented historic accounts regarding the management of duodenal injuries. Several characteristics of the duodenum may account for this fact: its retroperitoneal location, the difficulty in mobilizing it surgically, or the fact that it just did not emerge within the realm of surgical diagnosis or treatment during the last century. However, the primary reason for this lack of docu- mentation appears to be the infrequent use of exploratory laparotomy for the management of traumatic abdominal injuries. Although this technique had been readily available and used for nontraumatic abdominal problems, most surgeons did not view it with much respect.

Exploratory laparotomy was used by Baudens in 1836: however, it was not until the Civil War that the procedure was considered valuable in the management of abdominal trauma.’ It was not until World War I that American surgeons become more forceful and began to explore soldiers who sustained penetrating abdominal injuries.

Perhaps one of the earliest recorded cases of successful outcomes from penetrating duodenal injuries is credited to Larrey, the French surgeon who recorded the following case in 1811:

Etienne Belloc, age 17 fusileer of the guards was wounded by a sword in the abdomen about two inches above the umbilicus, and on the right side of the linea alba. He was brought to the hospital on April 1, 1811, and the attending surgeon applied a simple dressing and bandage. Next day, I examined the wound, which permitted the omentum to escape through it. The right rectus muscle and its tendinous sheath were cut quite through, and the instrument appeared to have passed in a transverse direction deeply, from before, backwards, between the great curve of the stomach, and the arch of the colon.

The paleness of death was on his countenance and he was tormented with intolerable anguish, nausea, and efforts to vomit; with hiccough, ardent thirst and acute pain at the bottom of the wound, and great anxiety; his pulse was small and feeble, his extremities cold, and voice no longer audible: We had reason to believe he could survive but a few moments.

Still, I reduced the omentum, with my fingers ascertained that the sword had glanced between the stomach and colon, but I could not decide on the place where it had stopped; the wound was dressed externally, with linen, etc., dipped in warm wine. The abdomen was embrocated with warm cam- phorated oil and covered with hot flannel. I prescribed cooling mucilaginous drinks, emollient enemata, low diet, a particular position of the body and perfect rest. He felt but a little relief from this treatment; the prostration continued as before, the pulse was small and tense, and anxiety and nausea attended: He was never at rest. On the night of the second day, vomiting came on with considerable efforts, cold sweat and alarming syncope, he first discharged the contents of his stomach by vomiting and then bilious matter with clots of black blood. On the fourth day, to this bilious evacuations succeeded the vomiting of thick black blood in such quantity that the chamber-


utensil was filled with it in a few minutes. On the iifth day, an alvine evacuation, equally copious took place, proceeded by violent colick and acute pains in the wound; the abdomen always remained flaccid and without any signs of effusion in its cavity. An alarming syncope succeeded this evacuation on the night of the 6th, and his companions believed him dead. When I visited the hospital very early the next morning, I found his face covered with a sheet and he opened his eyelids with difficulty; the pulse was imper- ceptible, and his body cold. I immediately gave him warm wine, had his body rubbed with oil of chamomile, and wrapped in hot flannels. The colick never returned and from this time he gradually recovered. I prescribed a mucilaginous drink with syrup of althea and orange-flower water, to which was added a small quantity of nitrated alcohol; emollient enemata were given, and the oily embrocations of the abdomen continued. . .3

The rest of the account continues with a detailed description of subsequent complications, convalescence, and the basis for diagnosis of duodenal injury.

During the American Civil War, five soldiers were reported to have incurred duodenal wounds resulting from “shot injuries,” with a 100% mortality rate and no surgical intervention. A detailed autopsy report was described as follows:

Case 2112. Pvt. James M.; Company I?. Wound of the abdomen at Winches- ter on September X9,1864. The missile conoidal ball entered at the‘ right side of the epigastrium, at the edge of the ribs, and emerged through the right buttock. He was admitted on the same day to the hospital of the Sixth Corps. He was an emaciated subject. Water dressings were applied to the wound and ferruginous preparations and opiates were administered with milk punch. A farinaceous and milk diet was allowed. Faeces escaped freely from the wound exit and also from the wound of entrance for a few days. After this, frequent and continued alvine ejections took place through the natural channels. Death resulted on October 12, 1864. At the autopsy it was found that the ball entering the right side of the epigastric region had carried away about half of the caliber of the duodenum, near the orifice of the cystic duct. It had passed obliquely downward and backward through the caecum above the ileo-cecal valve.4

The first successful surgical repair of a duodenal rupture was reported in 1896 by Herczel,’ who repaired the ruptured duodenum of a 36-year-old woman after blunt trauma. In 1901, Moynihan” closed a duodenal wound and performed a gastrojejunostomy with a prolonged survival of 104 days and subsequent death. In a paper read before the Western Surgical and Gynaecological Association on De- cember 28,1903, and published in 1904, Summers described what is perhaps the earliest and best-documented report of treatment of retroperitoneal perforation of the duodenum caused by a gunshot wound to the back. In this report, Summers described the unsuc- cessful outcome of a young man who sustained a gunshot from a .38-caliber Colt revolver. He described repair of the duodenal wound


TABLE 1. American military experience with duodenal injuries

Conflict Author Year Number of cases Mortality rate

American Civil War Otis4 1876 5 100.0% World War I Lee%’ 1927 10 80.0% World War II Cave” 1946 118 55.9% Korean War Sako et al? 1955 17 41.2%

from a posterior approach and the patient’s subsequent demise 3 days later as follows:

Had the man’s condition admitted, I would have sutured the wound in the posterior duodenal wall after freeing and rotating the duodenum to the left. In light of to-day, one should in a like case, in addition to repairing the duodenal wound or wounds, occlude the pylorus by means of a purse string stitch. This same operation or soon thereafter as reaction admitted a gastroenterostomy, must be made.7

In the same paper, Summers also quoted Jaenel, who reported 35 cases of duodenal injury culled from the literature. In 1905, Godwin’ described a series of ruptures of the duodenum and jejunum with a high mortality rate and a second successful operative repair. In the same fashion, other sporadic reports began to appear in the literature, including an article by Meerwin,’ who reported another successful operative outcome in 1907, and an article by Kanavel,” who reported on several other successful outcomes.

A noninterventional approach for management of traumatic injuries to the abdomen prevailed until World War I. In this war, as in other wars, the surgeon was provided with an opportunity to treat large numbers of casualties. During this period the first American military series was compiled by LeeI and reported in 1927. During World War II, Cave” compiled what is still the largest military series describing 118 cases. In 1955, Sako and colleagues13 reported 17 cases from the Korean War experience. The results of all American military series are tabulated in Table 1. Missing from this table are the results from America’s longest conflict, the Vietnam War. Although this conflict produced hallmark works regarding the management of traumatic vascular, colon, and rectal injuries, few reports are available on duodenal injuries, with the exception of two cases of combined pancreaticoduodenal injuries requiring pancreaticoduodenectomy reported by Halgrimson and colleagues14 in 1969.

DUODENAL ANATOMY

The anatomy of the structures in the right upper quadrant of the abdomen is complex. Every surgeon should be familiar with this area


and its multiple anatomic variations. The duodenum constitutes the beginning of the small bowel and measures approximately 21 cm.15

The duodenum is divided into four portions: superior, descending, transverse, and ascending. These divisions are also known as the first, second, third, and fourth portions, respectively. The first portion of the duodenum ranges from the pyloric muscle to the common bile duct superiorly and the gastroduodenal artery inferiorly. Its origin is marked by the pyloric vein of Mayo. The second portion extends from the common bile duct and the gastroduodenal artery to the ampulla of Vater. The third portion extends from the ampulla of Vater to the mesenteric vessels (superior mesenteric artery and vein), which cross anteriorly over the junction of the third and fourth portions as they emerge from the inferior border of the neck of the pancreas. The fourth portion extends from these vessels to the point at which the duodenum emerges from the retroperitoneum to join the jejunum just to the left of the second lumbar vertebra.

The entry to the duodenum is closed by the pyloric sphincter, and its exit is suspended by the fibromuscular ligament of Treitz. The duodenum is mobile at the pylorus and its fourth portion but remains totally Iixed at other points.16 The ligament of Treitz, present in 86% of the population, extends from the right pillar of the diaphragm to blend in with the smooth muscle of the duodenal wall (5% 1, the third and fourth portion of the duodenum, or a combination of the three (95%). It contains smooth muscle in 85% of the individuals in whom it is present.17

The duodenum is, for all practical purposes, a retroperitoneal organ, except for the anterior half of the circumference of its first portion. The first portion, the distal half of the third portion, and the fourth portion in its entirety lie directly over the vertebral column, which, coupled with the psoas muscles, aorta, inferior vena cava, and right kidney, form its posterior boundaries. Anteriorly, the duodenum is bounded by the liver that overlies the first and second portions, the hepatic flexure of the colon, right transverse colon, mesocolon, and stomach that overlies the fourth portion. Laterally, the gallbladder and medially, the pancreas, nestled in the C loop, are in proximity.

The duodenum shares its blood supply with the pancreas. Vessels that supply the duodenum include the gastroduodenal artery and its branches, the retroduodenal artery, the supraduodenal artery of Wilkie, the superior pancreaticoduodenal artery, and the superior mesenteric artery and its first branch, the inferior pancreaticoduodenal artery. Anatomic variations are common in this area because the gastroduodenal artery is known to arise occasionally from the left hepatic artery (ll%), right hepatic artery (?‘%), a replaced hepatic trunk (3.5%), or from the celiac or superior mesenteric arteries.18’1g The gastroduodenal artery courses from its hepatic origin at the su-


perior surface of the duodenum under its second portion and enters the pancreas just below and opposite the common bile duct above the duodenum.” It makes a loop on the ventral surface of the pancreas, runs along the groove between the pancreas and descending (second) portion of the duodenum, sinks into the substance of the pancreas, and is dorsal to the head of the pancreas as it anastomo- ses with the inferior pancreaticoduodenal artery. The dorsal and ventral pancreaticoduodenal arcades formed by the anastomosis of the superior and inferior pancreatic duodenal arteries supply numerous branches to the pancreas and the duodenum.”

The anastomosis between the gastroduodenal and inferior pancreaticoduodenal arteries serves as a collateral and communicating pathway between the celiac axis and the superior mesenteric artery. Anatomic variations occurring in proximity to the duodenal loop and uncinate process of the pancreas include an anomalous common hepatic artery arising from the superior mesenteric artery in 5% of patients and an anomalous right hepatic artery arising from the same vessel in 25% of patients.‘l’ ”

The common bile duct enters the posterior substance of the head of the pancreas in 83% of patients after it passes under the duodenum.23J 24 After piercing the caps&e of the pancreas posteriorly, the duct courses down within the pancreatic substance a few centime- ters from the curve of the duodenum, entering the duodenal lumen at the junction between the second and third portion of the duodenum approximately 2.0 to 2.5 cm from the py10rus.~~ Three main variations exist with regard to the way both the common bile duct and pancreatic duct enter the duodenum. In 85% of individuals, both ducts enter through a common channel at the ampulla of Vater, whereas in 5% both ducts enter the duodenum on the same ampulla but through separate channe1s.l’ In the remaining 10% of individuals, both ducts enter the duodenum separately.z6

l%IYSIOLOGIC ASPECTS

The duodenum serves as the mixing point for the partially digested chyle,from the stomach and the proteolytic and lipolytic secretions of the biliary tract and pancreas. As such, it commonly contains not only food but powerful activated digestive enzymes, including lipase, trypsin, amylase, elastase, and peptidases, among others.27

The pylorus, which acts as a metering mechanism, is estimated to be closed one third of the time.16 Approximately 10 L of fluid from the stomach, bile duct, and pancreas passes through the duodenum in a 24hour period. The high volume and high toxicity of the duodenal contents account for the disastrous effects that ensue if a


breach in the duodenal wall occurs. Escape of duodenal contents into the free peritoneal cavity or retroperitoneum incites an extremely de- structive process that is compounded by the inflammatory response that it provokes.”

INCIDENCE OF DUODENAL INJURIES

Duodenal injuries are uncommon, although not necessarily rare, in busy trauma centers. The retroperitoneal location of the duodenum, no doubt, has a strong role in protecting it and thus accounts for the low incidence of injury to this organ. The true incidence of duodenal injury is difficult to estimate from the literature. Among several major textbooks of surgery, none cite a figure.2s-34 Among seven major textbooks and yearly publications dealing exclusively with trauma, four publications failed to cite a figure for the incidence of duodenal trauma.“’ 35-40 Two of the remaining publications cited a figure of 3% to 12%, but both failed to provide adequate documenta- tion of the incidence of duodenal trauma. In only one of the major textbooks of trauma is a figure quoted on the basis of the experience of the author’s home institution.35

A review of more than 150 journal articles dating from 1901 again yields little data on the subject. As best estimated from the literature, duodenal injuries occur in approximately 4.3% of all patients with abdominal injuries, with a range of 3.7% to 5.0%. These figures, however, are based on only one military and two civilian reports.

