Duodenal injures - Diagnosis and management

1. Duodenal injuries
Dr. Joe M Das

2. • Duodenum
- Do-deka-dactulos (Gk)
- duodenum digitorum (Latin) =
- breadth of 12 fingers
• 12 inches (24-26 cm)
• Herophilus (300 B.C.)
• 3.7 – 5 % of laparotomies for trauma

3. Part Length From To Level
1st (Superior) 5 cm Pyloric V of
Mayo
Sup: CBD
Inf: GDA
L1
2nd
(Descending)
8-10 cm Sup: CBD
Inf: GDA
Ampulla L1
3rd
(Horizontal)
10 cm Ampulla SMA L3
4th
(Ascending)
2.5 cm SMA Lig of Treitz L2
First 2 cm of superior part is mobile

4. Relations
• Medial : HOP
• Superior : Quadrate lobe and GB
• Posterior : (R) kidney & psoas, IVC & portal V,
L1-L3
• Anterior : liver that overlies D1 & D2;
the hepatic flexure of the colon, right
transverse colon, mesocolon and stomach
that overlies D4.

6. Arterial supply
• Superior anterior pancreatico duodenal
• Superior posterior pancreatico duodenal
GDA from Hepatic A
• Inferior anterior pancreatico duodenal
• Inferior posterior pancreatico duodenal
SMA

9. • Others:
– (R) gastric
– Gastroepiploic
– Supraduodenal artery (Wilkie)
– Retroduodenal artery
• Venous drainage:
– SMV → Portal V

10. Physiology
• Mixing point for the partially digested chyle
and the proteolytic and lipolytic secretions of
the biliary tract and pancreas
• Powerful activated digestive enzymes including
lipase, trypsin, amylase, elastase, and
peptidases
• Approximately 6 L of fluid from the stomach,
bile duct, and pancreas passes through the
duodenum in a 24-hour period
• Escape of duodenal contents into the free
peritoneal cavity or retroperitoneum →
destructive process that is compounded by
the inflammatory response that it provokes.

11. History
• The earliest recorded cases of successful
outcomes from penetrating duodenal
injuries is credited to Larrey (Fr.)
• The first successful repair of a duodenal
injury after blunt trauma was reported by
Herczel in 1896
• Moynihan repaired a penetrating duodenal
injury; he performed a gastrojejunostomy
in a patient who lived for 104 days. (1901)

12. • Penetrating trauma accounts for 78% of all
duodenal injuries, whereas blunt trauma
accounts for 22%.
• D2 is most commonly injured
• ‘The epitome of an organ poorly designed
to withstand the ravages of trauma.’
• Asso: with injuries to liver, pancreas, small
bowel, colon

13. • 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

14. 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 with infrequent or muted borborygmus
• Detection of fluid like bile or intestinal juice by
diagnostic paracentesis.

15. When to suspect intra-operatively?
• Free gas or fluid looking like bile with
undetermined origin
• Extraction of intestinal juice or fluid like bile
from retro-peritoneal hematoma and
• Edema, hematoma, ecchymosis or crepitus in
the periduodenal retroperitoneum or root of
mesentery and mesocolon.
• Instillation of methylene blue via NG tube
(Brotman et al)
A test to help diagnosis of rupture in the injured duodenum. Injury 1981; 12:464-5

16. Severe duodenal injury (Snyder)
• Missile or blunt injury
• Injury of the first or second portion of the
duodenum
• Adjacent common bile duct injury.
Snyder WH 3rd, et al. The surgical management of duodenal trauma. Precepts based on a review of 247 cases.
Arch Surg 1980;115(4):422-429.

17. Problems in management
• The retroperitoneal location
• Proximity to important abdominal structures
• Marginal blood supply
• Biliary, pancreatic and gastro-intestinal
secretions in it
• Delay in the diagnosis

19. Plain X-ray findings in Duodenal injury
• Gas bubbles in retroperitoneum adjacent to
(R) psoas, around (R) kidney, ant to upper
lumbar spine
• Free intraperitoneal gas
• Gas in biliary tree
• Obliteration of (R) psoas shadow
• # transverse processes of lumbar vertebrae

20. Upper GI series
• Water soluble contrast (Meglumine –
Gastrografin) – via NG tube ↓ fluoroscopy
• (R) lat → Supine → (L) lat
• If neg → Barium contrast
• Complete obstruction by hematoma →
“Coiled spring appearance” or “Stacked coin
appearance”

