Mx duod injuries curr probl surg

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  • 1. MANAGEMENT OF DUODENAL INJURIESIN BRIEF With most of the duodenum protected deep within the ana-tomic confines of the retroperitoneum, injuries to this organ areuncommon but not rare. These injuries represent approximately4% of all abdominal injuries. However, because of difficultieswith initial assessment, establishment of the diagnosis, and, oc-casionally, management, the morbidity and mortality rates associ-ated with injuries of the duodenum approach 65% and 20%,respectively. The first successful repair of a duodenal injury after blunt traumawas reported by Herczel in 1896. It was 1901 before Moynihan re-paired a penetrating duodenal injury; he performed a gastrojejunos- tomy in a patient who lived for 104 days. With subsequent improve-ments in anesthesia, antibiotic therapy, and surgical techniques, sig- nificant decreases in operative morbidity and mortality rates havebeen 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, inparticular, provided surgeons the opportunity to improve the care ofmany battlefield casualties. The incidence of duodenal injuries is related to the geographic set-ting of the traumatic incident (i.e., urban or rural). Penetrating trauma accounts for 78% of all duodenal injuries, whereas blunt trauma ac-counts for 22%. Retroperitoneal duodenal ruptures caused by blunttrauma occur only rarely. The morbidity and mortality associated with duodenal injuries areincreased with associated injuries of the liver, pancreas, small bowel, and colon. The most commonly injured vascular structures are theinferior vena cava and the abdominal aorta. These associated inju-ries result in particularly high mortality from the resulting exsangui-nating hemorrhage. The second portion of the duodenum is injured more often thanany other portion and poses greater technical difficulties for surgicalmanagement. Injuries affecting multiple portions of the duodenum1026 Curr Probl Surg, November 1993
  • 2. occur with a frequency of 14%, resulting in greater technical chal-lenges to the surgeon. Successful diagnosis of a duodenal injury requires a high index ofsuspicion. The mechanism of injury represents important informa-tion that can be obtained from close communication with personnelfrom emergency medical services (EMS). Information such as thepresence of a bent steering wheel and related data on the velocity,direction, and impact of the motor vehicular accident often yield im-portant clues that alert the surgeon to the possibility of duodenal in-jury. Duodenal injury is often overlooked because of seemingly moredramatic 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 gen-eral, are not helpful. Radiographic studies such as plain abdominalfilms are helpful but only if positive. Important abnormal findingssuch as unexplained fluid collections surrounding the duodenumand retroperitoneal free air, particularly that outlining the upper poleof the right kidney, strongly suggest a duodenal injury. No studies, either retrospective or prospective, have compared theuse of upper gastrointestinal contrast study with the computed to-mographic scan. The upper gastrointestinal contrast study is per-formed initially by the ingestion or administration of a water-solublemedium and should confirm or exclude the presence of a leak. Ifnegative, this initial study should be followed by a thin solution ofbarium to provide better definition of the duodenal anatomy. Posi-tive computed tomography scan findings include extravasation fromthe lumen, perimural and intramural duodenal hematomas, and freeretroperitoneal air. The computed tomography scan also provides in-formation that helps to diagnose other associated injuries. Magneticresonance imaging is not yet a useful diagnostic tool in this setting. Diagnostic peritoneal lavage is not useful in detecting retroperito-neal injuries. It is positive in approximately 50% of all cases resultingfrom 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 basicprinciples of initial assessment and resuscitation recommended bythe Advanced Trauma Life Support course of the American College of Surgeons, including early control of the airway and adequate vol-ume resuscitation. When a decision has been made to operate, ap-propriate broad-spectrum antibiotics are administered. The abdo-men is entered through a generous midline incision extending fromxiphoid to pubis. A meticulous exploratory laparotomy and retroperi-toneal exploration should avoid the severe consequences of over-looked injuries.Curr Probl SW,, November 1993 1027
  • 3. When a duodenal injury is detected intraoperatively, the surgeonmust be aware of factors that increase the morbidity and mortality ofthe injury, including the presence of associated biliary and pancre-atic injuries. We recommend intraoperative grading of all duodenalinjuries by the Penetrating Abdominal Trauma Index. Injuries oflesser grade should be treated by simpler surgical techniques, andinjuries of greater severity should be treated by more complex tech-niques. The American Association for the Surgery of Trauma has alsodevised a scoring system to grade these injuries and establish a uni-form reporting standard. Surgeons who treat patients with traumatic injuries to the duode-num must be able to use an armamentarium of surgical proceduresto repair these injuries. Approximately 75% to 80% of all duodenalinjuries can be repaired safely by simple surgical techniques such asdebridement to viable tissue, primary repair by double-layer duode-norrhaphy, and drainage using a closed system. The role of tube duo-denostomy as an adjunct to management and as a means of decom-pression and protection of the suture line is controversial. Complexsurgical procedures such as the jejunal serosal patch, duodenal re-section with Roux-en-Y duodenojejunostomy, duodenal resectionwith end-to-end duodenoduodenostomy, pedicled grafts, duodenaldiverticularization, pyloric exclusion, and pancreatoduodenectomyare each useful in selected patients. Duodenal injuries are uncommon in the trauma patient, and thusmany general surgeons do not develop the expertise necessary tomanage patients with this unique and challenging clinical problem.The potential for morbidity and mortality is ample and is related tothe accuracy and timing of diagnosis as well as to the skill of the sur-geon.1028 Cur-r Probl Surg, November 1993
  • 4. 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 af- ter active duty in the U.S. Navy. He furthered his training in trauma surgery at Detroit General Hospital during resi- dency 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 ab- dominal and vascular trauma, endocrine and general SUF- gery, and surgical critical care.Curr Probl Surg, November 1993 1029