In 1955, Sako and colleagues13 reported the Korean War experience of 17 duodenal injuries in 402 cases of abdominal injury treated in a forward surgical hospital, for an incidence of 4.2%. In 1968, Morton and Jordan41 reported 13 cases of duodenal injury among 280 abdominal trauma cases, for an incidence of 5%. In 1978, Kelly and col- leagues4’ reported 34 cases of duodenal trauma in a 68-month period, representing only 3.7% of all patients explored for abdominal trauma at their institution. These figures are validated in a recent and excellent review of duodenal trauma reported by Levinson and colleagues,43 in which they cited an incidence of duodenal injury of 3% to 5% in patients who sustained abdominal injury.

MECHANISM OF INJURY

The anatomic location of the duodenum protects it from casual injury. Most duodenal injuries are either penetrating or blunt, Pene- trating injuries include gunshot wounds, stab wounds, or shotgun wounds, whereas blunt injuries occur as the result of motor vehicle accidents, falls, or aggravated assaults. The mechanism of injury that

Cum Probl Surg, November 1993 1037

TABLE 2. Mechanism of iniurv in duodenal iniuries

Author and year Total no.

of patients

Mechanism of injury

Penetrating Blunt

Morton and Jordan, 196S41 131 Smith et al., 197145 53 McInnis et al., 197?” 22 Corley et al., 197447 98 Lucas and Ledgewood, 197548 36 Matolo et al., 197549 32 Kelly et al., 197S4’ 34

Stone and Fabian, 197g5’ 321 Flint et al., 197g51 75 Snyder et al., 19805’ 228

Levinson et al., 198243 93 Adkins and Keyser, 198453 56 Fabian et al., 198454 10 Ivatury et al., 198555 100 Bostman et al., 198gs6 18 Cogbill et al., 199057 164

Cuddington et al., 199O58 42 TOTAL 1513

117 14 46 7 17 5 75 23

0 36 19 13 28 6

294 27 56 19

180 48

74 19 39 17

0 10 100 0

16 6 102 62

16 26 1175 338

(77.7%) (22.3%)

occurs most often depends on the surgeon’s practice location.44 Pen- etrating injuries are more common in the inner city population, whereas blunt injuries predominate in the rural environment.

Overall, penetrating injuries are the most common causes of duodenal trauma. In a review of the literature encompassing 17 series published during the last 22 years, 1513 cases of duodenal injuries were identified; 1175 (77.7%) occurred as the result of penetrating trauma, whereas 338 (22.3%) occurred as the result of blunt trauma.41-43J45-58 Thus the ratio of penetrating to blunt trauma was 3.5:1 (Table 2).

Of these 17 series, 12 provided an accurate breakdown of the wounding agent causing penetrating injuries,41-43’4s-53’55-57 and 8 provided the same breakdown for blunt injuries.43J 47, 48J 51-53J 56J 57 Among 1096 penetrating injuries, 818 (74.6%) were caused by gunshots, 214 09.5% 1 were caused by stabbings, and 64 (5.9% 1 were caused by shotgun blasts (Table 3). Among 230 blunt injuries, 178 (77.3%) were caused by motor vehicle accidents, 22 (9.6% 1 were caused by falls, 22 (9.6%) were caused by aggravated assault, and 8 (3.5%) were caused by miscellaneous injuries (Table 4).

The actual mechanisms of wounding in penetrating trauma occur by simple violation of the duodenal wall either by a sharp object (e.g., knife blade) or, in the case of missiles, by penetration and actual dis-


TABLE 3. Penetrating injuries-wounding agents

Total no. Author and year of penetrating injuries

Gunshot Stab Shotgun wound wound wound

Morton and Jordan, 1968”

Corley et al., 197447 Matolo et al., 197E? Kelly et al., 197S4’ Stone and Fabian, 197g5’ Flint et al., 197g51 Snyder et al., 19805’ Levinson et aI., 198243 Adkins and Keyser, 198453 Ivatury et al., 198E? Bostman et al., 198gs6 Cogbill et al., 19905’ TOTAL

117 87 22 8

75 19 28

294 56

180 74 39

100 12

102 1096

51 24 0 18 1 0 23 5 0

239 31 24 51 4 1

143 23 14 43 27 4 27 5 7 69 30 1

1 11 0 66 31 5

818 214 64 (74.6%) (19.5%) (5.9%)

TABLE 4. Blunt injuries-wounding agents

Author and vear No. of blunt Motor vehicle Aggravated

iniuries accident Falls assault Miscellaneous

Corley et al., 197447 Lucas and Ledgerwood,

197548 Flint et al., 197g51 Snyder et al., 1980” Levinson et aI., 198243 Adkins and Keyser, 198453 Bostman et aI., 198gs6 Cogbill et al., 19905’ TOTAL

23 12 4 7 0 36 30 3 3 0

19 48 19

7 6

62 230

13 3 0 3 44 3 0 1 11 3 2 3

8 5 3 1 6 0 0 0

54 1 7 0 178 22 22 8

(77.3%) (9.6%) (9.6%) (3.5%)

sipation of the kinetic energy imparted on the missile at the time of its exit from the gun.

Much more complex kinematics exist when blunt injury occurs. The duodenum is a retroperitoneal organ that lies against a rigid vertebral column. It is a highly mobile hollow viscus, which is fixed at two points, the second portion by the common bile duct and the fourth portion by the ligament of Treitz. The portals of entry and exit can be closed, the former by the pyloric sphincter mechanism and the latter by the fibromuscular ligament of Treitz. Therefore disruption of this hollow viscus is subject to crushing, shearing, or burst- ing.


Crushing injuries usually occur when a direct force is applied against the abdominal wall and transmitted to the duodenum, which is then projected posteriorly against the rigid and unyielding vertebral column. A good example of crush injury occurs when the steering wheel impacts on the midepigastrium. Shearing injuries occur when the mobile and nonfixed portions of the duodenum accelerate and decelerate forward and backward, respectively, against the fixed and stable portions, as may occur during falls from great heights,

Finally, blow-out injuries occur when a force is applied to a gas and fluid-filled duodenum against a closed pylorus and acutely flexed duodenojejunal angle resulting from the contracted fibromuscular ligament of Treitz, as described by Cocke and Meyer.” The pylorus is closed approximately one third of the time when a peristal- tic wave passes over it into the duodenum. This wave migrates over the duodenum, resulting in closure of the pylorus and contraction of the suspensory ligament of Treitz. Therefore a closed-loop effect is established periodically such that a blow delivered to the abdomen at a given point in time would provide both an anatomic pre- disposition and physiologic state favorable to rupture of the duodenal wall.

ASSOCIATED INJURIES

The duodenum, by virtue of its anatomic proximity to other important organs, is rarely injured alone. In fact, multiple associated injuries are the rule rather than the exception. This situation is particularly true with penetrating trauma, but it also occurs with blunt trauma. Isolated duodenal injuries usually are seen in the form of duodenal hematomas.

TABLE 5. Associated injuries

Author and year No. of Patients with

patients associated injuries Associated

iniuries

McInnis et al., 197546 22 Corley et al., 197447 98 Lucas and Ledgerwood, 1975- 36 Matolo et al., 197E? 32 Kelly et al., 197S4’ 34 Stone and Fabian, 197g5’ 321 Flint et al., 197g51 75 Snyder et al., 19805’ 228 Levinson et al., 198243 87 Adkins and Keyser, 1984j3 56 Cogbill et al., 1990” 164 T0T.Q 1153

18 (81.8%) 47 88 187.8%) 206 25 169.4%1 49 26 181.3%) 66 31 (91.2%) 97

294 191.5% i 1143 59 (78.6%) 16.5

217 (95.2%) 575 85 (97.7%) 184 50 189.2%) 122

152 (92.6%) 393 1045 186.94%) 3047

1040 Cm- Probl Surg, November 1993

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., 19

7447

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197P

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. 19

75””

Kelly

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., ;9

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bian

, 19

7g5”

Fl

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et

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197Y

51

Snyd

er

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1980

”’ Le

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., 19

8P

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s an

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, 19

8453

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., 19

90”7

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5 1

7 11

4

3 11

2

5 6

2 32

37

19

24

19

20

7

13

15

14

4 7

19

2 1

0 3

5 0

2 5

3

11

7 10

10

5

6 6

13

9 8

13

14

11

18

186

101

147

100

98

98

185

31

20

2.5

29

13

24

0

99

64

60

73

77

60

0

39

21

26

23

14

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11

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16

10

8

8 74

65

29

43

45

27

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517

355

351

343

299

278

253

1 5

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4 5

74

91

63

11

0 12

51

39

52

15

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9

11

6 6

29

22

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2 0 0 0 0 6 2 18

37

TABLE 7. Associated injuries

Organ No. of injuries Percentage of total

Liver 517

Pancreas 355 Small bowel 351 Colon 343

Major veins 299

Stomach 278 Miscellaneous injuries 253 Biliary tree and gallbladder 209

Major arteries 202

Genitourinary injuries 203 Spleen 37

TOTAL 3047

16.9

11.6 11.6 11.5

9.8

9.1 8.3 6.8 6.6

6.6 1.2

A review of 11 series during the last 22 years identified a total of 1153 cases of duodenal injury.41’43’46-53, 57 Among these patients, 1045 (86.9% 1 sustained a total of 3047 associated injuries (Tables 5-7). The liver was the most commonly injured organ; a total of 517 injuries occurred, with a frequency of 16.9%. Other commonly injured organs included the pancreas, with 355 injuries (11.6%); small bowel, with 351 injuries (11.6% 1; and colon, with 343 injuries (11.5%).42,43,46-53, 57 Miscellaneous injuries, mostly extraabdominal, accounted for 253 injuries (8.3%). Major abdominal venous injuries occurred in 299 patients (9.8%). The inferior vena cava accounted for most of these injuries. Arterial injuries occurred in 202 patients (6.6% 1, with the aorta accounting for most of these injuries. Interestingly, genitourinary tract injuries occurred in 6.6% of the patients, and the spleen was the abdominal organ injured least frequently. Only six diaphragmatic injuries were identified. The lung was the most frequently injured extraabdominal organ5’

ANATOMIC LOCATION OF INJURY

To identify the anatomic locations of duodenal injuries, we reviewed nine series published during the last 22 years.41J 46J 47J 50-55 Se- lection criteria included an accurate description of the anatomic location of the duodenal injury and a description of the sites of other organ injuries. From this review, a total of 1003 injuries were analyzed. The most frequent site of duodenal injury was the second portion, with 331 injuries (33.0%). The third and fourth portions sustained 194 (19.4% 1 and 190 (19.0%) injuries, respectively. The least frequently injured portion of the duodenum was the first, accounting for 144 injuries (14.4%). Multiple sites of injury occurred in 142 patients (14.2% 1 (Table 8).

1042 Curr Probl Sur. November 1993

TABLE 8. Anatomic location of duodenal injury (blunt and penetrating1

Portion of duodenum injured

Author and vear No. of uatients 1st 2nd 3rd 4th Multi&e

Morton and Jordan, 196s4*

McInnis et al., 197,? Corley et al., 197447 Stone and Fabian, 197g5’ Flint et al., 197g51 Snyder et al., 19805’ Adkins and Keyser, 198453 Fabian et al., 198454 Ivatury et al., 198555 TOTAL

NA, Not available.

131 24 56 18 17 16

22 98

302 72

228 56 10 84

1003

1 9 7 5 NA 5 49 16 13 15

63 74 84 81 NA 9 18 8 16 21

23 67 33 37 68 10 16 13 5 12

0 4 4 2 0 9 40 11 14 10

144 331 194 190 142 (14.4%) (33.0%) (19.4%) 119.0% 1 (14.2%)

The second portion is the most frequent site of injury for both penetrating and blunt trauma.41’ 46, 47J 50-55 However, with penetrating trauma, injuries were distributed throughout the anatomic course of the duodenum, whereas in blunt trauma most injuries remained confined to the second portion of the duodenum, usually its posterior surface.51

DIAGNOSIS

The diagnosis of duodenal injury requires a high index of suspicion. The physician must understand that delays in the diagnosis and management of these injuries result in increased morbidity and mortality. Information must be obtained from EMS personnel because they often provide helpful information in establishing the diagnosis.

The diagnosis of duodenal injury presents a greater challenge after blunt trauma than after penetrating trauma. Important information to be obtained includes the hemodynamic status of the victim in the field and, for example, the state in which a vehicle was found (e.g., overturned, pointing in the opposite direction of impact, or having sustained passenger compartment invasion), Furthermore, the physician must ascertain the status of the steering wheel (e.g., bent or intact), the direction of force impact, and whether extrication was used to retrieve the victim.

With such information, a series of characteristics emerge that col- lectively increase the surgeon’s suspicion for duodenal injuries. For example, patients who have head-on collisions or force impacts from the right, who have struck the steering wheel, or who needed extrication may harbor duodenal injuries.

Cur-r Probl Surg, November 1993 1043

Patients who have sustained blows to the midepigastrium must be evaluated thoroughly. Even an impact of a small magnitude, given the right anatomic and physiologic conditions, can cause duodenal blow- outs. Finally, patients who have fallen from great heights are subject to deceleration injuries of the duodenum.”