21. CT findings in Duodenal injury
• Retroperitoneal collection of contrast
• Extraluminal gas
• Lack of continuity of the duodenal wall.
• Duodenal contusion is suspected with
– Edema or hematoma of the duodenal wall
– Intramural gas accumulations
– Focal duodenal wall thickening (>4 mm) as findings of
small bowel injury.
• Fluid or a hematoma in the retroperitoneum,
stranding of retroperitoneal fatty tissue, or
pancreatic transection can be present in both
conditions

22. Grade 1,2 & 3 duodenal injuries

23. Cattell and Braasch maneuver

24. • 1st part
• 2nd part
• 3rd part
• 4th part
Upper
portion
Lower
portion
Cholangiogram
Visual inspection
Complex repair
Debridement
Closure
Resection - Anastomosis

25. Intramural hematoma
• Most common in children
• Submucosa / subserosa → Obstruction
• GOO in 48 hrs
• “Coiled spring appearance” or “Stacked coin
appearance”
• Conservative ℞ (NGA + TPN)  3 weeks
No improvement
Laparotomy (To r/o duo perforation /
injury to HOP)

26. Intramural hematoma
• If detected intra-operatively,
– Open serosa, evacuate hematoma, repair the wall
( May convert partial tear to a full thickness one)
– Explore to exclude perforation, leaving hematoma
intact with post-op NGA

28. Principles in the management
4 basic principles in managing duodenal trauma:
– Restore intestinal continuity
– Decompress the duodenal lumen
– Provide wide, external drainage
– Provide nutritional support

29. Duodenorrhaphy
(>½ of circumference of duodenum)

30. Duodenorrhaphy
(<½ of circumference of duodenum)

31. Tube duodenostomy

32. Suck-me, feed-me jejunostomy

33. Addition of gastrostomy

34. Serosal patch technique

35. Jejunal mucosal
patch /
pedicled graft

36. Duodenal perforation
• High risk injuries:
– Associated pancreatic injury
– Blunt / Missile injury
– Involvement of >75% of duodenal wall
– Injury to D1 / D2
– Time interval between injury & repair > 24 hrs
– Associated CBD injury
• Repair / Diversion / Pancreaticoduodenectomy

37. Repair
• Most injuries – primary closure in one or two
layers
• Longitudinal duodenotomies closed
transversely if length of duo injury < 50% of
circumference
• If chance of lumen compromise:
– Pedicled mucosal graft (segment of jejunum /
gastric island flap)
– Jejunal serosal patch
– Buttress of duo repair by jejunal loop

38. Repair of complete transection
• First part:
– Antrectomy + Closure of duodenal stump +
Billroth II GJ
• Third / Fourth parts (Distal to ampulla):
– Closure of distal duodenum + Roux-en-Y DJ
• Second part:
– Direct E-S duodenal defect to Roux-en-Y loop
• Soft silicone rubber closed system drainage

39. Debridement, segmental resection,
EEA

43. Vaughan / Jordan pyloric exclusion
technique

44. Duodenal Diversion
• In high risk duodenal injury
• Earliest technique – Tube decompression
• Stone & Garoni “triple ostomy”
– Gastrostomy tube to decompress stomach
– Retrograde jejunostomy to decompress duo
– Antegrade jejunostomy for feeding
• Duodenal diverticulation
– Distal Billroth II gastrectomy + Closure of duodenal
wound + Placement of decompressive catheter into
duodenum (± Truncal vagotomy + Biliary drainage)

45. Triple ostomy

46. Duodenal diverticulisation
Primary duodenorrhaphy +
Truncal vagotomy +
Antrectomy with GJ +
Tube choledochostomy +
External drainage

47. Pacreaticoduodenectomy

48. Indications for Whipple’s procedure
• Massive and uncontrollable bleeding from the
head of the pancreas, adjacent vascular
structures, or both.
• Massive and unreconstructable ductal injury in
the head of the pancreas.
• Combined unreconstructable injuries of the
following:
– Duodenum and head of the pancreas
– Duodenum, head of the pancreas, and common
bile duct

50. Complications
• Duodenal fistula
• Intra-abdominal abscess
• Pancreatitis
• Duodenal obstruction
• Bile duct fistula
• Mortality ≈ 17%

51. Bibliography
• Complex duodenal injuries - Rao R. Ivatury, MD
et al
• Diagnosis and Classification of Pancreatic and
Duodenal Injuries in Emergency Radiology - Ulrich
Linsenmaier, MD, PhD et al -Radiographics
• Management of duodenal trauma - CHEN Guo-
qing and YANG Hua - Chinese Journal of
Traumatology 2011; 14(1):61-64
• Duodenal injuries – E Degiannis – BJS 2000, 87,
1473-79