  • 5. 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 Schoolof Public Health. Dr. Britt is currently Chief of the Divisionof 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. Afterserving on the faculty of the Yale University School of Medi-cine, the University of Chicago, and the Tulane UniversitySchool of Medicine, Dr. Kerstein was appointed as theEdgar 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 tourfrom 2965 to 1967 with the U.S. Navy during the Vietnam conflict. His continued interest in trauma and the Navy con- tributed 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
  • 6. MANAGEMENT OF DUODENAL INJURIESINTRODUCTION The duodenum is the epitome of an organ poorly designed to with-stand the ravages of trauma. Located in the inaccessible and darkreaches of the retroperitoneum, injuries to the duodenum usually arenot suspected or are diagnosed rather late while more apparent in-juries to other organs are addressed. The small, thin-walled duode-num possesses a marginal blood supply shared with the pancreas.Therefore this organ is not amenable to sound technical closure, andparts of it are very difficult to resect. Lying against the vertebral col-umn, the duodenum is highly susceptible to severe crushing inju-ries. It is also fixed at two separate points-the portal triad and theligament of Treitz- thereby subjecting it to decelerating injuries. Fur-thermore, it is subject to “blow-out” injury by being, at times, closedat its portals of entrance (the pylorus) and exit (the duodenojejunaljunction). The duodenum is surrounded by many vital structures, includingthe aorta, inferior vena cava, superior mesenteric vessels, portal ves-sels, right renovascular pedicle, and the biliary tree. When injured,these structures produce large amounts of blood and bile that mayobscure injuries of the duodenal wall. Finally, its matrimony of con-venience to the pancreas (by virtue of its shared blood supply) is eas-ily disrupted at the time of injury by the action of the pancreatic en-zpes released frequently during combined pancreatic and duode-nal injuries. Given these considerations, it is no wonder that duodenal injuriesremain one of the most complex challenges for modern-day trauma surgeons. The objectives of this monograph are (1) to familiarize thereader with duodenal anatomy as it relates to trauma surgery, (2) toprovide an in-depth analysis of the incidence and mortality rate of duodenal injuries, and (3) to provide a concise approach to diagno- sis, surgical management, and treatment of complications of duode- nal trauma.Curr Probl Surg November 1993 1031
  • 7. HISTORIC PERSPECTIVE There is a scarcity of well-documented historic accounts regard-ing the management of duodenal injuries. Several characteristics ofthe duodenum may account for this fact: its retroperitoneal location,the difficulty in mobilizing it surgically, or the fact that it just did notemerge within the realm of surgical diagnosis or treatment duringthe last century. However, the primary reason for this lack of docu-mentation appears to be the infrequent use of exploratory laparotomyfor the management of traumatic abdominal injuries. Although thistechnique had been readily available and used for nontraumatic ab-dominal problems, most surgeons did not view it with much respect. Exploratory laparotomy was used by Baudens in 1836: however, itwas not until the Civil War that the procedure was considered valu-able in the management of abdominal trauma.’ It was not until WorldWar I that American surgeons become more forceful and began toexplore soldiers who sustained penetrating abdominal injuries. Perhaps one of the earliest recorded cases of successful outcomesfrom penetrating duodenal injuries is credited to Larrey, the Frenchsurgeon who recorded the following case in 1811: Etienne Belloc, age 17 fusileer of the guards was wounded by a sword inthe abdomen about two inches above the umbilicus, and on the right sideof the linea alba. He was brought to the hospital on April 1, 1811, and theattending surgeon applied a simple dressing and bandage. Next day, I ex-amined the wound, which permitted the omentum to escape through it. Theright rectus muscle and its tendinous sheath were cut quite through, andthe instrument appeared to have passed in a transverse direction deeply,from before, backwards, between the great curve of the stomach, and thearch of the colon. The paleness of death was on his countenance and he was tormentedwith intolerable anguish, nausea, and efforts to vomit; with hiccough, ardentthirst and acute pain at the bottom of the wound, and great anxiety; his pulsewas small and feeble, his extremities cold, and voice no longer audible: Wehad reason to believe he could survive but a few moments. Still, I reduced the omentum, with my fingers ascertained that the swordhad glanced between the stomach and colon, but I could not decide on theplace 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 mucilaginousdrinks, emollient enemata, low diet, a particular position of the body andperfect rest. He felt but a little relief from this treatment; the prostration con-tinued as before, the pulse was small and tense, and anxiety and nauseaattended: He was never at rest. On the night of the second day, vomitingcame on with considerable efforts, cold sweat and alarming syncope, he firstdischarged the contents of his stomach by vomiting and then bilious matterwith clots of black blood. On the fourth day, to this bilious evacuations suc-ceeded the vomiting of thick black blood in such quantity that the chamber-1032 Curr Probl Surg, November 1993
  • 8. utensil was filled with it in a few minutes. On the iifth day, an alvine evacu-ation, equally copious took place, proceeded by violent colick and acutepains in the wound; the abdomen always remained flaccid and without anysigns of effusion in its cavity. An alarming syncope succeeded this evacua-tion on the night of the 6th, and his companions believed him dead. When Ivisited the hospital very early the next morning, I found his face coveredwith 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 bodyrubbed with oil of chamomile, and wrapped in hot flannels. The colick neverreturned and from this time he gradually recovered. I prescribed a muci-laginous drink with syrup of althea and orange-flower water, to which wasadded 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 ofsubsequent complications, convalescence, and the basis for diagno-sis of duodenal injury. During the American Civil War, five soldiers were reported to haveincurred duodenal wounds resulting from “shot injuries,” with a100% mortality rate and no surgical intervention. A detailed autopsyreport 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 sideof the epigastrium, at the edge of the ribs, and emerged through the rightbuttock. 