When examining the patient, the physician must remember that the retroperitoneal location of the duodenum may preclude early manifestation of injury on physical examination. Abdominal discom- fort may be out of proportion to the physical findings, and peritoneal irritation may occur late and become apparent only when extravasated blood, enteric contents, or enzymes that were initially con- tained retroperitoneally have entered the peritoneal cavity. By then, much time has been lost, and significant morbidity and mortality can be expected from this delay in diagnosis.

The physical examination may be characterized by minimal findings. Any tenderness over the right upper quadrant or midepigastrium should be evaluated with the suspicion of duodenal injuries. Signs of rebound tenderness, abdominal rigidity and absence of bowel sounds indicate intraabdominal injury and should prompt early surgical intervention. Rarely, referred pain in the neck has been reported to occur with duodenal injuries.“? Severe testicular pain and priapism have also been reported in association with duodenal injury. Some researchers have postulated that pain impulses are con- ducted by sympathetic nerve fibers running alongside the gonadal vessels.61

Laboratory tests are of little help in the early diagnosis of duodenal injuries. The serum amylase level is frequently mentioned as a possible indicator of duodenal injury. In 1972, Northrup and Sim- mons62 reported a rise in the serum amylase level in more than 90% of all patients sustaining pancreatic injury. However, a rise in the serum amylase level associated with duodenal injury is usually mod- est and less predictable. In 1980, Snyder and colleaguess2 reported the serum amylase level to be elevated in 53% of 21 patients evaluated. The numbers of patients are small and should not prompt the reader to assign the amylase level a predictive value in the diagnosis of duodenal injury. Unfortunately, the serum amylase level is sensitive but nonspecific for duodenal injury. Flint and colleaguessl stated that the serum amylase level is not helpful in early diagnosis of duodenal injuries. The serum amylase level should not be used as an indicator for exploratory laparotomy.63’ 64

The serum amylase level may have a predictive value in patients admitted for observation. Lucas and Ledgerwood4’ suggested that the serum amylase level be determined at 6-hour intervals. A persistently elevated or rising amylase level may be of prognostic significance in detecting delayed manifestation of duodenal injury. This concept is supported by Levinson and colleagues,43 who reported three patients


who had elevations of their serum amylase levels between 4 and 12 times normal during a period of observation. At exploration, they were found to have extensive duodenal injuries.

Radiologic studies have been suggested to be the diagnostic procedure of.choice in establishing the diagnosis of duodenal injury. Plain films of the abdomen are useful only if they are positive. The first case of duodenal rupture diagnosed radiographically was described in 1937 by Sperling and Rigler.65 These authors correlated the presence of air collections outlining the right kidney with extraperitoneal rupture of the duodenum. A second case report of duodenal rupture diagnosed by plain films of the abdomen was reported in 1940 by Cittenheimer and Gilman.

In 1944, Jacobs and colleagues67 described other radiographic findings associated with duodenal rupture, including the presence of gas around the right psoas muscle and in the retrocecal region. They confirmed that the finding of gas outlining the right kidney was a valuable radiographic finding. These investigators observed that free air was usually not present in the peritoneal cavity. They also described the possible routes of extension of extravasated material from a perforation of the retroperitoneal duodenum. These routes were as follows: along the transverse mesocolon; along the mesentery of the small intestine; over the right kidney and, rarely, over the leftxkidney; downward along the route of the mesentery of the ascending colon and cecum; downward along the psoas muscle to the brim of the bony pelvis or to Poupart’s ligament; and, finally, along the great vessels through the diaphragm into the inferior mediastinum. Further- more, these authors outlined the protocols for obtaining abdominal x-ray fiIms and recommended that the x-ray films be repeated several hours after the injury if the initial x-ray findings were negative. This group also recommended against the use of barium for establishing diagnasis of duodenal rupture:

The use of barium or bismuth salts in the roentgen diagnosis of any acute perforation of the gastrointestinal tract is contraindicated.

Barium in the tissue may act as a foreign body irritant and may serve to enlarge the retroperitoneal area of infiltration further. The procedure may be shocking to a patient who is already on the verge.67

In 1949, Siler reported four cases of rupture of the duodenum caused by violence and advocated the use of radiographic visualization of the duodenum with the upper gastrointestinal series using Lipiodol or thin barium sulfate. He described the following radiographic findings of both intraperitoneal and retroperitoneal rupture of the duodenum:

In intraperitoneal rupture of the duodenum, a definite sinus may be visualized and the diagnosis in this location may be demonstrated clearly. In the case of extraperitoneal rupture of the duodenum, the roentgenogram,

Cum Probl Surg, Navember 1993 1045

taken either in the oblique or lateral position, may demonstrate a sinus leading from the duodenal lumen to the retroperitoneal space.68

In 1951, Jacobson and Carter further corroborated the findings described by Jacobs and colleagues67 and added scoliosis as an associated finding in retroperitoneal extravasation of duodenal contents. These authors cautioned that most patients with duodenal ruptures did not have positive radiographic findings:

The marked paucity of positive findings makes the roentgen examination of the abdomen of little value in excluding perforations of the small intestine following non-penetrating abdominal injuries.6g

In 1952, Cohn and his surgical colleagues stated:

We believe the most important feature about x-ray diagnosis is that we cannot await a positive diagnosis.70

With greater experience in the use of the upper gastrointestinal series, Felson and Levin71 described the “coiled-spring” sign they found in the upper gastrointestinal radiologic examination using thin barium. These authors believed this sign to be diagnostic of intramural hematoma.

In 1961, Wiot and colleagues7’ described an additional sign on the basis of similar diagnostic findings. The study involved the mucosal folds in two patients with intramural duodenal hematoma whose conditions were diagnosed on the basis of anticoagulant-induced bleeding, which the authors described as the “stacked coin sign.”

Radiographic signs are detectable on plain films in fewer than one third of patients. In 1964, Cocke and Meyer,l’ on the basis of data collected from the literature, reported 48 patients with retroperitoneal duodenal rupture and documented that 17 patients had positive radiographic signs. These authors also pointed out that in a small percentage of patients free intraperitoneal air may exist, as was found in 3 of their 48 patients.

In 1974, a similar scarcity of radiographic findings was reported by Corley and colleagues47 in 17 patients with blunt rupture of the duodenum from nonpenetrating trauma. Three patients had free intraperitoneal air. However, in 12 patients with penetrating trauma, free or retroperitoneal air was demonstrated on plain films of the abdomen. These investigators suggested that positive radiographic findings on plain films of the abdomen are somewhat more common in patients sustaining penetrating trauma than in patients sustaining blunt trauma. This scarcity of radiographic findings has also been documented by Cleveland and Waddell”’ and by Stone and Fabian5’

In 1972, King and Provan and Toxepeus and colleagues74 noted that retroperitoneal air overlying the upper pole of the right kidney can be misinterpreted as the hepatic flexure of the colon. Toxepeus


and his coworkers stated that air in the transverse mesocolon is occasionally misread as a mixture of air and feces in the transverse colon. However, close scrutiny will reveal that the hepatic flexure is well below and distinctly separated from the air bubbles over the kidney and that the so-called transverse mesocolon appears much wider than is normal.

In 1975, Lucas and Ledgerwood4’ studied 36 patients with blunt duodenal injury and stated that early suspicion of retroperitoneal duodenal rupture is best confirmed or excluded by an emergency meglumine diatrizoate (Gastrografin; Squibb) swallow. This contrast material may also be infused into a nasogastric tube with the patient lying on the right side to facilitate passage of the contrast through the pylorus into the retroperitoneal space. If no duodenal rupture is present, thin barium can then be given to outline the duodenal anatomy in greater detail. In this series, Lucas and Ledgerwood found that more than 50% of the patients had the diagnostic findings of retroperitoneal air along the upper pole of the right kidney, the right psoas muscle, or overlying the transverse colon. This study, the largest percentage reported of positive radiographic findings, is at variance with other series described previously.16J 47S 50, 6oJ 66J 67

The best method for visualizing the retroperitoneal organs without an operation is the computed tomography (CT) scan with intraluminal and intravascular contrast. CT scanning has also been demonstrated to have a high degree of accuracy in detecting injuries to intraperitoneal organs. This technique detects free intraperitoneal blood. Donohue and associates75 documented the ability to quantitate intraperitoneal bleeding. The applicability of CT is limited to hemodynamically stable patients. CT scanning has proved capable of detecting retroperitoneal ruptures of the duodenum.75-81

Given its ability to visualize the retroperitoneal structures and to detect injuries of the solid intraperitoneal viscera and quantitate free intraperitoneal blood, some researchers have suggested that the CT scan is the diagnostic procedure of choice in stable patients with blunt abdominal trauma where retroperitoneal injury is suspected. Because of the infrequency of blunt duodenal rupture, the absolute value of CT scanning versus other diagnostic modalities in detecting injury of the duodenum remains uncertain. Most large reported series were accumulated before CT scans became widely available, and studies on the use of CT scanning are just now being reported. Given its unique ability to visualize the retroperitoneal structures, CT scanning is likely to be the most sensitive method for detecting retroperitoneal duodenal rupture. To our knowledge, no studies have compared CT scanning with the upper gastrointestinal series for diagnosis of duodenal injury.

We recommend use of the CT scan with oral and intravenous contrast in hemodynamically stable patients who have sustained blunt


abdominal trauma as the diagnostic method of choice in patients suspected of having duodenal injury. If the CT scan identifies extravasation of oral contrast from the duodenum associated with a retroperitoneal hematoma, no further studies need to be undertaken. How- ever, if the CT scan is inconclusive, we recommend an upper gastrointestinal series with Gastrografin and fluoroscopic visualization of duodenal peristalsis to confirm extravasation of contrast from the duodenum. If no extravasation is identified, thin barium is then administered, which can provide a much better delineation of duodenal anatomy and establish the presence of duodenal hematoma. We recommend a CT scan as the first diagnostic study in patients suspected of having sustained duodenal or retroperitoneal injury. We make this recommendation not because we believe it to be superior to the upper gastrointestinal series but rather because it yields additional information regarding intraperitoneal organs not otherwise obtained with the upper gastrointestinal study.82-85

Although CT scanning is thought to be the most reliable procedure to diagnose duodenal injuries, Cook and colleagues” demonstrated some pitfalls. These investigators reviewed retrospectively the medical records and CT scans of 83 patients with upper abdominal trauma to determine errors in diagnosis. In three of the patients in this series with subsequently surgically proven small-bowel perforations (one duodenal and two proximal jejunal), the injuries were not diagnosed on CT scans. These authors ascertained retrospectively that positive CT findings were present in the case of duodenal rupture. Additionally, in two patients, duodenal rupture was suspected on the basis of CT findings of extraluminal gas and fluid near the duodenum, but in both patients the duodenum was normal at operation.

Hofer and Cohens3 described two patients with duodenal perforation resulting from blunt abdominal trauma and described CT findings of focal bowel wall thickening, interruption of progress of bowel contrast medium, and extraluminal gas and fluid as findings consistent with duodenal injury. These investigators noted that, in each patient, thickening of the duodenal wall was consistent with intramural edema, hematoma, or both. In neither patient did oral contrast medium reach the site of injury. They therefore concluded that to maximize CT findings of duodenal perforation radiologists must rely heavily on the use of oral contrast medium.

Buckman and Asensio (unpublished data, 1990 to 1992) collected a series of four patients with retroperitoneal duodenal rupture in whom CT scan findings such as those previously described by Hofer and Cohens3 were ignored, thus leading to delayed surgical intervention in the management of retroperitoneal blunt ruptures of the duodenum. These investigators suggested that any edema or hematoma of the paraduodenal/periduodenal area should be investigated aggressively with an upper gastrointestinal study using Gastrografin fol-


lowed by thin barium. Additionally, in patients in whom no conclu- sion could be reached from both the contrast and the CT scan studies, exploratory laparotomy and retroperitoneal exploration of the duodenum should be strongly considered to rule out a duodenal injury. These investigators concluded that they would rather accept the minimal morbidity and mortality of a negative exploratory laparotomy than risk the greater morbidity and mortality associated with a delay in the diagnosis and management of a duodenal injury.

Hahn and colleaguess4 studied the possible use of magnetic resonance imaging (MRI) in the diagnosis of duodenal injury. They described two patients with duodenal hematoma in whom an MRI and CT scan were performed. In both patients, the hematoma had a well- defined concentric ring configuration on MRI, a finding that helped to establish the diagnosis. These investigators indicated that MRI may provide tissue-specific characterization of duodenal hematomas.

Diagnostic peritoneal lavage, which has assumed a crucial role in the detection of intraperitoneal injuries, is equivocal and unreliable and has no value in detecting injuries to the retroperitoneal organs.43’ 48, 85 Although some authors have found that diagnostic lavage is positive in 50% to 70% of patients with duodenal injuries,51’86 the positivity is due to associated intraperitoneal injuries and not to the duodenal injury itself.

Levinson and colleagues43 and Lucas and Ledgerwood4’ noted the unreliability of diagnostic peritoneal lavage in patients with duodenal trauma. A positive lavage indicating intraperitoneal bleeding may trigger an operation during which a duodenal injury may be discovered.51’ 83 A negative diagnostic peritoneal lavage has no significance in patients suspected of having an injury to the retroperitoneal organs.

