management of duodenal trauma

1. Management of Duodenal
trauma
Dr. Uday

2. Introduction
• The epitome of an organ poorly designed to
withstand the ravages of trauma.’
• Duodenal injuries are uncommon
• Duodenal injuries are both difficult to diagnose
and repair due to its retroperitoneal location
• Mortality is high in duodenal injuries

3. Introduction
• Isolated duodenal injuries are rare
• They are associated with IVC and Aortic
injuries, pancreatic injuries
• In cases of pancreaticoduodenal injuries there
will be leakage of pancreatic juice which
provokes the inflammatory process

4. Applied Anatomy
• First portion of the small
intestine
• From the pylorus to the
ligament of Treitz
• 25-30 cm in length
• Divided into 4 portions

5. Incidence
• 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%
o Penetrating injury –more common
o Blunt injury
o Iatrogenic injury

6. Incidence
• Penetrating trauma accounts for 78% of all
duodenal injuries, whereas blunt trauma
accounts for 22%.
• Descending part or 2nd part of the duodenum is
more commonly injured
• Organs most commonly injured in association are
liver and pancreas

7. Incidence
• Blunt trauma from:
– Crushing of duodenum b/w spine and
steering wheel
– Flexion-distraction fracture of L1-L2
(Chance fracture)
– Stomping and striking in midepigastrium
– Sudden deceleration

8. CLINICAL FEATURES
• Abdominal pain especially when the right upper
quadrant is injured
– Intensified with apparent peritoneal stimulation
and Radiation pain to the back
• Retching or vomiting with blood in the vomitus
• Abdominal distension especially in the upper
quadrant
• Detection of fluid like bile or intestinal juice by
diagnostic paracentesis.

9. Diagnosis
• Requires a high index of suspicion
• More difficult to diagnose in blunt trauma than
penetrating as penetrating injuries tend to
necessitate an operative exploration
• No specific diagnostic test found to be accurate all of
the time
Abdominal X-rays
UGI
Endoscopy
CT Scan

10. Abdominal x-ray
• Free air was usually not
present in the peritoneal
cavity.
• Presence of air collections
outlining the right kidney
• Presence of gas around the
right psoas muscle and in
the retro ceacal region

11. Upper GI series
– Usually with Gastrograffin or thin barium
– May see a leak with fluoroscopy
– Complete obstruction by hematoma → “Coiled
spring appearance” or “Stacked coin appearance”

12. Endoscopy
• May visualize a intra-
luminal blood, a
perforation or a hematoma
directly
• Not usually used acutely
due to the possibility of
worsening injury with
either the scope or the
insufflation

13. CT abdomen
• Must be performed with both oral and
intravenous contrast
• Best method for visualizing retroperitoneal
structures without an operation
• Helpful in evaluating the remaining intra-
abdominal cavity in stable patients
• Not always very sensitive

14. CT abdomen
• Extravasation of oral contrast
from the duodenum with a
retroperitoneal hematoma
• Extra luminal gas/fluid around
the duodenum
• Focal bowel wall thickening
• Interruption of progress of the
bowel contrast medium

15. DPL
• Unreliable in detecting isolated duodenal and other
retroperitoneal injuries
• But DPL is often helpful because of 40% of patients
have associated intra-abdominal injuries that will
result in a positive DPL
• The finding of amylase or bile are more specific
indicators of possible duodenal injury

16. EXPLORATORY LAPAROTOMY
• It remains the ultimate diagnostic test if a high
degree of suspicion of duodenal injury continues.
• Indications for duodenal exploration are
 Free fluid looking like biile with undetermined
origin
 Documented bile leak
Right-sided retroperitoneal or periduodenal
hematoma

17. Duodenum organ injury scale (AAST)

18. Grade I duodenal injury
• Axial CT image shows
thickening of the
duodenal wall (arrow)
in the descending
• part without evidence
of free air. There is
stranding of the peri
pancreatic fat

19. Grade II duodenal injury
• Thickening of the duodenal
wall in the descending part
(black arrow).
• Adjacent to the duodenum
is a small collection of extra
luminal air (white arrow),
which indicates a small
grade II laceration of the
wall

20. Grade III duodenal injury.
• Axial CT image shows thickening of
the duodenal wall in the
descending part (black arrow).
• At the transition zone to the
horizontal part, there is disruption
of the wall (white arrow).
• A retroperitoneal hematoma and
hypo perfusion of the right kidney
due to right renal artery occlusion.