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 woundand ferruginous preparations and opiates were administered with milkpunch. A farinaceous and milk diet was allowed. Faeces escaped freely fromthe wound exit and also from the wound of entrance for a few days. Afterthis, frequent and continued alvine ejections took place through the naturalchannels. Death resulted on October 12, 1864. At the autopsy it was foundthat the ball entering the right side of the epigastric region had carried awayabout half of the caliber of the duodenum, near the orifice of the cystic duct.It had passed obliquely downward and backward through the caecum abovethe ileo-cecal valve.4 The first successful surgical repair of a duodenal rupture was re-ported in 1896 by Herczel,’ who repaired the ruptured duodenum ofa 36-year-old woman after blunt trauma. In 1901, Moynihan” closeda duodenal wound and performed a gastrojejunostomy with a pro-longed survival of 104 days and subsequent death. In a paper readbefore the Western Surgical and Gynaecological Association on De-cember 28,1903, and published in 1904, Summers described what isperhaps the earliest and best-documented report of treatment of ret-roperitoneal perforation of the duodenum caused by a gunshotwound 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 woundCurr Probl Surg, November 1993 1033
  • 9. TABLE 1. American military experience with duodenal injuriesConflict Author Year Number of cases Mortality rateAmerican 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 3days later as follows: Had the man’s condition admitted, I would have sutured the wound inthe posterior duodenal wall after freeing and rotating the duodenum to theleft. In light of to-day, one should in a like case, in addition to repairing theduodenal wound or wounds, occlude the pylorus by means of a purse stringstitch. This same operation or soon thereafter as reaction admitted a gastro-enterostomy, must be made.7 In the same paper, Summers also quoted Jaenel, who reported 35cases of duodenal injury culled from the literature. In 1905, Godwin’described a series of ruptures of the duodenum and jejunum with ahigh mortality rate and a second successful operative repair. In thesame fashion, other sporadic reports began to appear in the litera-ture, including an article by Meerwin,’ who reported another suc-cessful operative outcome in 1907, and an article by Kanavel,” whoreported on several other successful outcomes. A noninterventional approach for management of traumatic inju-ries to the abdomen prevailed until World War I. In this war, as inother wars, the surgeon was provided with an opportunity to treatlarge numbers of casualties. During this period the first Americanmilitary series was compiled by LeeI and reported in 1927. DuringWorld War II, Cave” compiled what is still the largest military seriesdescribing 118 cases. In 1955, Sako and colleagues13 reported 17 casesfrom the Korean War experience. The results of all American militaryseries are tabulated in Table 1. Missing from this table are the resultsfrom America’s longest conflict, the Vietnam War. Although this con-flict produced hallmark works regarding the management of trau-matic vascular, colon, and rectal injuries, few reports are available onduodenal injuries, with the exception of two cases of combined pan-creaticoduodenal injuries requiring pancreaticoduodenectomy re-ported by Halgrimson and colleagues14 in 1969.DUODENAL ANATOMY The anatomy of the structures in the right upper quadrant of theabdomen is complex. Every surgeon should be familiar with this area1034 Curr Probl Surg, November 1993
  • 10. and its multiple anatomic variations. The duodenum constitutes thebeginning of the small bowel and measures approximately 21 cm.15 The duodenum is divided into four portions: superior, descend-ing, transverse, and ascending. These divisions are also known as thefirst, second, third, and fourth portions, respectively. The first por-tion of the duodenum ranges from the pyloric muscle to the com-mon bile duct superiorly and the gastroduodenal artery inferiorly. Itsorigin is marked by the pyloric vein of Mayo. The second portion ex-tends from the common bile duct and the gastroduodenal artery tothe ampulla of Vater. The third portion extends from the ampulla ofVater to the mesenteric vessels (superior mesenteric artery and vein),which cross anteriorly over the junction of the third and fourth por-tions as they emerge from the inferior border of the neck of the pan-creas. The fourth portion extends from these vessels to the point atwhich the duodenum emerges from the retroperitoneum to join thejejunum just to the left of the second lumbar vertebra. The entry to the duodenum is closed by the pyloric sphincter, andits exit is suspended by the fibromuscular ligament of Treitz. Theduodenum is mobile at the pylorus and its fourth portion but remainstotally Iixed at other points.16 The ligament of Treitz, present in 86%of the population, extends from the right pillar of the diaphragm toblend in with the smooth muscle of the duodenal wall (5% 1, the thirdand fourth portion of the duodenum, or a combination of the three (95%). It contains smooth muscle in 85% of the individuals in whomit is present.17 The duodenum is, for all practical purposes, a retroperitoneal or-gan, except for the anterior half of the circumference of its first por-tion. The first portion, the distal half of the third portion, and thefourth portion in its entirety lie directly over the vertebral column,which, coupled with the psoas muscles, aorta, inferior vena cava, andright 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 gallblad- der and medially, the pancreas, nestled in the C loop, are in proxim- ity. 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 ofWilkie, the superior pancreaticoduodenal artery, and the superior mesenteric artery and its first branch, the inferior pancreaticoduo- denal 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-Curr Probl Surg, November 1993 1035