SURGICAL MANAGEMENT OF DUODENAL INJURIES

Proven or suspected duodenal injury, coupled with the classic findings of intraabdominal injury (i.e., abdominal tenderness, guarding, rebound tenderness, or decreased bowel sounds), mandates immediate exploratory laparotomy. The basic resuscitative maneuvers described by the Advanced Trauma Life Support manual of the Ameri- can College of Surgeons, including early management of the airway and fluid resuscitation, should be carried out, and a sample of blood should be sent to the blood bank for type and crossmatch. If the patient’s status is such that an immediate laparotomy is warranted, type-specific or O-negative blood can be used for immediate resuscitation.88’ ” Broad-spectrum antibiotics are then administered before the abdominal incision. We prefer the use of a second-generation cephalosporin and are in agreement with Jones and colleagues” and


Nichols and colleaguesgl that cefoxitin provides ample coverage initially.

Abdominal injuries should be explored through a midline incision extending from xiphoid to pubis. Immediate control of life- threatening hemorrhage from vascular structures or parenchymatous organs such as the liver or spleen should constitute the first goals in the operation, followed by immediate control of sources of gastrointestinal spillage. The next step in the management of abdominal trauma should consist of a thorough exploration of the abdominal cavity. The duodenum must be thoroughly explored with all four portions visualized directly. Findings that should increase suspicion of a duodenal injury include crepitation along the duodenal sweep, bile staining of paraduodenal tissue or a documented bile leak, or the presence of a right-sided retroperitoneal hematoma or perirenal hematoma. The duodenum should then be mobilized by a Kocher maneuver, a Cattell and Braasch maneuver, or both.” These maneuvers should provide full visualization of the anterior and posterior walls of all portions of the duodenum. A word of caution to the neophyte surgeon must be added here: performance of these maneuvers in the presence of active bleeding or a large retroperitoneal hematoma can be fraught with danger.

A Kocher maneuver is performed by incising the lateral peritoneal attachments of the duodenum and sweeping both the second and third portions medially using a combination of sharp and blunt dissection. The assistant should provide gentle traction of the duodenal loop while the surgeon continues the dissection. The nasogastric tube should be advanced through the pylorus and palpated digitally while the surgeon performs the dissection. This procedure provides a guide to identify the duodenum in the midst of a large retroperitoneal hematoma and will avoid iatrogenic lacerations to the duodenal wall during dissection. Inspection of the third portion of the duodenum requires mobilization of the hepatic flexure of the colon according to the method described by Cattell and Braasch.” The retroperitoneal attachments of the small bowel are incised sharply from the right lower quadrant to the duodenojejunal junction, and the small bowel is reflected in its entirety out of the abdominal cavity.gz This maneuver is often unnecessary, and its performance in the presence of a large retroperitoneal hematoma, especially those caused by pel- vic fractures, may lead to exsanguination. The fourth portion of the duodenum can be visualized by transecting the ligament of Treitz while avoiding injury to the inferior mesenteric vein or, again, by performing the Cattell and Braasch maneuver.

Duodenal injuries can easily be missed and are associated with disastrous consequences. Massive injury, such as may occur with associated vascular injuries to the aorta or vena cava, may divert the


surgeon’s attention from the duodenum. If findings such as minimal hematoma or insignificant edema are deemed trivial and disregarded, a significant duodenal injury may be missed. Thus underestimation of minimal abnormal findings and failure to explore the duodenum fully are the nemeses of the surgeon and the friends of disaster. A constant awareness that duodenal injury may be associated with minimal intraoperative findings will assure more frequent diagnosis and the avoidance of increased morbidity and mortality.

After a duodenal injury is identified, its extent should be defined. Factors that have a role in its management include the number of associated injuries, especially to the pancreas and biliary tree, and the period of time that has elapsed from identification to treatment. Snyder and colleagues5’ identified several important factors that were of value in evaluating the severity of the duodenal injury. Factors such as the agent of entry, the size and site of injury, the interval from injury to repair (in hours), and an associated injury to the common bile duct proved to be statistically significant predictors of outcome. Injuries were classified as mild on the basis of the following: (1) the agent of entry consisted of a stab wound; (2) the size of injury encompassed less than 75% of the duodenal wall; (3) the site of injury was located in the third or fourth portion of the duodenum; (4) the injury repair interval was less than 24 hours; and (5) no associated injury occurred to the common bile duct. Injuries were classified as severe on the basis of the following: (1) the agent of entry was blunt trauma or a missile; (2) the size of injury encompassed more than 75% of the duodenal wall; (3) the site of injury was located in the first or second portion of the duodenum; (4) the repair interval was greater than 24 hours; and (5) an associated injury to the common bile duct had occurred. Curiously, in this series the presence of associated pancreatic injury was not found to alter morbidity and mortality significantly. This finding is at variance with that of other authors who have reported the presence of associated pancreatic injury to be a good predictor of increased morbidity and mortality.46, 48, 93, g4

Identification of the presence or absence of such factors allows the surgeon to assess the injury fully. We recommend that all duodenal injuries be staged according to some classification scheme so that it might stratify the injuries according to severity. This recommendation is made with the hope that the most simple and effective surgical technique or techniques will be selected for management of the simpler injuries and that the most complex techniques will be reserved for the more challenging and severe injuries.

A concise and uniformly accepted classification scheme that pre- dicts the outcome of traumatic injuries to various organs is sorely lacking in trauma surgery. Lucas and Ledgerwood”’ and Adkins and

Cum- Probl Surg, November 1993 1051

TABLE 9. Duodenum organ injury scale

Grade* Injury Descriptiont

I Hematoma Involving single portion of duodenum Laceration Partial thickness, no perforation

II Hematoma Involv& more than one portion

Laceration Disruption <SO% of circumference III Laceration Disruption 50% to 75% circumference of D2

Disruption 50% to 100% circumference of Dl, D3, D4

Iv Laceration Disruption >75% circumference of D2

Involving ampulla or‘ distal common bile duct V Laceration Massive disruption of duodenopancreatic complex

Vascular Devascularization of duodenum

Dz, 1st portion duod,enum; 02, 2nd portion duodenum; 03, 3rd portion duodenum; 04, 4th portion duodenum. *Advance one grade for multiple injuries to the same organ. tBa:ed on most accurate assessment at autopsy, laparoromy, or radiologic study.

Keyser53 described various classification schemes indigenous to their respective trauma centers, but neither provided statistically significant predictors of outcome.

We have favored the use of the Penetrating Abdominal Trauma In- dex (PATI) as described by Moore and colleagues.g5 In this index, each abdominal organ is assigned a risk factor on the basis of the known incidence of complications and each injury is graded on a scale of 1 to 5. Duodenal injuries are assigned a risk factor of 5 and are graded as follows: contusion, grade 1; injury to less than 25% of the ‘wall, grade 2; injury to 25% to 50% of the wall, grade 3; injury to more than 50% of the wall, grade 4; and ampullary injuries, grade 5. Multiplica- tion of the grade of injury by the risk factor allows for calculation of the duodenal injury score iDIS), which may serve as a quantifiable means of categorizing duodenal injuries. It then follows that the more complex surgical repair techniques would be used for injuries with higher scores. The value of this procedure for quantifying duodenal injury severity objectively was validated by Ivatury and colleagues,55 who reported 100 patients with penetrating duodenal trauma and correlated their PAT1 and DIS with immediate death.

The American Association for the Surgery of Trauma, along with its Organ Injury Scaling Committee, devised injury severity scores for individual organs to facilitate clinical research (Table 9). Thus far, experience with the new duodenal organ injury scale is limited, although Cogbill and colleagues57 used this scale successfully in a cooperative multicenter trial in which they graded 164 duqdenal injuries. In this study, the mortality rates for classes I, II, III, IV, and V duodenal injuries were 8%, 19%) 21%, 75%) and 25%, respectively. The authors found that mortality did not correlate well with the severity of duodenal injury and concluded that anatomic features of duode-

1052 Curr Probl Sy-g, November 1993

TABLE 10. Surgical techniques and procedures used for repair of duodenal and uancreaticoduodenal injuries

Duodenorrhaphy Duodenorrhaphy with external drainage Duodenorrhaphy with tube duodenostomy

Primary (through duodenum) Antegrade (through pylorusJ Retrograde (through jejunumi

Triple ostomy technique (gastrostomy and antegrade and retrograde jejunostomiesl Jejunal serosal patch Jejunal mucosal patch Pedicled grafts

Ileum Jejunum Stomach (gastric island)

Duodenal resection Duodenoduodenostomy Duodenojejunostomy

Duodenal diverticulization (vagotomy and antrectomy, gastrojejunostomy, duodenorrhaphy, T-tube drainage and external drainage)

Pyloric exclusion With sutures (absorbable and nonabsorbable) Staples

Pancreaticoduodenectomy (Whipple’s procedure)

nal injury represent only a part of the risk of morbidity and mortality.

Approximately 75% to 85% of all duodenal injuries can be repaired safely using simple surgical techniques. The surgeon must possess the technical capabilitjr to repair injuries of high severity. Many dif- ferent surgical techniques for the treatment of duodenal injuries have been described (Table 10). Basic surgical ptinciples, such as debridement of the duodenal injuries to viable tissues and a meticulous double-layer technique for closure approximating the innet layer using fine absorbable sutures and a seromuscular closure of iriterrupted nonabsorbable Lembert sutures, should be used (Fig. 1).

Duodenorrhaphy alone carries a small risk of narrowing the duodenal lumen. Several technical points must be kept in mind to &void this problem when closing duodenal lacerations. These technical points were outlined by Kraus and Condons on the basis of the results of an animal model in which they established that longitudinal duodenotomies can be closed transversely if the length of the duodenotomy does not exceed one half of the circumference of the duodenum (Fig. 2). These investigators recommehded that longitudinal closures be performed if the duodenotomy exceeds one haif of the circumference of the duodenum. In neither of these closures was the duodenal lumen narrowed. The authors strongly recommended


FIG. 1. Most duodenal lacerations can be repaired primarily after meticulous debridement of all damaged tissue. The repair can be accomplished with a double-layer closure, including an inner layer of fine running absorbable sutures encompassing the entire width of the duodenal wall followed by a second layer of fine seromuscular interrupted nonabsorbable Lembert sutures. Meticulous attention must be paid to imbricate the duodenal mucosa because it tends to extrude from suture lines. (From Juan A. Asensio, MD, and Robert F. Buckman, MD, Duodenal Injuries, Shackleford’s Surgery of the Alimentary Tract, George D. Zuidema [editor]. Volume 2, Chapter 10, Pages 104-l 17, W.B. Saunders, Phila- delphia, 1991. Reprinted by permission.)

against transverse closures of transverse duodenotomies, which they consistently showed to narrow the duodenal lumen.

The use of drains placed adjacent to duodenal repairs should be considered for all duodenorrhaphies. No prospective studies have addressed the risk/benefit ratio. We recommend that drains be used routinely, but we strongly emphasize that this drain system should be of the closed-suction type and should not be placed directly against the suture line to avoid duodenal fistula formation.

Before discussing the surgical techniques available for repair of complex duodenal injuries, a word of caution is in order. Surgical judgment is needed to select the best surgical technique for repair of particular duodenal injuries. The surgeon must consider the anatomic extent of the injury; the magnitude of associated injuries, especially those to the biliary tree and pancreas; and the time elapsed


FIG. 2. Longitudinal duodenotomies can be closed transversely if the length of the duodenotomy does not exceed one half the circumference of the duodenum.

from injury to repair. Finally, the overall condition of the patient must be evaluated. Other points to be considered for penetrating injuries include the potential for blast effect. For blunt injuries, the degree of associated retroperitoneal and periduodenal inflammatory processes resulting from extruded duodenal contents should be assessed. Af- ter evaluating these factors, the surgeon can choose the procedures that are needed to repair or decompress the duodenum, resect devitalized areas, buttress the repair, or exclude the duodenum from the passage of gastric contents.

Controversies surround the use of adjacent maneuvers to safeguard the duodenal closure. One of these maneuvers is the tube duodenostomy (Fig. 3), of which the following three types exist: (1) primary, in which the tube is placed through a separate stab wound in the duodenum; (2) antegrade, in which the duodenum is decompressed by way of the passage of a tube through the pylorus; or (31 retrograde, in which the tube is passed through a jejunostomy site. Primary tube duodenostomies were first used for decompression in 1909 by New- mann” and LangenBuch”; however, the technique remained obscure until 1949, when Welch” described this application in patients


FIG. 3. Adjunct techniques in management of anatomically severe duodenal wounds are used to protect the anastomosis. The simplest of these techniques is a tube duodenostomy. This tube should be brought out through an area of uninjured duodenum rather than through the duodenal repair. Its goals are to decompress the duodenum and protect the suture line; however, a tube duodenostomy does not totally divert the stream of gastric contents. (From Juan A. Asensio, MD, and Robert F. Buckman, MD, Duodenal Injuries, Shackleford’s Surgery of the Alimentary Tract, George D. Zuidema [editor]. Volume 2, Chap- ter 10, Pages 104-l 17, W.B. Saunders, Philadelphia, 1991. Reprinted by permission.)

with tenuous duodenal closures. In 1967, Jones and colleagues1oo described a refinement of the technique by advocating use of a small (No. 10 French) Foley catheter as a decompressive vent, with its bal- loon minimally inflated with 2 to 3 ml of normal saline. In this series of 44 patients with tenuous duodenal stump closures, only two complications occurred.