21. Management of duodenal trauma
• Diagnostic laparoscopy has got no much significance.
• A long, midline exploratory laparotomy
• A thorough search for intraperitoneal injuries
• KOCHERS & CATTELL- BRASCH Manoeuvres.
• All 4 parts of duodenum are to be inspected.
• After a duodenal injury is identified, its extent should be
defined.

22. Principles in the management
• Basic principles are
Restore intestinal continuity
Decompress the duodenal lumen
Provide external drainage
Provide nutritional support

23. Predictors of out come
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.

24. 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
(5) an associated injury to the common bile duct had occurred.

25. Grade I or II hematoma
If detected pre operatively
• Observation
• Naso gastric aspiration
• TPN
if detected intra operatively
• evacuation

26. Grade I or II laceration
• Primary closure in one or two layers
• Pyloric exclusion only if there is associated
pancreatic injury

27. Grade III
• Attempt primary closure as first option, with
concomitant pyloric exclusion
If its not feasible ,treat as follows
• injury proximal to ampulla-perform antrectomy plus
GJ and stump closure
• Injury distal to ampulla-Roux-en-y
duodenojejunostomy to proximal end of duodenal
injury with oversewing of distal duodenum

28. Grade IV or v
• Patients who present with this degree of trauma usually
present either in shock or with concomitant severe
injuries
to other organs.
These patients are best served
• with a damage control strategy, focusing on hemorrhage
control, debriding devitalized tissue, containing
gross contamination, and using liberal external drainage
in an effort to minimize operative time and maximize
time in the intensive care unit for ongoing
resuscitation and correction of the lethal triad

29. Grade IV or V
Management options are as follows
• Pancreaticoduodenectomy
• Reconstruction with hepaticojejunostomies
• Reimplantation of distal CBD into roux-en-y
jejunal limb

31. Various techniques

32. Duodenorrhaphy
• Meticulous debridement of
all damaged tissue.
• Double-layer closure,
including
• Meticulous attention must
be paid to imbricate the
duodenal mucosa because
it tends to extrude from
suture lines.

33. Duodenorrhaphy
• Duodenorrhaphy alone carries a
small risk of narrowing the
duodenal lumen.
• Kraus and Condons 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.
• Longitudinal closures be
performed if the duodenotomy
exceeds one half of the
circumference of the duodenum

34. Tube duodenostomies
• three types
(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
(3) Retrograde, in which the
tube is passed through a
jejunostomy site

35. Triple ostomy technique

36. Jejunal serosal patch
The technique of jejunal-
serosal patch was first
described by Kobbold
and Thall
To prevent severe
narrowing which may
occur due to primary
closure.

37. Jejunal mucosal patch
• Described by Jones and Joergenson
• 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.

38. Jejunal mucosal patch

39. Pedicled graft
• Pedicle grafts of the stomach, otherwise known as gastric
island flaps.
• Obtained from the body of the stomach at the greater
curvature rather than the antrum because exposure to
alkaline secretions of antral tissue will stimulate secretion of
hydrochloric acid.
• A gastric island flap is usually based on the gastroepiploic
vessels.
• Similarly, Seidel and colleagues have used open pedicle grafts
of ileum to repair duodenal defects

40. Duodenal resection
• If the entire circumference of the duodenum has been
devitalized, a segmental resection and end-to-end
duodenoduodenostomy may be performed.

41. Duodenal resection
• 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

42. • 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

43. Duodenal Diverticulisation
• Described by Berne and colleaguesl” in
1968
• Was aimed at decreasing the high rate of
morbidity and mortality in patients with
combined duodenal and pancreatic
injuries.
• The goal of excluding the duodenum from
the passage of gastric contents.

44. Duodenal Diverticulisation
Includes antrectomy,
debridement, and
closure of the
duodenum, tube
duodenostomy,
vagotomy, biliary
tract drainage, and a
feeding jejunostomy

45. Duodenal Diverticulisation
• The operation of duodenal diverticulization
appeared to reduce morbidity and mortality
when compared with other procedures.
• The overall mortality rate of 16% compared
favorably with a 35% mortality rate in other
studies.
• Duodenal diverticulization is a time-consuming
and often complicated surgical procedure that
many critically ill patients cannot tolerate.

46. Pyloric exclusion
• 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.

47. Pancreaticoduodenectomy
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

48. Pancreaticoduodenectomy
Pancreaticoduode
nectomy is clearly
a formidable
procedure in
critically ill
patients.

49. complications
• Duodenal fistula
• Intra abdominal abscess
• Pancreatitis
• Duodenal obstruction
• Bile duct fistula

50. summary
• Duodenal injuries are uncommon and usually
associated with other visceral injuries and
isolated duodenal injuries are rare.
• Management of duodenal injuries is difficult
• Mortality is high