  • 11. perior surface of the duodenum under its second portion and entersthe pancreas just below and opposite the common bile duct abovethe duodenum.” It makes a loop on the ventral surface of the pan-creas, runs along the groove between the pancreas and descending(second) portion of the duodenum, sinks into the substance of thepancreas, and is dorsal to the head of the pancreas as it anastomo-ses with the inferior pancreaticoduodenal artery. The dorsal and ven-tral pancreaticoduodenal arcades formed by the anastomosis of thesuperior and inferior pancreatic duodenal arteries supply numerousbranches to the pancreas and the duodenum.” The anastomosis between the gastroduodenal and inferior pancre-aticoduodenal arteries serves as a collateral and communicatingpathway between the celiac axis and the superior mesenteric artery.Anatomic variations occurring in proximity to the duodenal loop anduncinate process of the pancreas include an anomalous common he-patic artery arising from the superior mesenteric artery in 5% of pa-tients and an anomalous right hepatic artery arising from the samevessel in 25% of patients.‘l’ ” The common bile duct enters the posterior substance of the headof the pancreas in 83% of patients after it passes under the duode-num.23J 24 After piercing the caps&e of the pancreas posteriorly, theduct courses down within the pancreatic substance a few centime-ters from the curve of the duodenum, entering the duodenal lumenat the junction between the second and third portion of the duode-num approximately 2.0 to 2.5 cm from the py10rus.~~ Three mainvariations exist with regard to the way both the common bile ductand pancreatic duct enter the duodenum. In 85% of individuals, bothducts enter through a common channel at the ampulla of Vater,whereas in 5% both ducts enter the duodenum on the same ampullabut through separate channe1s.l’ In the remaining 10% of individu-als, both ducts enter the duodenum separately.z6l%IYSIOLOGIC ASPECTS The duodenum serves as the mixing point for the partially digestedchyle,from the stomach and the proteolytic and lipolytic secretionsof the biliary tract and pancreas. As such, it commonly contains notonly 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 tobe closed one third of the time.16 Approximately 10 L of fluid fromthe stomach, bile duct, and pancreas passes through the duodenumin a 24hour period. The high volume and high toxicity of the duo-denal contents account for the disastrous effects that ensue if a1036 Curr Probl Surg, November 1993
  • 12. breach in the duodenal wall occurs. Escape of duodenal contents intothe free peritoneal cavity or retroperitoneum incites an extremely de-structive process that is compounded by the inflammatory responsethat it provokes.”INCIDENCE OF DUODENAL INJURIES Duodenal injuries are uncommon, although not necessarily rare,in busy trauma centers. The retroperitoneal location of the duode-num, no doubt, has a strong role in protecting it and thus accountsfor the low incidence of injury to this organ. The true incidence ofduodenal injury is difficult to estimate from the literature. Among sev-eral major textbooks of surgery, none cite a figure.2s-34 Among sevenmajor textbooks and yearly publications dealing exclusively withtrauma, four publications failed to cite a figure for the incidence ofduodenal trauma.“’ 35-40 Two of the remaining publications cited afigure of 3% to 12%, but both failed to provide adequate documenta-tion of the incidence of duodenal trauma. In only one of the majortextbooks of trauma is a figure quoted on the basis of the experienceof the author’s home institution.35 A review of more than 150 journal articles dating from 1901 againyields little data on the subject. As best estimated from the literature,duodenal injuries occur in approximately 4.3% of all patients withabdominal injuries, with a range of 3.7% to 5.0%. These figures, how-ever, are based on only one military and two civilian reports. In 1955, Sako and colleagues13 reported the Korean War experienceof 17 duodenal injuries in 402 cases of abdominal injury treated in aforward surgical hospital, for an incidence of 4.2%. In 1968, Mortonand Jordan41 reported 13 cases of duodenal injury among 280 ab-dominal trauma cases, for an incidence of 5%. In 1978, Kelly and col-leagues4’ reported 34 cases of duodenal trauma in a 68-month pe-riod, representing only 3.7% of all patients explored for abdominaltrauma at their institution. These figures are validated in a recent andexcellent review of duodenal trauma reported by Levinson and col-leagues,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 in-jury. Most duodenal injuries are either penetrating or blunt, Pene-trating injuries include gunshot wounds, stab wounds, or shotgunwounds, whereas blunt injuries occur as the result of motor vehicleaccidents, falls, or aggravated assaults. The mechanism of injury thatCum Probl Surg, November 1993 1037
  • 13. TABLE 2. Mechanism of iniurv in duodenal iniuries Mechanism of injury Total no.Author and year of patients Penetrating BluntMorton and Jordan, 196S41 131 117 14Smith et al., 197145 53 46 7McInnis et al., 197?” 22 17 5Corley et al., 197447 98 75 23Lucas and Ledgewood, 197548 36 0 36Matolo et al., 197549 32 19 13Kelly et al., 197S4’ 34 28 6Stone and Fabian, 197g5’ 321 294 27Flint et al., 197g51 75 56 19Snyder et al., 19805’ 228 180 48Levinson et al., 198243 93 74 19Adkins and Keyser, 198453 56 39 17Fabian et al., 198454 10 0 10Ivatury et al., 198555 100 100 0Bostman et al., 198gs6 18 16 6Cogbill et al., 199057 164 102 62Cuddington et al., 199O58 42 16 26TOTAL 1513 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 ofduodenal trauma. In a review of the literature encompassing 17series published during the last 22 years, 1513 cases of duodenalinjuries were identified; 1175 (77.7%) occurred as the result ofpenetrating trauma, whereas 338 (22.3%) occurred as the result ofblunt trauma.41-43J45-58 Thus the ratio of penetrating to blunt traumawas 3.5:1 (Table 2). Of these 17 series, 12 provided an accurate breakdown of thewounding agent causing penetrating injuries,41-43’4s-53’55-57 and 8 pro-vided the same breakdown for blunt injuries.43J 47,48J51-53J 57 Among 56J1096 penetrating injuries, 818 (74.6%) were caused by gunshots, 21409.5% 1 were caused by stabbings, and 64 (5.9% 1 were caused by shot-gun blasts (Table 3). Among 230 blunt injuries, 178 (77.3%) werecaused 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 causedby miscellaneous injuries (Table 4). The actual mechanisms of wounding in penetrating trauma occurby 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-1038 Cur-r Probl Surg, November 1993