Antegrade decompression of the duodenal closure by passage of a nasogastric tube through the pylorus beyond the point of injury appears to have been used first by Smith and colleagues45 in 1971 and later by McInnis and coworkers46 in 1975. Retrograde duodenostomy was first used at the Grady Memorial Hospital in 1962,50 and described in the literature by Stone and Garonil’l in 1966 (Fig. 4). Two separate tubes can be placed by way of two separate jejunal sites. The proximal tube is threaded retrograde past the duodenal junction and placed on suction to decompress the duodenum while the distal tube is used as a feeding jejunostomy. This system has been termed the “suck-me, feed-me jejunostomy.” This system is also ad-


FIG. 4. This variation of the tube duodenostomy adds a feeding jejunostomy for early institution of enteral feeding. It has been dubbed the “suck-me, feed-me jejunostomy.” The proximal tube that acts to decompress the duodenum and protect its suture line is usually placed at a point beyond the duodenal-jejunal flexure and generally requires a longer tube such as a Baker tube.

vacated by Corley and co11eagues,47 who recommend the addition of a gastrostomy tube to achieve better decompression (Fig. 5).

Addition of tube decompression for duodenorrhaphy is controversial; opinions are strongly divided between those who staunchly support its routine use, such as Corley and colleagues,47 Stone and colleagues,50’101 and Hasson and colleagues,1o2 and those who advocate against its use, including Ivatury and co11eagues55’ lo3 and Kashuk and colleagues.104 Stone and Fabian” reported a high rate of duodenal complications in 8 of 44 duodenal wounds closed without tube decompression, with three subsequent deaths attributed to duodenal complications before the routine use of decompressive techniques that began in 1962. These investigators reported only one duodenal


FIG. 5. In this variation of tube duodenostomy, a gastrostomy has been added to further divert the gastric stream and increase protection of the duodenal suture line. (From Juan A. Asensio, MD, and Robert F. Buckman, MD, Duodenal Injuries, Shackleford’s Surgery of the Alimentary Tract, George D. Zuidema [editor]. Volume 2, Chapter 10, Pages 104-l 17, W.B. Saunders, Philadelphia, 1991. Reprinted by permission.)

fistula in 237 patients after the routine use of decompression began. Hasson and associateslo reviewed several series of duodenal injuries and found a 2.3% rate of fistula formation in decompressed repairs compared with an 11.8% rate in patients without decompression.

Contrasting data are presented by Ivatury and colleagues55, lo3 in two separate papers in which they evaluated patients who sustained duodenal injuries and associated injuries of comparable severity, as analyzed by the PAT1 and DIS. These investigators found consistently higher duodenal morbidity rates in the form of duodenal fistulas and abdominal sepsis as well as higher mortality rates in the group treated with duodenal repair and decompression.

Snyder and associates5’ did not find any statistically significant difference between 101 patients treated with duodenorrhaphy and decompression (nine fistulas, 9%) and 89 patients treated with duodenorrhaphy alone (five fistulas, 6%). Most other series in the literature advocate the use of decompression in a selective fashion.43’ 51-53 Flint and colleagues51 recommend the selective use of decompressive

1058 Curr Probl Sur5 November 1993

techniques only when the duodenal laceration involves more than 20% of the luminal circumference. Ten patients with lacerations involving more than 20% of the duodenal circumference underwent duodenorrhaphy and decompression with no suture line leaks; on the other hand, 23 patients with similar lacerations underwent primary repair with no decompression, and suture line leaks developed in 7 patients (30%). Four of these patients subsequently died.

Recently, Griffin and co11eagues1o5 described a simplified technique for gastric and duodenal decompression for duodenal injuries by way of a Moss esophagogastric decompression tube inserted through a gastrostomy to provide decompression of the stomach and duodenum through a single tube. The authors described their experience with two patients and indicated that complications with decompressive tube duodenostomies and long-term nasogastric tube drainage can be avoided.

In a recent multicenter cooperative study in which they reported 164 duodenal injuries, Cogbill and colleagues57 stated that on the basis of their data no apparent role exists for tube duodenostomy. These investigators cited I2 patients in whom a duodenostomy tube was placed: 7 patients (58% 1 had duodenal-related complications, including intraabdominal abscess in 5 patients (42%), duodenal fistula in 3 patients (25% ), and duodenal dehiscence in 1 patient (8% 1. These authors concluded that the tube duodenostomy is neither necessary nor effective in preventing duodenal-related complications. We advocate individualization of treatment with regard to decompressive techniques and agree strongly with Kelly and colleagues that “treatment of duodenal injuries, perhaps more than any other bowel trauma, must be individualized.“42

In some cases, either the injury itself or debridement necessary to remove devitalized tissue may leave a defect in the duodenal wall that, if repaired primarily, might narrow the duodenal lumen or subject the suture line to undue tension and possible breakdown. The reasons cited for disruption of duodenal closures after tissue loss are as follows: high intraluminal pressure, tendency of duodenal mucosa to extrude through closures adding to the leakage, and breakdown from autodigestive enzymes of the pancreas and bile. In these cases, a jejunal patch may be used to effect a safe closure.lo6

The technique of jejunal-serosal patch was first described by Kob- bold and Thallo7 (Fig. 61. These investigators were prompted to study this problem because of difficulties experienced in management of large duodenal lacerations attributed to the “fixation of the duodenum to the pancreas which makes resection hazardous and simple closure complicated.” In this study, areas of the duodenal wall in dogs measuring 1.5 X 3 cm or larger were excised and repaired by sewing the serosa of a loop of jejunum to the edges of the duodenal defect. After killing the animals and performing a histologic study of the


FIG. 6. Injuries In which loss of duodenal wall has occurred that cannot be repaired primarily without severe narrowing of the lumen may be repaired by use of a serosal patch technique. The serosa of a loop of jejunum is sutured to the edges of the duodenal defect. Experimental studies have demonstrated that the serosa exposed to the duodenal lumen rapidly undergoes complete mucosal resurfacing. (From Juan A. Asensio, MD, and Robert F. Buckman, MD, Duodenal Injuries, Shackleford’s Surgery of the Alimentary Tract, George D. Zuidema [editor]. Volume 2, Chapter 10, Pages 104-l 17, W.B. Saunders, Philadelphia, 1991. Reprinted by permission.)

specimens, these authors found complete mucosal resurfacing of the jejunal serosa at 8 weeks with no narrowing or dbstruction of thiz duodenal lumen. This method was also studied and performed clinically by Wolfman and colleagues.lo8

Wynn and colleagueslo described 19 patients with dubdenal per-

FIG. 7. Severe duodenal injuries with larger defects may be closed by use of jejunal mucosal patch or pedicled graft. Meticulous attention must be paid to preserving the blood supply of the pedicled graft. The segment of jejunum from which the graft has been taken is repaired by an end-to-end anastomosis (From Juan A. Asensio, MD, and Robert F. Buck- man, MD, Duodenal Injuries, Shackleford’s Surgery of the Alimentary Tract, George D. Zuidema [editor]. Volume 2, Chapter 10, Pages 104-l 17, W.B. Saunders, Philadelphia, 1991. Reprinted by permission.)

1060 Curr Probl Surg November 1993

See opposite page for legend.

&UT P&Z Surg, November 1993 1061

forations, 8 of whom were treated with primary closure protected by a serosal patch of a Roux-en-Y jejunal loop. One of the patients underwent reexploration for persistent postoperative fever, and at that time the patch was inadvertently pulled off the duodenum and not repaired. Postoperatively, a duodenal fistula developed and the patient died as the result of the complication. These authors warn of the consequence of this type of surgical mishap. Jones and col- leaguesll’ criticized the technique of using a separate Roux-en-Y loop of jejunum to cover duodenal defects because it creates a new suture line.

For larger defects, the ingenious techniques of a jejunal mucosal patch were described by Jones and Joergensonlll and later modified to include a fairly large pedicle graft by DeShazo and colleagues11z (Fig. 7). This patch can be constructed by using a proximal segment of jejunum, which can be carried up in a retrocolic location on its vascular pedicle. The antimesenteric border of the jejunum can then be split longitudinally and anastomosed using a double-layer technique to the duodenum to close the defect. This technique has also been used successfully by several other authors.106,113 Other techniques used for closure of duodenal wall defects include pedicle grafts of the stomach, otherwise known as gastric island flaps.l14 These flaps should be obtained from the body of the stomach at the greater curvature rather than the antrum because exposure to alka- line secretions of antral tissue will stimulate secretion of hydrochlo- ric acid. A gastric island flap is usually based on the gastroepiploic vessels. Similarly, Seidel and colleagues115 have used open pedicle grafts of ileum to repair duodenal defects.

If the entire circumference of the duodenum has been devitalized, a segmental resection and end-to-end duodenoduodenostomy may be performed (Fig. 8). Resections of segments of the first, third, and fourth portions of the duodenum, although technically challenging, are not associated with the high risk of vascular compromise during mobilization of the second portion. The rate-limiting step in mobilization of the second portion of the duodenum is attributed to the shared blood supply with the pancreas. Nevertheless, segmental re-

FIG. 8. In cases where the entire circumference of the duodenum has been devitalized or transection of the duodenum has occurred (A), the technique of debridement, segmental resection, and end-to-end duodenoduodenostomy (6) may be used. Limited mobilization is possible in the descending portion of the duodenum because of the shared blood supply of the pancreas and duodenum. Meticulous dissection must be carried out so that the blood supply is not compromised. Furthermore, care must be taken to avoid injury or obstruction of the ampulla of Vater. (From Juan A. Asensio, MD, and Robert F. Buckman, MD, Duodenal Injuries, Shackleford’s Surgery of the Alimentary Tract, George D. Zuidema [editor]. Volume 2, Chapter IO, Pages 104-117, W.B. Saunders, Philadelphia, 1991. Re- printed by permission.)


See opposite page for legend.

Curt- Probl Surg, November 1993 1063

section and primary end-to-end duodenoduodenostomy are possible in the second portion.

In cases where the duodenal wound is immediately adjacent to the ampulla of Vater, extreme caution must be exercised to preserve the integrity of this structure. In such cases, a choledochostomy is necessary, with the passage of a probe to identify the ampulla and keep it in view during the creation of the anastomosis. Avulsions of the ampulla of Vater have been treated successfully by duodenorrhaphy and im- plantation of the ampulla into a Roux-en-Y limb of jejunum, as reported by Fish and Johnson.116 Similarly, avulsions of the common bile duct resulting from lacerations of the second portion of the duodenum have been repaired successfully with common bile duct reim- plantation, as reported by Lee and associates117 and Longmire and McArthur.‘l’ If an end-to-end anastomosis cannot be performed without tension, a Roux-en-Y duodenojejunostomy may be performed and the distal portion of the duodenum oversewn (Fig. 9) .ll’, lzo

FIG. 9. Extensive disruptions of the duodenum may be treated by resection with end-to- end Roux-en-Y duodenojejunostomy. (From Juan A. Asensio, MD, and Robert F. Buckman, MD, Duodenal Injuries, Shackleford’s Surgery of the Alimentary Tract, George D. Zuidema [editor]. Volume 2, Chapter 10, Pages 104-117, W.B. Saunders, Philadelphia, 1991. Re- printed by permission.)


Patients with severe duodenal injuries should be considered as candidates for more complex duodenal repairs such as duodenal diverticulization or pyloric exclusion.g5 Such injuries include those caused by blunt trauma or missiles, those involving more than 75% of the wall, those involving the first and second portions of the duodenum, those associated with a delay in repair of more than 24 hours, and those with associated injuries to the pancreas, common bile duct, or both. Injuries described as grades 3 and 4 by PATIg8 and as grades III and IV of the Duodenum Organ Injury Scalelzl can also be considered for these repairs.

Other criteria that may lead the surgeon to consider one of these more complex surgical procedures include compromised blood supply to the duodenum and associated injury to the head of the pancreas without disruption of the main pancreatic ductlo We consider injuries involving more than 50% of the circumference of the duodenal wall, whether associated with pancreatic injuries or not, to be high-risk injuries amenable to repair by one of these two procedures. The main purpose of these procedures is to exclude the duodenum from the passage of gastric contents to allow time for the duodenal repair to heal and to prevent suture line dehiscence. We emphasize that these procedures can only be used if the duodenal injury is amenable to primary repair.

The original duodenal diverticulization (Fig. 10) was described by Berne and colleaguesl” in 1968 and was aimed at decreasing the high rate of morbidity and mortality in patients with combined duodenal and pancreatic injuries. In a previous study by this same group in 1966, these investigators reported a mortality rate of 5% in 20 patients with duodenal perforation and no associated pancreatic injury.123 However, they noted a mortality rate of 33% in nine patients with associated pancreatic injuries. These investigators also noted the high morbidity present in these patients, with complications including lateral duodenal fistula, pancreatitis, pancreatic fistula, intraperitoneal abscess, secondary hemorrhage, duodenal obstruction, and major wound infection. Prompted by unacceptably high complication rates, the authors devised the duodenal diverticulization procedure with the goal of excluding the duodenum from the passage of gastric contents. This concept was not new, having been first suggested by Summers7 This procedure was performed by Berglz4 in 1907, who stated that a gastrojejunostomy with the stomach and duodenum in continuity did not provide the total diversion necessary to achieve healing from a duodenal fistula. As such, he treated two patients by side-to-side gastroenterostomy and pyloric occlusion, which was achieved in the first patient with a large silk ligature and in the second with an occlusive tape.

The procedure by Berne and colleagueslz5 included antrectomy, debridement, and closure of the duodenum, tube duodenostomy, va-


FIG. 10. Severe combined duodenal and pancreatic injuries demand diversion of gastric contents away from the duodenal repair, provided the duodenal injury is amenable to safe primary closure. This procedure was originally described by Berne and colleagues125 as the duodenal diverticulization procedure. The original procedure consists of primary duodenorrhaphy, truncal vagotomy, antrectomy with gastrojejunostomy, tube choledochostomy, and external drainage of the duodenal repair. Indications for this procedure are now limited to severe injuries of the first portion of the duodenum and/or pyloric channel or antrum of the stomach, which demand resection and are associated with pancreatic injuries. (From Juan A. Asensio, MD, and Robert F. Buckman, MD, Duodenal Injuries, Shackleford’s Surgery of the Alimentary Tract, George D. Zuidema [editor]. Volume 2, Chapter 10, Pages 104-l 17, W.B. Saunders, Philadelphia, 1991, Reprinted by permission.)

gotomy, biliary tract drainage, and a feeding jejunostomy. This procedure was performed in 16 patients with severe duodenal- pancreatic injuries. Three of the 16 patients died because of profound irreversible shock; their deaths were not related directly to this procedure. In this series, only three duodenal fistulas developed, and these healed promptly. The morbidity and mortality rates for these patients were markedly decreased. Interestingly, of the original 16 patients, only 8 underwent vagotomy; the remaining patients did not. In most instances, this decision reflected pressure to terminate the operation quickly in these critically ill patients. The authors also recommend that the vagi be sectioned if the surgeon believes the condition of the patient is stable. Also interestingly, biliary tract drainage was carried out in 7 of the 16 patients whose indications included


injuries to the extrahepatic biliary tract, severe pancreatic injury, or periampullary duodenal injury.

In 1974, Berne and colleagues1z5 again reported 34 patients in whom this operation had been performed for severe duodenal or combined duodenal-pancreatic injury. These 34 patients were added to the 16 from the original report. An overall mortality rate of 16% was reported. In this series, associated injuries to major vessels and the colon proved more deadly than the duodenal and pancreatic injuries. The operation of duodenal diverticulization appeared to re- duce morbidity and mortality when compared with other procedures. The overall mortality rate of 16% compared favorably with a 35% mortality rate reported for similar injuries by Anderson and col- leagues126 in 1963.

In a recent series of 105 survivors in a group of 115 patients, an overall mortality rate of 4% was reported.lz7 Twelve of the 105 survivors underwent duodenal diverticulization; three of these patients died. Two of the patients had duodenal fistulas and died as a result of septic complications and multisystemic organ failure, for a mortality rate of 17%. The third patient died from complications of massive transfusion.

Duodenal diverticulization is a time-consuming and often complicated surgical procedure that many critically ill patients cannot tol- erate. An alternate means of securing exclusion of the duodenal suture line and diversion of the gastric contents using a simpler, less time-consuming technique was devised by George Jordan and reported by Vaughan and colleagues128 (Fig. 11). This procedure en- tailed duodenorrhaphy plus a gastrotomy in the most dependent portion of the greater curvature of the stomach through which the pylorus is identified and occluded using a large, running suture of chromic catgut. Care must be taken to avoid exclusion of antral tissue from the gastric lumen. A gastrojejunostomy is then performed through the previously created gastrotomy to achieve complete ny- loric occlusion and diversion of gastric contents.

Vagotomy is not a part of this surgical procedure. A mortality rate of 19% and a rate of fistula formation of 5% in the 75 patients under- going this surgical procedure are comparable with the figures reported by Berne and colleagues.125 Gastrojejunostomy without a vagotomy is suspected as being an ulcerogenic procedure by many surgeons. The authors of this study investigated 25 patients in whom the pyloric exclusion procedure was performed by upper gastrointestinal studies after periods ranging from 2 months to 3 years after the operations. All these patients demonstrated a functioning pylorus with passage of contents into the duodenum. The authors also studied 10 patients readmitted to the hospital for additional follow-up studies pertaining to the effects of this procedure on gastric physiologic and gastrointestinal anatomic functions. These pa-


FIG. 11. Pyloric exclusion procedure is useful in the management of severe pancreaticoduodenal injuries provided the duodenal injury can safely be closed primarily. The pylorus is occluded with nonabsorbable suture material through a gastrotomy in the dependent portion of the distal stomach. A gastrojejunostomy is then performed. (From Juan A. Asensio, MD, and Robert F. Buckman, MD, Duodenal Injuries, Shackleford’s Surgery of the Alimentary Tract, George D. Zuidema [editor]. Volume 2, Chapter 10, Pages 104-l 17, W.B. Saunders, Philadelphia, 1991. Reprinted by permission.)

tients were studied using serum gastrin levels, all of which were within normal range, as well as gastric analysis. The acid secretory rates were within the normal range of 1 to 3 mEq/hr in 8 patients. Two patients, however, had elevated acid secretory rates ranging from 6 to 7 mEq/hr. All patients underwent upper gastrointestinal endoscopy that confirmed the radiologic findings of a patent pylorus. No significant pyloric abnormality was noted in any of these patients. One significant finding among these patients was development of three marginal ulcers at periods of 4 months to 2 years after the operations. One of the patients had a history of previous duodenal ulcer despite normal gastric adid levels. This patient was treated conservatively, and the ulcer was found to heal spontaneously. The other two patients had gastric hypersecretion, and both were treated surgically. One patient was treated simply by takedown of the gastrojejunostomy, and the other patient was treated by vagotomy and gastric resection.

In a more recent series, Graham and colleaguess4 reported 68 pa-


FIG. 12. An alternate method of pyloric exclusion is represented in which the proximal duodenum is stapled distal to the pylorus. A gastrojejundstomy is then performed.

tients who sustained combined pancreaticoduodenal injuries, 32 of which necessitated pyloric exclusion (30 temporarily and two per- manently) resulting from gastric antral wounds. No deaths occurred, and only two duodenal fistulas developed, for an incidence rate of 6.9%. Both of these fistulas healed successfully.

An alternate method for achieving pyloric exclusion is using a sta- pling device placed across the pylorus. This procedure has been popularized by Kelly and colleagues4’ (Fig. 12). Martin and colleaguesl” reported a follow-up study describing an expanded experience with pyloric exclusion in which 128 of 313 patients (41% 1 who sustained duodenal injuries vere treated with this procedure; a 5.5% duodenal fistula rate was seen. In this study, 42 patients underwent upper gastrointestinal tract examination after their operations. In patients examined 21 days or more after their operations, 94% had a patent pylorus. Marginal ulceration was infrequent and reported in only four of these patients, thus confirming the efficacy of this surgical procedure. These authors also advocated the use of nonabsorbable monofilament polypropylene sutures or absorbable polyglycolic acid sutures. Other authors have supported the use of the pyloric exclusion procedure and recommended the use of polygalactin sutures to occlude the duodenum.1zs,130


FIG. 13. Pancreaticoduodenectomy is reserved for the most severe combined pancreaticoduodenal injuries. It has a high mortality rate. Technical difficulties with this procedure include creation of a choledochojejunostomy because the common bile duct is usually small and undilated. Other technical difficulties can be expected in the creation of the pancre- aticojejunostomy because the pancreas is usually soft and nonindurated and does not hold sutures well. These technical difficulties may predispose to fistula formation.

Recently, Buck and colleagues131 described a series of 17 patients with severe pancreaticoduodenal injury, 15 of whom survived long enough to undergo pyloric exclusion with gastrojejunostomy as part of their initial treatment. Of the remaining 15 patients, 2 died within 48 hours. Eight of the surviving patients underwent a vagotomy in addition to pyloric exclusion. Three patients experienced complications related to the pyloric exclusion; two had marginal ulcers that either perforated or bled and required additional operations. One of these patients required vagotomy and antrectomy for severe bleeding, and the other required a takedown of the gastrojejunostomy for perforation. These authors reported a 33% incidence of marginal ul- cerations on the basis of their data, a rate significantly higher than reported previously. They therefore recommended the addition of vagotomy to pyloric exclusion at the time of the initial procedure if the patient’s condition permits. This report is at variance with a greater experience of Martin and colleagues1zg and Feliciano and colleagues.13’

1070 Curr Probl Surg November 1993

TABLE 11. Indications for pancreaticoduodenectomy (Whipple’s procedure)

1. Massive and uncontrollable bleeding from the head of the pancreas, adjacent vascular structures, or both.

2. Massive and unreconstructable ductal injury in the head of the pancreas. 3. Combined unreconstructable injuries of the following:

A. Duodenum and head of the pancreas B. Duodenum, head of the pancreas, and common bile duct

Monsour and colleagues13’ and Flynn and co11eagues133 reported their experiences in the management of pancreaticoduodenal injuries. These investigators concluded that well-defined protocols, with careful selection of surgical procedures according to the grade of injury, yield much better outcomes. They also concluded that techniques such as pyloric exclusion should be reserved for the infrequent complex injuries that involve both the pancreas and duodenum.

Pancreaticoduodenectomy was first suggested by Thal and Wil- son134 in 1964 as a treatment for patients sustaining severe blunt trauma to the head of the pancreas (Fig. 13). These authors reported on three patients who underwent pancreaticoduodenectomy, two of whom also had massive accompanying duodenal injuries.: Indica- tions for pancreaticoduodenectomy were outlined by Foley and col- leagues13” in 1969 (Table 111. Pancreaticoduodenectomy is clearly a formidable procedure in critically ill patients.

A review of 52 series reported in the literature from 1964 to 1990 yielded a total of 170 patients who underwent pancreaticoduodenectomy (Table 12).* Fifty-six of these patients subsequently died. The tabulated mortality rate for all the series reviewed was 33%, which is not at variance with the range of 30% to 40% reported in the literature.*

Two of the largest series in the literature are those of Yellin and Ros~ff~~~ and Oreskovich and Carrico.161 The Oreskovich series is remarkable because no deaths occurred in 10 patients. However, in this series radiologic confirmation of contrast extravasation was used as an indication of significant pancreatic ductal disruption, which pointed to the need for pancreatic resection. This represented a lib- eral indication and is at variance with the indications reported by most authors.

MORTALITY

Duodenal injuries, as a whole, carry a significant mortality rate. The overall mortality rates as reported in several recent large series range from 5.3% to 30% .41-43J 45-54 The lower overall mortality rate cited here

*References 14,43,45, 50, 53-55, 64, 76, 92, 93,125,X29,134-173


TABLE 12. Pancreaticoduodenectomy for trauma

Author Year No. of patients Deaths

Thai and Wilsor? Walter et alT3” Thompson and

Hindshawx3’ Salyer and McClellandx3’ Sawyers et alT3’ Wilson et al.14’ Brawler et al?41 Werschky and Jordan14’ Pantazelos et al.‘43 Halgrimson et alT4 Foley et al.‘35 Gibbs et al?” Bach and Frey145 Nance and DeLoach146 Jones and Shires14’ Smith et al.45 Salam et alF4a Anderson et al.lz6 White and Benfields Owens and Wolfman Steele et al?” Strum et al.1’l Yellin and Rosoi? Ananeh-Sefahs3 Chambers et alT5a Heitsch et al.ls4 Lowe et al?55 Karl and Chandler*‘” Hagan et alT5’ Grahan? Stone and Fabian” Majeski and Tyle?s Cogbill et al?” Levinson et al.43 Henarejos et al?a’ Oreskovich and Carrlco’G1 Adkins and Keyse? Moore and Moots? Fabian et alF4 Sims et al?“’ Donahue et al.‘” JonesxG3

1964 2 1 1966 1 0 1966 2 1

1967 1 1967 1 1967 2 1968 3 1968 1 1969 1 1969 3 1969 3 1971 1 1971 3 1971 5 1971 (Recorded in other series.1 1971 5 1972 4 1973 2 1972 5 1973 3 1973 3 1973 5 1975 10 1975 6 1975 1 1976 2 1977 6 1977 1 1978 2 1979 6 1979 3 1980 1 1982 1 1982 1 1983 1 1984 10 1984 5 1984 1 1984 1 1984 2 1985 1 1985 12

0 0 0 1 1 0 0 0 0 0 2

2 1 1 0 1 3 2 6 0 0 2 0 1 2 3 3 0 0 1 0 0 1 0 1 0 1 7

(including studies in 1971 and 19781 Ivatury et al? 1985 Smego et al.‘“a 1985 Wynn et all”’ 1985 Walke? 1986 Feliciano et alT3’ 1987 Melissas et al?a’ 1987

7 3 1 0 3 2 1 0

13 6 1 0

Continued.