  • 14. TABLE 3. Penetrating injuries-wounding agents Total no. Gunshot Stab ShotgunAuthor and year of penetrating injuries wound wound woundMorton and Jordan, 117 87 22 8 1968”Corley et al., 197447 75 51 24 0Matolo et al., 197E? 19 18 1 0Kelly et al., 197S4’ 28 23 5 0Stone and Fabian, 197g5’ 294 239 31 24Flint et al., 197g51 56 51 4 1Snyder et al., 19805’ 180 143 23 14Levinson et aI., 198243 74 43 27 4Adkins and Keyser, 198453 39 27 5 7Ivatury et al., 198E? 100 69 30 1Bostman et al., 198gs6 12 1 11 0Cogbill et al., 19905’ 102 66 31 5TOTAL 1096 818 214 64 (74.6%) (19.5%) (5.9%)TABLE 4. Blunt injuries-wounding agents No. of blunt Motor vehicle AggravatedAuthor and vear iniuries accident Falls assault MiscellaneousCorley et al., 197447 23 12 4 7 0Lucas and Ledgerwood, 36 30 3 3 0 197548Flint et al., 197g51 19 13 3 0 3Snyder et al., 1980” 48 44 3 0 1Levinson et aI., 198243 19 11 3 2 3Adkins and Keyser, 198453 7 8 5 3 1Bostman et aI., 198gs6 6 6 0 0 0Cogbill et al., 19905’ 62 54 1 7 0TOTAL 230 178 22 22 8 (77.3%) (9.6%) (9.6%) (3.5%)sipation of the kinetic energy imparted on the missile at the time ofits exit from the gun. Much more complex kinematics exist when blunt injury occurs.The duodenum is a retroperitoneal organ that lies against a rigid ver-tebral column. It is a highly mobile hollow viscus, which is fixed attwo points, the second portion by the common bile duct and thefourth portion by the ligament of Treitz. The portals of entry and exitcan be closed, the former by the pyloric sphincter mechanism andthe latter by the fibromuscular ligament of Treitz. Therefore disrup-tion of this hollow viscus is subject to crushing, shearing, or burst-ing.Curr Probl Surg, November 1993 1039
  • 15. Crushing injuries usually occur when a direct force is appliedagainst the abdominal wall and transmitted to the duodenum, whichis then projected posteriorly against the rigid and unyielding verte-bral column. A good example of crush injury occurs when the steer-ing wheel impacts on the midepigastrium. Shearing injuries occurwhen the mobile and nonfixed portions of the duodenum accelerateand decelerate forward and backward, respectively, against the fixedand stable portions, as may occur during falls from great heights, Finally, blow-out injuries occur when a force is applied to a gasand fluid-filled duodenum against a closed pylorus and acutelyflexed duodenojejunal angle resulting from the contracted fibromus-cular ligament of Treitz, as described by Cocke and Meyer.” The py-lorus is closed approximately one third of the time when a peristal-tic wave passes over it into the duodenum. This wave migrates overthe duodenum, resulting in closure of the pylorus and contractionof the suspensory ligament of Treitz. Therefore a closed-loop effectis established periodically such that a blow delivered to the abdo-men at a given point in time would provide both an anatomic pre-disposition and physiologic state favorable to rupture of the duode-nal wall.ASSOCIATED INJURIES The duodenum, by virtue of its anatomic proximity to other im-portant organs, is rarely injured alone. In fact, multiple associatedinjuries are the rule rather than the exception. This situation is par-ticularly true with penetrating trauma, but it also occurs with blunttrauma. Isolated duodenal injuries usually are seen in the form ofduodenal hematomas.TABLE 5. Associated injuries No. of Patients with AssociatedAuthor and year patients associated injuries iniuriesMcInnis et al., 197546 22 18 (81.8%) 47Corley et al., 197447 98 88 187.8%) 206Lucas and Ledgerwood, 1975- 36 25 169.4%1 49Matolo et al., 197E? 32 26 181.3%) 66Kelly et al., 197S4’ 34 31 (91.2%) 97Stone and Fabian, 197g5’ 321 294 191.5% i 1143Flint et al., 197g51 75 59 (78.6%) 16.5Snyder et al., 19805’ 228 217 (95.2%) 575Levinson et al., 198243 87 85 (97.7%) 184Adkins and Keyser, 1984j3 56 50 189.2%) 122Cogbill et al., 1990” 164 152 (92.6%) 393T0T.Q 1153 1045 186.94%) 30471040 Cm- Probl Surg, November 1993
  • 16. TABLE 6. Associated injuries, bv organ small Major Mist Biliary tree MajorAuthor and year Liver Pancreas bowel Colon veins Stomach injuries and gallbladder arteries Genilourinary SpleenMcInnis et al., 197E?” 5 1 7 11 4 3 11 2 5 6 2Corley et al., 197447 32 37 19 24 19 20 7 13 15 14 4Lucas and Ledgerwood, 7 19 2 1 0 3 5 0 2 5 3 197PMatolo et al. 1975”” 11 7 10 10 5 6 6 1 5 3 2Kelly et al., ;97g4’ 13 9 8 13 14 11 18 2 4 5 0Stone and Fabian, 197g5” 186 101 147 100 98 98 185 74 91 63 0Flint et al, 197Y51 31 20 2.5 29 13 24 0 11 0 12 0Snyder et al., 1980”’ 99 64 60 73 77 60 0 51 39 52 0Levinson et al., 198P 39 21 26 23 14 18 0 15 13 9 6Adkins and Keyser, 198453 20 11 18 16 10 8 8 11 6 6 2CogbiLl et al., 1990”7 74 65 29 43 45 27 13 29 22 28 18ToTAl 517 355 351 343 299 278 253 37
  • 17. TABLE 7. Associated injuriesOrgan No. of injuries Percentage of totalLiver 517 16.9Pancreas 355 11.6Small bowel 351 11.6Colon 343 11.5Major veins 299 9.8Stomach 278 9.1Miscellaneous injuries 253 8.3Biliary tree and gallbladder 209 6.8Major arteries 202 6.6Genitourinary injuries 203 6.6Spleen 37 1.2TOTAL 3047 A review of 11 series during the last 22 years identified a total of1153 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). Theliver was the most commonly injured organ; a total of 517 injuriesoccurred, with a frequency of 16.9%. Other commonly injured organsincluded the pancreas, with 355 injuries (11.6%); small bowel, with351 injuries (11.6% 1; and colon, with 343 injuries (11.5%).42,43,46-53, 57Miscellaneous injuries, mostly extraabdominal, accounted for 253 in-juries (8.3%). Major abdominal venous injuries occurred in 299 pa-tients (9.8%). The inferior vena cava accounted for most of these in-juries. Arterial injuries occurred in 202 patients (6.6% 1, with the aortaaccounting for most of these injuries. Interestingly, genitourinarytract injuries occurred in 6.6% of the patients, and the spleen wasthe abdominal organ injured least frequently. Only six diaphragmaticinjuries were identified. The lung was the most frequently injuredextraabdominal organ5’ANATOMIC LOCATION OF INJURY To identify the anatomic locations of duodenal injuries, we re-viewed nine series published during the last 22 years.41J 46J 50-55 Se- 47Jlection criteria included an accurate description of the anatomic lo-cation of the duodenal injury and a description of the sites of otherorgan injuries. From this review, a total of 1003 injuries were ana-lyzed. The most frequent site of duodenal injury was the second por-tion, with 331 injuries (33.0%). The third and fourth portions sus-tained 194 (19.4% 1 and 190 (19.0%) injuries, respectively. The least fre-quently injured portion of the duodenum was the first, accountingfor 144 injuries (14.4%). Multiple sites of injury occurred in 142 pa-tients (14.2% 1 (Table 8).1042 Curr Probl Sur. November 1993