TABLE 12. (cont.)

Author Year No. of patients Deaths

McKonek et aI?” 1988 5 0 Eastlick et al?71 1990 1 0 Gentile110 et aI?” 1990 3 1 Heimonsohn et aI? 1990 6 0 TOTAL 170 56 Average mortality rate 33.0%

was reported by Adkins and Keyser53 in their 1984 series in which 3 of 56 patients died. Although this figure is quite remarkable, it is at variance with most other figures of overall mortality rates reported in the literature41‘43’ 45-52J 55 and definitely at variance with a calcu- lated averaT mortality rate of 17% from the review of these series (Table 13) .4 -43J 45-58

Remarkable improvements have occurred since 1876 when Otis4 reported a 100% mortality rate during the American Civil War. Subse- quent decreases in mortality rates have been reported in each of America’s major wars (see Table 1).

Recently, several authors have evaluated the overall mortality rates reported in their series separate from the mortality rates caused exclusively by duodenal injuries. They found mortality rates in the

TABLE 13. Mortabty rate associated with duodenal injuries

Author and year Overall

mortalitv rate

Mortality by mechanism of injury

Penetrating Blunt

Morton and Jordan, 196S41 21.0 22.0 14.0 Smith et al., 1~71~~ 21.0 McInnis et al., 1975@ 14.0 Corley et al., 197447 23.5 20.0 35.0 Lucas and Ledgerwood, 197548 19.4 Matolo et al., 197549 9.3 Kelly et aI., 197S4’ 14.0 Stone and Fabian, 197S5’ 14.0 13.0 15.0 Flint et al., 197S51 19.0 11.0 20.0 Snyder et al., 19805’ 17.4 Levinson et al., 198243 18.0 Adkins and Keyser, 198453 5.3 Fabian et al., 19&ls4 30.0 Ivatury et al., 198555 25.0 Bostman et al., 198g5” 5.5 Cogbill et al., 19905’ 18.0 14.4 3.6 Cuddington et al., 19905’ 14.0 Average mortality rate

All numbers expressed as percentages.

17.0 16.0 17.5

Curr Probl Sur. November 1993 1073

range of 6.5% to 12.5% .42, 43J 5oJ 52, 54, lz8 These figures were confirmed in an excellent review of duodenal injuries by Weigelt and Borman4’

Mortality can be analyzed using several variables. It can be reviewed on a temporal basis and subdivided into early and late mortality. Most early deaths are caused by exsanguination, usually resulting from associated major vascular injuries. This finding is repeatedly borne out in the literature. Morton and Jordan41 reported that 55% of the early deaths they studied occurred in patients initially in shock. Stone and Fabian5’ reported that 46% of the early deaths they studied occurred in patients of similar clinical diagnosis. McInnis and colleagues46 reported a 100% mortality rate for all patients with shock.46 Further- more, several authors reported that early mortality rates associated with shock, prolonged bleeding, and the sequelae of massive blood replacement ranged from 35.7% to 73%, with an average of 52.85% ~29,41,44,51 When these early deaths are excluded, mortality rates range from 6.5% to 12.5%, as reported previously. 40,42,43,52,55,128

These figures on mortality rates can be attributed exclusively to the end results of the duodenal injury and associated complications that include sepsis, duodenal fistula formation, and multiple organ failure.

Other methods for analyzing mortality include examination of selective mortality related to the mechanism of injury. Five authors presented a breakdown of mortality according to mechanism of in- juTy.41,47,50,51,57 Duodenal death caused by penetrating trauma averaged a rate of 14.4%, whereas death caused by blunt trauma was slightly greater at 17.5% (Table 13).

Factors known to increase mortality rates include the presence of associated pancreatic41’ 42, 45, 5o and common bile duct injuries.52 Per- haps the most important associated factor in determining the mortality associated with duodenal injury is the delay in time from recognition to definitive repair. This factor has been well documented, especially in cases of blunt duodenal rupture. Lucas and Ledger- wood4’ found a 40% mortality rate in patients who underwent operations more than 24 hours after injury, whereas those patients operated on with less delay experienced a 14% mortality rate. Levinson and colleagues43 reported a 50% mortality rate in patients operated on after 24 hours and noted a high incidence of fistula formation in the survivors. Snyder and colleagues5’ reported a 50% mortality rate in patients who underwent delayed operations, with a 50% incidence of fistula formation in survivors. The same high increases in mortality rates have also been reported by Flint and colleagues51 and Cleve- land and Waddell,” whereas Cocke and Meyer” reported a 71% mortality rate in patients whose diagnoses had been missed initially and in those in whom the injury was missed at the time of the operation.

*References 41-43,45,47-50,52,53,57,58.


MORBIDITY

Just as duodenal injuries are associated with high rates of death, they are also associated with very high rates of morbidity. Twelve recent series in the literature were selected and reviewed because they clearly outlined morbidity figures.* Overall, morbidity rates ranged from 38% to 125%) with an average morbidity of 63.7%. The lowest morbidity rate, 38%, was reported by Kelly and colleagues.42 In this series 19 major complications were reported in 12 of the 32 surviving patients, The highest morbidity rate was reported by Stone and Fa- bian,50 who reported 376 significant complications from 302 patients, for a morbidity rate of 125% (Table 14).

Duodenal morbidity is represented primarily by duodenal fistula formation resulting from failure of surgical repair because of suture line dehiscence and is represented occasionally by duodenal obstruction. Other complications are commonly related to associated injuries. In 15 recent series reviewed, a total of 82 duodenal fistulas were identified.41,43,45-53,55, 57,58 Duodenal fistula rates ranged from 0% to 16.2%, with an average of 6.6% incidence for all series reviewed (Table 15). Flint and colleagues51 reported no duodenal fistulas in their series, whereas Corley and coworkers47 reported 14 duodenal fistulas in their series of 98 patients. Of these patients, 10 achieved satisfactory outcomes and 4 died, for a reported incidence of 14.2%. Duodenal obstruction is stated to occur in between 1.1% to 1.8% of the patients.3s, 43, 50, 52

Other important complications caused by associated injuries include intraabdominal abscess, 10.9% to 18.4%; recurrent pancreatitis, 2.5% to 14.9% ; and bile duct fistula, 1.3% .3s, 43P 50, 52

*References 41-43,45,47-50,52,53,57,58.

TABLE 14. Overall morbidity associated with duodenal injuries

Author and year No. of patients Complication rate (o/a)

Morton and Jordan, 196841 Smith et al., 197145 Corley et al., 197447 Lucas and Ledgerwood, 197P Matolo et al., 197.? Kelly et al., 197S4’ Stone and Fabian, 197g5’ Synder et al., 19805’ Levinson et al., 198P Adkins and Keyser, 19S453 Cogbill et al., 19905’ Cuddington et al., 1990s8 Average morbidity rate

131 26 98 36 32 34

302 228

93 56

139 36

64.0 58.0 63.0 72 .O 47.0 38.0

124.5 63.0 49.0 39.2

100.0 47.2 63.7


TABLE 15. Duodenal fistulas after trauma

Author and year No. of duodenal fistulas Duodenal fistulas (% i

Morgan and Jordan, 196S4* 8 Smith et al., 197145 1 McInnis et al., 19754” 2 Corley et al., 197447 14 Lucas and Ledger-wood, 197548 4 Matolo et al., 197549 1 Kelly et al., 197S4’ 2 Stone and Fabian, 197g5’ 9 Flint et al., 197g51 0 Snyder et al., 19805’ 16 Levinson et al., 198243 5 Adkins and Keyser, 198453 3 Ivatury et al., 1985” 3 Cogbill et al., 19905’ 6 Cuddington et al., 199058 6

6.1 3.8 9.0

14.2 11.1

3.1 5.8 2.9 0.0 7.0 6.b 5.6 4.0 4.3

16.6 Average 6.6%

SPECIAL SITUATIONS

BLUNT DUODENAL RUPTURE

Diagnosing blunt injuries of the duodenum is difficult. All sizable series of blunt duodenal injuries include multiple instances in which this diagnosis was delayed.16’ 43J 48J 60, 83, 174 In many cases, the delays in diagnosis occurred while the patient was under the observation of competent and experienced surgeons within a trauma center. Kerry and GlaslT5 reviewed the literature in 1962 and found a 54% mortality rate in the 192 patients reported. In 1963, Cleveland and Waddell” reviewed 37 patients with blunt rupture of the duodenum. These authors found instances of delays in six patients ranging from 2 l/2 days to 7 months. In 1964, Cocke and Meyer?’ reviewed 48 cases from the literature and found that 15% of the patients having sustained blunt duodenal injuries had not undergone an operation or had not had the injury diagnosed at laparotomy; 71% of these patients died.

In 1974, Corley and colleagues, noting the 35% mortality rate with blunt duodenal rupture in the Cook County series, wrote:

The clinical manifestations may be unimpressive early in the post-injury period. . . . These injuries test the diagnostic capabilities of the most astute surgeon. Early treatment is the exception rather than the rule.47

Lucas and Ledgerwood4’ reported an experience with 28 blunt ruptures of the duodenum encountered over a 14-year period. In 10 patients, the diagnosis was delayed beyond 24 hours; 4 of these 10 patients subsequently died. Flint and colleaguessl reported 19 patients

1076 Cum Probl Surg, November 1993

with blunt duodenal rupture. In two of these patients, the diagnosis was delayed beyond 24 hours; both of these patients died. In the large series by Snyder and colleagues5’ of 48 blunt duodenal injuries over an lb-year period, delays in diagnosis averaged 8 hours and ranged up to 7 days. Talbot and Shuck176 reported a series of 8 patients with retroperitoneal duodenal injury from blunt trauma in whom 5 were not readily identified as having duodenal injury. These authors found that frequent physical examination was the most reliable diagnostic technique.

Levinson and colleagues43 reported that of 17 patients with blunt duodenal injuries evaluated initially by the trauma service at San Francisco General Hospital, 10 were explored immediately because of shock, free intraperitoneal air, or a positive diagnostic peritoneal lavage. Seven other patients, including several with negative results from peritoneal lavage, were admitted for observation. Four of these patients had delays in diagnosis of more than 24 hours. Of these, two patients had delays from 4 to 10 days after injury. Another patient had a duodenal injury that was overlooked at the initial operation,

Adkins and Keyser53 reported 17 patients with blunt duodenal injuries, of which 1.2 were transmural perforations. The average time from injury to operation was 16 hours. Two of the 12 injuries were not diagnosed for more than 2 days.

Fabian and colleagues54 reported 10 cases of duodenal disruption caused by blunt trauma, with a 30% mortality rate. The serum amylase level was elevated in seven patients (70% ). In this series, a 30% mortality rate was reported. The average interval from injury to operation was 9.3 hours for survivors and 16.3 hours for nonsurvivors. These findings support the concept that early surgical intervention improves outcome and demonstrate that the critical delay period is less than the classically reported 24 hours.

The frequent difficulty with diagnosis of blunt rupture of the duodenum and the extreme danger posed by the delayed recognition merit special discussions of the diagnostic features of these injuries. The most common cause of blunt rupture of the duodenum is impact of the epigastrium of an unrestrained driver against the steering wheel of an automobile. A variety of other blows to the abdomen may also cause this injury; it has occurred as a result of punches, kicks, falls, deceleration, and handlebar injuries.47’ 48, 83

The history of trauma may be minima147; in fact, there may be no history. Frequently the patient is inebriated, causing a delay in seeking medical attention immediately after the accident. In addition to these historic factors, the symptoms are often extremely mild.48 In the early stages after injury, the patient may have only vague epigastric or right upper quadrant pain, although the pain may occasionally be manifested in the right lower quadrant, with

Cur-r mob1 Surg, November 1993 1077

radiation to the back or flank. Pain rarely has been reported to radiate to the testicles61 or neck.60 Frequent serial physical examina- tions performed by the same observer, ideally an experienced surgeon, coupled with the high index of suspicion in the presence of the patient having sustained upper abdominal trauma, have been found by Talbot and Shuck176 to be one of the more reliable ways to make this diagnosis.

Often, none of the classic signs of an acute abdominal catastrophe are present. Because the retroperitoneal duodenal injury is often isolated, or at least not accompanied by any significant intraperitoneal injury, the patient may be perfectly stable. Over a period of hours to days, the abdominal symptoms and physical findings become more pronounced even if the injury remains confined to the retroperitoneum. If the rupture gains entry into the free peritoneal cavity, signs of localized or generalized peritonitis may develop. This change in condition may be sudden.

In cases of early retroperitoneal rupture of the duodenum, and while the process remains confined to the retroperitoneum, it is no- toriously difficult to detect by history and physical examination alone. In addition, standard laboratory tests may provide little help. The serum amylase level may or may not be elevated. In the early stages, the white blood cell count may be normal or only slightly elevated. Hematuria may indicate the severity of the blow to the kid- neys but provide no specific information about the status of the duodenum. Plain films of the abdomen are useful only if they are positive. Only in the vast minority of cases is the classic radiographic finding of retroperitoneal air outlining the right upper pole of the kidney or obliterating the right psoas shadow present. Furthermore, the presence of free air is rare in these cases. The best way to establish the diagnosis is by CT scan with both oral and intravenous contrast or by the upper gastrointestinal series.