  • 18. TABLE 8. Anatomic location of duodenal injury (blunt and penetrating1 Portion of duodenum injuredAuthor and vear No. of uatients 1st 2nd 3rd 4th Multi&eMorton and Jordan, 131 24 56 18 17 16 196s4*McInnis et al., 197,? 22 1 9 7 5 NACorley et al., 197447 98 5 49 16 13 15Stone and Fabian, 197g5’ 302 63 74 84 81 NAFlint et al., 197g51 72 9 18 8 16 21Snyder et al., 19805’ 228 23 67 33 37 68Adkins and Keyser, 198453 56 10 16 13 5 12Fabian et al., 198454 10 0 4 4 2 0Ivatury et al., 198555 84 9 40 11 14 10TOTAL 1003 144 331 194 190 142 (14.4%) (33.0%) (19.4%) 119.0% 1 (14.2%)NA, Not available. The second portion is the most frequent site of injury for both pen-etrating and blunt trauma.41’ 46,47J50-55 However, with penetratingtrauma, injuries were distributed throughout the anatomic course ofthe duodenum, whereas in blunt trauma most injuries remained con-fined to the second portion of the duodenum, usually its posteriorsurface.51DIAGNOSIS The diagnosis of duodenal injury requires a high index of suspi-cion. The physician must understand that delays in the diagnosis andmanagement of these injuries result in increased morbidity and mor-tality. Information must be obtained from EMS personnel becausethey often provide helpful information in establishing the diagnosis. The diagnosis of duodenal injury presents a greater challenge af-ter blunt trauma than after penetrating trauma. Important informa-tion to be obtained includes the hemodynamic status of the victimin the field and, for example, the state in which a vehicle was found(e.g., overturned, pointing in the opposite direction of impact, or hav-ing sustained passenger compartment invasion), Furthermore, thephysician must ascertain the status of the steering wheel (e.g., bentor intact), the direction of force impact, and whether extrication wasused to retrieve the victim. With such information, a series of characteristics emerge that col-lectively increase the surgeon’s suspicion for duodenal injuries. Forexample, patients who have head-on collisions or force impacts fromthe right, who have struck the steering wheel, or who needed extri-cation may harbor duodenal injuries.Cur-r Probl Surg, November 1993 1043
  • 19. Patients who have sustained blows to the midepigastrium must beevaluated thoroughly. Even an impact of a small magnitude, given theright anatomic and physiologic conditions, can cause duodenal blow-outs. Finally, patients who have fallen from great heights are subjectto deceleration injuries of the duodenum.” When examining the patient, the physician must remember thatthe retroperitoneal location of the duodenum may preclude earlymanifestation of injury on physical examination. Abdominal discom-fort may be out of proportion to the physical findings, and perito-neal irritation may occur late and become apparent only when ex-travasated 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 canbe expected from this delay in diagnosis. The physical examination may be characterized by minimal find- ings. Any tenderness over the right upper quadrant or midepigas- trium should be evaluated with the suspicion of duodenal injuries. Signs of rebound tenderness, abdominal rigidity and absence ofbowel 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 in- jury. Some researchers have postulated that pain impulses are con- ducted by sympathetic nerve fibers running alongside the gonadalvessels.61 Laboratory tests are of little help in the early diagnosis of duode- nal 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 se- rum 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 evalu- ated. 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 sensi- tive but nonspecific for duodenal injury. Flint and colleaguessl stated that the serum amylase level is not helpful in early diagnosis of duo- denal 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 patients1044 Cur-r Probl Surg, November 1993
  • 20. who had elevations of their serum amylase levels between 4 and 12times normal during a period of observation. At exploration, theywere found to have extensive duodenal injuries. Radiologic studies have been suggested to be the diagnostic pro-cedure of.choice in establishing the diagnosis of duodenal injury.Plain films of the abdomen are useful only if they are positive. Thefirst case of duodenal rupture diagnosed radiographically was de-scribed in 1937 by Sperling and Rigler.65 These authors correlated thepresence of air collections outlining the right kidney with extraperi-toneal rupture of the duodenum. A second case report of duodenalrupture diagnosed by plain films of the abdomen was reported in1940 by Cittenheimer and Gilman. In 1944, Jacobs and colleagues67 described other radiographic find-ings associated with duodenal rupture, including the presence of gasaround the right psoas muscle and in the retrocecal region. They con-firmed that the finding of gas outlining the right kidney was a valu-able radiographic finding. These investigators observed that free airwas usually not present in the peritoneal cavity. They also describedthe possible routes of extension of extravasated material from a per-foration of the retroperitoneal duodenum. These routes were as fol-lows: along the transverse mesocolon; along the mesentery of thesmall intestine; over the right kidney and, rarely, over the leftxkidney;downward along the route of the mesentery of the ascending colonand cecum; downward along the psoas muscle to the brim of thebony pelvis or to Poupart’s ligament; and, finally, along the great ves-sels through the diaphragm into the inferior mediastinum. Further-more, these authors outlined the protocols for obtaining abdominalx-ray fiIms and recommended that the x-ray films be repeated sev-eral hours after the injury if the initial x-ray findings were negative.This group also recommended against the use of barium for estab-lishing diagnasis of duodenal rupture: The use of barium or bismuth salts in the roentgen diagnosis of any acuteperforation of the gastrointestinal tract is contraindicated. Barium in the tissue may act as a foreign body irritant and may serve toenlarge the retroperitoneal area of infiltration further. The procedure maybe shocking to a patient who is already on the verge.67 In 1949, Siler reported four cases of rupture of the duodenumcaused by violence and advocated the use of radiographic visualiza-tion of the duodenum with the upper gastrointestinal series usingLipiodol or thin barium sulfate. He described the following radio-graphic findings of both intraperitoneal and retroperitoneal ruptureof the duodenum: In intraperitoneal rupture of the duodenum, a definite sinus may be visu-alized and the diagnosis in this location may be demonstrated clearly. Inthe case of extraperitoneal rupture of the duodenum, the roentgenogram,Cum Probl Surg, Navember 1993 1045
  • 21. taken either in the oblique or lateral position, may demonstrate a sinus lead-ing from the duodenal lumen to the retroperitoneal space.68 In 1951, Jacobson and Carter further corroborated the findings de-scribed by Jacobs and colleagues67 and added scoliosis as an associ-ated finding in retroperitoneal extravasation of duodenal contents.These authors cautioned that most patients with duodenal rupturesdid not have positive radiographic findings: The marked paucity of positive findings makes the roentgen examinationof the abdomen of little value in excluding perforations of the small intes-tine 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 wecannot await a positive diagnosis.70 With greater experience in the use of the upper gastrointestinal se-ries, Felson and Levin71 described the “coiled-spring” sign they foundin the upper gastrointestinal radiologic examination using thinbarium. These authors believed this sign to be diagnostic of intramu-ral hematoma. In 1961, Wiot and colleagues7’ described an additional sign on thebasis of similar diagnostic findings. The study involved the mucosalfolds in two patients with intramural duodenal hematoma whoseconditions were diagnosed on the basis of anticoagulant-inducedbleeding, which the authors described as the “stacked coin sign.” Radiographic signs are detectable on plain films in fewer than onethird of patients. In 1964, Cocke and Meyer,l’ on the basis of datacollected from the literature, reported 48 patients with retroperito-neal duodenal rupture and documented that 17 patients had posi-tive radiographic signs. These authors also pointed out that in a smallpercentage of patients free intraperitoneal air may exist, as was foundin 3 of their 48 patients. In 1974, a similar scarcity of radiographic findings was reported byCorley and colleagues47 in 17 patients with blunt rupture of the duo-denum from nonpenetrating trauma. Three patients had free intra-peritoneal air. However, in 12 patients with penetrating trauma, free or retroperitoneal air was demonstrated on plain films of the abdo-men. These investigators suggested that positive radiographic find- ings 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. Toxepeus1046 Curr Probl Surg, November 1993
  • 22. and his coworkers stated that air in the transverse mesocolon is oc-casionally misread as a mixture of air and feces in the transverse co-lon. However, close scrutiny will reveal that the hepatic flexure is wellbelow and distinctly separated from the air bubbles over the kidneyand that the so-called transverse mesocolon appears much widerthan 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 emergencymeglumine diatrizoate (Gastrografin; Squibb) swallow. This contrastmaterial may also be infused into a nasogastric tube with the patientlying on the right side to facilitate passage of the contrast through the pylorus into the retroperitoneal space. If no duodenal rupture ispresent, 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 rightpsoas muscle, or overlying the transverse colon. This study, the larg- est percentage reported of positive radiographic findings, is at vari- ance with other series described previously.16J 47S 6oJ 67 50, 66J The best method for visualizing the retroperitoneal organs without an operation is the computed tomography (CT) scan with intralumi- nal and intravascular contrast. CT scanning has also been demon- strated to have a high degree of accuracy in detecting injuries to in- traperitoneal organs. This technique detects free intraperitonealblood. Donohue and associates75 documented the ability to quanti- tate intraperitoneal bleeding. The applicability of CT is limited to he- modynamically 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 se- ries 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 scan- ning is likely to be the most sensitive method for detecting retroperi- toneal duodenal rupture. To our knowledge, no studies have com- pared CT scanning with the upper gastrointestinal series for diagno- sis of duodenal injury. We recommend use of the CT scan with oral and intravenous con- trast in hemodynamically stable patients who have sustained bluntCur-r Probl Surg, November 1993 1047
  • 23. abdominal trauma as the diagnostic method of choice in patients sus-pected of having duodenal injury. If the CT scan identifies extravasa-tion of oral contrast from the duodenum associated with a retroperi-toneal hematoma, no further studies need to be undertaken. How-ever, if the CT scan is inconclusive, we recommend an upper gas-trointestinal series with Gastrografin and fluoroscopic visualizationof duodenal peristalsis to confirm extravasation of contrast from theduodenum. If no extravasation is identified, thin barium is then ad-ministered, which can provide a much better delineation of duode-nal anatomy and establish the presence of duodenal hematoma. Werecommend a CT scan as the first diagnostic study in patients sus-pected of having sustained duodenal or retroperitoneal injury. Wemake this recommendation not because we believe it to be superiorto the upper gastrointestinal series but rather because it yields addi-tional information regarding intraperitoneal organs not otherwise ob-tained with the upper gastrointestinal study.82-85 Although CT scanning is thought to be the most reliable procedureto diagnose duodenal injuries, Cook and colleagues” demonstrated some pitfalls. These investigators reviewed retrospectively the medi- cal records and CT scans of 83 patients with upper abdominal traumato determine errors in diagnosis. In three of the patients in this se-ries with subsequently surgically proven small-bowel perforations (one duodenal and two proximal jejunal), the injuries were not diag- nosed on CT scans. These authors ascertained retrospectively thatpositive CT findings were present in the case of duodenal rupture.Additionally, in two patients, duodenal rupture was suspected on thebasis of CT findings of extraluminal gas and fluid near the duode- num, but in both patients the duodenum was normal at operation. Hofer and Cohens3 described two patients with duodenal perfora- tion resulting from blunt abdominal trauma and described CT find- ings of focal bowel wall thickening, interruption of progress of bowel contrast medium, and extraluminal gas and fluid as findings consis- tent with duodenal injury. These investigators noted that, in each pa- tient, thickening of the duodenal wall was consistent with intramu- ral 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 interven- tion in the management of retroperitoneal blunt ruptures of the duo- denum. These investigators suggested that any edema or hematoma of the paraduodenal/periduodenal area should be investigated ag- gressively with an upper gastrointestinal study using Gastrografin fol-1048 Curr Probl Surg, November 1993