The ultimate diagnostic test in blunt abdominal trauma remains the exploratory laparotomy. Because no noninvasive test is com- pletely accurate, patients having met the clinical profile described previously and who have persistent or increasing abdominal pain 6 hours after injury, especially if accompanied by increased abdominal tenderness or rising white blood cell count or serum amylase level, should be considered candidates for exploratory laparotomy. The devastating consequences of duodenal rupture, coupled with mortality rates ranging from 40% to 71% 16’ 43J 48J 52, 60, 70, g7 and the high incidence of fistula formation in survivors as high as 50% ,43J 52, 83 war- rant an aggressive diagnostic approach in establishing this diagnosis and instituting early surgical treatment. The surgeon must also be aware that retroperitoneal rupture of the duodenum may be overlooked at the operation.12J I’, 41, 45J loo, 177


DUODENAL HEA4ATOMA

Another type of duodenal injury that requires special consideration and judgment is the intramural duodenal hematoma. The management of this entity, first described in 1838, remains a subject of controversy.17’ Duodenal hematomas are usually caused by blunt abdominal trauma and can occur in any part of the duodenum. Al- though most cases have been documented in normal persons (including many children), their occurrence has been associated with clotting disorders, anticoagulant therapy, and alcoholism.*7g

Intramural hematomas of the duodenum are believed to be the result of shearing forces that rupture vessels within the duodenal wal1.18o They are most often submucosal, but subserosal and intra- muscular hematomas have also been reported.17’

Duodenal hematomas are usually manifested by signs of upper gastrointestinal obstruction after trauma. Copious bilious vomiting after blunt abdominal trauma should raise the suspicion of the evaluating physician. Often, a symptom-free interval of several hours occurs. In the series by Janson and Stockinger,17’ 76% of patients had symptoms of upper intestinal obstruction and another 22% had abdominal pain. Physical examination usually discloses mild epigastric tenderness. A history of trauma may not be obtainable. An abdominal mass is rarely palpable.

Laboratory values may show a mild elevation in the white blood cell count and, occasionally, an elevation of the serum bilirubin or amylase level. Profound fluid and electrolyte disturbances may be present if the obstruction has been long-standing, but this is rare. The basic findings on plain films of the abdomen often are gastric distention, sometimes dilation of the proximal duodenum, an air fluid level in the duodenum, and absence of the right psoas shadow.181 Diagnostic peritoneal lavage will be negative unless an associated intraperitoneal injury is present. The diagnostic test of choice is an upper gastrointestinal series using water-soluble contrast material. This technique may demonstrate the classic “coiled spring” deformity of the duodenal mucosa known as Felson’s sign71 or the “stacked coin” sign.” This radiographic finding reflects mucosal dissection of the hematoma. The obstruction is usually partial. If no duodenal perforation is observed, superior detail may be seen by repeating the upper gastrointestinal series using thin barium. Evi- dence of duodenal perforation must be sought diligently. If the serum amylase level is elevated, it is wise to obtain an abdominal CT scan or ultrasound image to look for an associated pancreatic injury. The CT scan may also detect peritoneal air or extravasated contrast material in occult perforations.

Although some authors have recommended operative intervention for duodenal hematoma,*82~18s the consensus expressed in the litera-


ture is to avoid surgical intervention because most patients can be treated successfully without operations.1g0-1g3 Nasogastric suction and parenteral or hyperalimentation should be instituted. Careful attention should be paid to the fluid and electrolyte balance. If the patient exhibits no sign of increase in abdominal pain or tenderness, then nonoperative therapy should be continued until the obstruction resolves. In most cases, this resolution occurs within 1 week; however, duodenal obstruction has persisted up to 38 days.ls3 Pa- tients with a diagnosis of duodenal hematoma must be observed care- fully because a small number may harbor an occult duodenal perforation The appearance of increased abdominal pain or tenderness on clinical examination, or retroperitoneal gas on follow-up of plain abdominal films, mandates immediate surgical intervention. The serum amylase and lipase values should be observed closely. A rising serum amylase level may indicate significant pancreatic injury or traumatic pancreatitis.“, 48 Although some authors have recommended operation if the serum amylase level continues to rise during a period of 6 hours, the evidence for this approach is not clear.48 Approximately 3% of the patients with duodenal hematoma have occult duodenal perforations.17s

Some authors have recommended that an obstructing duodenal hematoma be evacuated through a seromuscular incision if one is discovered at the time of laparotomy for trauma.182~18s If this evacuation cannot be accomplished, performance of a gastrojejunostomy has been recommended”; however, most authors would not recommend intervention and would prefer to leave the duodenal hematoma undisturbed and allow for a period of 2 to 4 weeks for its resolution.180~1s0~1s3 After this time has elapsed, and if the duodenal hematoma is not resolved, surgical intervention is then recommended for evacuation. Evacuation after this time may be technically easier. The evacuation is carried out by way of a seromuscular incision, avoiding penetration into the duodenal lumen. The seromuscular layer is then approximated with Lembert sutures of nonabsorbable materials.

Recently, Jewett and colleaguesls4 reviewed the English literature and collected 182 cases of intramural hematoma of the duodenum in the pediatric population. Apparently, this injury is one of the least commonly encountered in children. Given the rarity of this problem, little consensus has existed regarding the relative merits of operative versus nonoperative management. Of these 182 patients, 121 were treated surgically and 61 conservatively. The average hospital stay was 14 days for the surgical group and 11 days for the conservative group. Of the surgical group, 38 patients underwent immediate surgery, and, remarkably, the correct diagnosis of intramural hematoma of the duodenum was not suspected in 26 of the patients. In the same surgical group, 83 patients underwent surgery on a delayed basis (later than


24 hours after admission), and 26 had a delay in diagnosis. In the surgical group, 18 complications occurred. No complications occurred in the nonsurgical, conservatively managed group. In this series, patients who underwent surgical management were exposed to a 16% risk of having serious complications. Simple evacuation of the hematoma resulted in only a 5% complication rate, whereas some form of bypass procedure carried an excessively high rate of 40%. The authors concluded that, in the pediatric population, intramural duodenal hematoma is the least common intraabdominal injury resulting from blunt trauma.

A higher rate of suspicion of this injury will result in fewer unnecessary operative procedures. Jewett and co11eagues1g4 recommended conservative management as the treatment of choice in the uncom- plicated case in the pediatric population because obstruction is re- lieved in almost all patients. In contrast, the surgical approach carries a higher complication rate and results in an appreciably longer hospital stay. These authors recommended that surgery should be reserved for those cases complicated by perforation or a severely damaged duodenum. They also recommended hematoma evacuation, rather than bypass operations, for those few cases in which perforation or severe injury to the duodenum occurred.

UNUSUAL DUODENAL INJURIES

Rare forms of duodenal injury include iatrogenic injuries occurring during surgical procedures such as nephrectomies or abdominal aor- tic aneurysm repair. Duodenal injuries can also occur after endoscopic procedures such as flexible endoscopy and endoscopic retrograde cholangiopancreatography. Bleeding from the papilla of Vater after endoscopic sphincterotomy may occur and, although rare, may require operative intervention. In general, duodenal injuries after endoscopic procedures are rare. Endoscopic perforations are treated as any other transmural duodenal injuries of the same anatomic severity, and they are repaired using an inner layer of absorbable suture material followed by seromuscular Lembert sutures of nonabsorbable material. Bleeding from the papilla of Vater is controlled by suturing the edges of the sphincterotomy through a duodenotomy in the second portion of the duodenum.

Zinelis and colleagues1g5 recently reported what they believed to be the first case of an intramural duodenal hematoma after upper gastrointestinal endoscopic biopsy. This hematoma caused total obstruction of the duodenum, obstructive jaundice, and pancreatitis, and resolved with nonoperative management. These authors specu- lated that the limited mobility of the duodenum and its rich submucosal vascular plexus were the crucial factors in the development of this complication.

Cum Probl Surg, November 1993 1081

Sarr and colleagues1s6 reported on a series of 254 patients who had complications related to therapeutic endoscopic sphincterotomy and related procedures on the ampulla of Vater. Of 254 patients, 5 patients had duodenal (peri-Vaterian) perforation and 6 patients had clinically significant pancreatitis. Most patients were not suspected of having a significant complication the night of the procedure, despite abdominal pain. CT scan proved to be the most accurate radiographic study for establishing the existence of a significant complication. A periduodenal collection of fluid (abscess) without significant pancreatic enlargement was the most common complication in patients with duodenal perforation. In patients who had pancreatitis after peri- Vaterian procedures, generalized pancreatic enlargement and pancreatic edema were most prominent. Four of the five patients with duodenal perforation required surgical drainage, and all recovered. In contrast, four of the six patients with pancreatitis had medical therapy. One patient with pancreatitis died after multiple pancreatic debridements were performed. A second patient with pancreatitis who underwent exploration recovered eventually. Pancreaticoduode- nal complications after a therapeutic endoscopic sphincterotomy and related procedures are difficult to diagnose early. These complications should be suspected early and approached aggressively to limit morbidity and death.

Booth and colleagueslg7 reviewed 574 cases of endoscopic sphincterotomy. In this group, 56 precut papillotomies were performed. Complications were identified in 16% of these patients, with perforation present in 9%, pancreatitis in 5%, bleeding in 2%, and pancreatic abscess in 2%. Duodenal perforation accounted for more than half of all major complications. Five patients had duodenal perforations, and in two patients the perforation was diagnosed immediately after sphincterotomy. Both patients underwent operations within 8 hours and required only simple closure; these patients survived and were discharged within 10 days. Three patients had delayed diagnosis ranging from 16 to 28 hours. All three patients required multiple operations and prolonged intensive care for an average of 3 months. One patient died of multiple organ failure. The authors reported from their review of the literature that duodenal perforation has been reported in 1% to 7% of patients who undergo endoscopic sphincterotomy and that it is even less common after endoscopic retrograde cholangiopancreatography alone. These authors cite as the predis- posing factor for this complication a short intramural segment of the distal common bile duct, transampullary obstruction with larger gall- stones, and the so-called extended sphincterotomy. They defined the difference between the so-called precut papillotomy and endoscopic sphincterotomy. These terms are apparently used interchangeably in the literature. Anatomically, two identifiable sphincters are present in the ampulla of Vater: the papillary sphincter located near the ori-


fice of the papilla and the true or Vaterian sphincter located more proximally. When only one papillary sphincter is cut, the procedure should be called an endoscopic papillotomy. When both sphincters are divided, the procedure is known as endoscopic sphincterotomy. The authors concluded that endoscopic sphincterotomy remains a valuable additional method of treatment of several disease processes of the ampulla of Vater. Precut papillotomy carries a significantly higher complication rate than conventional sphincterotomy, and the complications occurring from the latter procedure are much more serious than those with sphincterotomy. The authors also recommended that duodenal perforations be repaired immediately, and they strongly supported the concept that duodenal perforations should not be managed conservatively. Bell and colleagues”’ described eight proven perforations of the duodenum that occurred in 441 patients who underwent endoscopic sphincterotomy. This complication developed with a frequency of 1.8% in this series. These authors reported that physical laboratory findings were of little diagnostic value, whereas plain abdominal radiographs showed evidence of perforation in 86%. Two of the eight patients underwent operations within 8 hours of the diagnosis and recuperated. Six patients underwent operations between 24 hours and 120 hours after endoscopic sphincterotomy (mean, 43 hours). Three of the six patients required a second procedure for recurring abscesses, and two of the six eventually died as a result of multiple organ failure. The authors therefore recommended immediate intervention on discovering this complication and concluded that delay in diagnosis of perforation beyond 24 hours was associated with higher morbidity and death. This observation is well supported in their extensive review of the literature. Among 6349 cases of endoscopic sphincterotomy, 80 perforations (1.3% 1 were noted to have a mortality rate of 26%.

Gould and colleaguesl” reported a case of duodenal perforation as a delayed complication of placement of a biliary endoprosthesis. Dine?” reported a case of duodenal perforation after a small-bowel enema examination (enteroclysis). Grindlinger and Vesterzol reported an unusual case of a patient who had transvaginal impalement on a broomstick. At the initial exploration, the broad ligament and vagina were repaired. When bile drained from suction catheters, reexploration disclosed an injury to the duodenum and diaphragm. The authors stated that, in general, vaginal injuries that occur from penetrating trauma are rarely associated with intraperitoneal injury. These authors recommended that vaginal penetrating wounds be treated like any other abdominal penetrating injuries.

Caustic ingestions of acid or alkali may rarely involve the duodenum; this situation is usually prevented by spasm of the pylorus. In those rare cases in which transmural duodenal necrosis has occurred, resection will usually be required. Sarfati and colleagueszo2

Cur-r Probl SW.. November 1993 1083

recently reviewed their experience with 484 adults with caustic ingestion injury and documented a very high mortality rate of patients with this type of injury.

The authors are indebted to Mrs. Dolores Williams for her help in assembling this manuscript. The authors also thank Mrs. Gae Decker for her help in compiling this manuscript.

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