  • 24. lowed by thin barium. Additionally, in patients in whom no conclu-sion could be reached from both the contrast and the CT scan stud-ies, exploratory laparotomy and retroperitoneal exploration of theduodenum should be strongly considered to rule out a duodenal in-jury. These investigators concluded that they would rather accept theminimal morbidity and mortality of a negative exploratory lapa-rotomy than risk the greater morbidity and mortality associated witha delay in the diagnosis and management of a duodenal injury. Hahn and colleaguess4 studied the possible use of magnetic reso-nance imaging (MRI) in the diagnosis of duodenal injury. They de-scribed two patients with duodenal hematoma in whom an MRI andCT scan were performed. In both patients, the hematoma had a well-defined concentric ring configuration on MRI, a finding that helpedto establish the diagnosis. These investigators indicated that MRI mayprovide tissue-specific characterization of duodenal hematomas. Diagnostic peritoneal lavage, which has assumed a crucial role inthe detection of intraperitoneal injuries, is equivocal and unreliableand has no value in detecting injuries to the retroperitoneal or-gans.43’ 48,85 Although some authors have found that diagnostic la-vage is positive in 50% to 70% of patients with duodenal injuries,51’86the positivity is due to associated intraperitoneal injuries and not tothe duodenal injury itself. Levinson and colleagues43 and Lucas and Ledgerwood4’ noted theunreliability of diagnostic peritoneal lavage in patients with duode-nal trauma. A positive lavage indicating intraperitoneal bleeding maytrigger an operation during which a duodenal injury may be discov-ered.51’ 83 A negative diagnostic peritoneal lavage has no significancein patients suspected of having an injury to the retroperitoneal or-gans.SURGICAL MANAGEMENT OF DUODENAL INJURIES Proven or suspected duodenal injury, coupled with the classic find-ings of intraabdominal injury (i.e., abdominal tenderness, guarding,rebound tenderness, or decreased bowel sounds), mandates imme-diate exploratory laparotomy. The basic resuscitative maneuvers de-scribed by the Advanced Trauma Life Support manual of the Ameri-can College of Surgeons, including early management of the airwayand fluid resuscitation, should be carried out, and a sample of bloodshould be sent to the blood bank for type and crossmatch. If thepatient’s status is such that an immediate laparotomy is warranted,type-specific or O-negative blood can be used for immediate resusci-tation.88’ ” Broad-spectrum antibiotics are then administered beforethe abdominal incision. We prefer the use of a second-generationcephalosporin and are in agreement with Jones and colleagues” andCurr Probl Surg November 1993 1049
  • 25. Nichols and colleaguesgl that cefoxitin provides ample coverage ini-tially. Abdominal injuries should be explored through a midline incisionextending from xiphoid to pubis. Immediate control of life-threatening hemorrhage from vascular structures or parenchymatousorgans such as the liver or spleen should constitute the first goals inthe operation, followed by immediate control of sources of gastroin-testinal spillage. The next step in the management of abdominaltrauma should consist of a thorough exploration of the abdominalcavity. The duodenum must be thoroughly explored with all four por-tions visualized directly. Findings that should increase suspicion ofa duodenal injury include crepitation along the duodenal sweep, bilestaining of paraduodenal tissue or a documented bile leak, or thepresence of a right-sided retroperitoneal hematoma or perirenal he-matoma. The duodenum should then be mobilized by a Kocher ma-neuver, a Cattell and Braasch maneuver, or both.” These maneuversshould provide full visualization of the anterior and posterior wallsof all portions of the duodenum. A word of caution to the neophytesurgeon must be added here: performance of these maneuvers in thepresence of active bleeding or a large retroperitoneal hematoma canbe fraught with danger. A Kocher maneuver is performed by incising the lateral peritonealattachments of the duodenum and sweeping both the second andthird portions medially using a combination of sharp and blunt dis-section. The assistant should provide gentle traction of the duodenalloop while the surgeon continues the dissection. The nasogastrictube should be advanced through the pylorus and palpated digitallywhile the surgeon performs the dissection. This procedure providesa guide to identify the duodenum in the midst of a large retroperito-neal hematoma and will avoid iatrogenic lacerations to the duodenalwall during dissection. Inspection of the third portion of the duode-num requires mobilization of the hepatic flexure of the colon accord-ing to the method described by Cattell and Braasch.” The retroperi-toneal attachments of the small bowel are incised sharply from theright lower quadrant to the duodenojejunal junction, and the smallbowel is reflected in its entirety out of the abdominal cavity.gz Thismaneuver is often unnecessary, and its performance in the presenceof a large retroperitoneal hematoma, especially those caused by pel-vic fractures, may lead to exsanguination. The fourth portion of theduodenum can be visualized by transecting the ligament of Treitzwhile avoiding injury to the inferior mesenteric vein or, again, by per-forming the Cattell and Braasch maneuver. Duodenal injuries can easily be missed and are associated with di-sastrous consequences. Massive injury, such as may occur with as-sociated vascular injuries to the aorta or vena cava, may divert the1050 Curr Probl Surg, November 1993
  • 26. surgeon’s attention from the duodenum. If findings such as minimalhematoma or insignificant edema are deemed trivial and disregarded,a significant duodenal injury may be missed. Thus underestimationof minimal abnormal findings and failure to explore the duodenumfully are the nemeses of the surgeon and the friends of disaster. Aconstant awareness that duodenal injury may be associated withminimal intraoperative findings will assure more frequent diagnosisand 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 ofassociated injuries, especially to the pancreas and biliary tree, andthe period of time that has elapsed from identification to treatment.Snyder and colleagues5’ identified several important factors that wereof value in evaluating the severity of the duodenal injury. Factors suchas the agent of entry, the size and site of injury, the interval frominjury to repair (in hours), and an associated injury to the commonbile duct proved to be statistically significant predictors of outcome.Injuries were classified as mild on the basis of the following: (1) theagent of entry consisted of a stab wound; (2) the size of injury en-compassed less than 75% of the duodenal wall; (3) the site of injurywas located in the third or fourth portion of the duodenum; (4) theinjury repair interval was less than 24 hours; and (5) no associatedinjury occurred to the common bile duct. Injuries were classified assevere on the basis of the following: (1) the agent of entry was blunttrauma or a missile; (2) the size of injury encompassed more than75% of the duodenal wall; (3) the site of injury was located in thefirst or second portion of the duodenum; (4) the repair interval wasgreater than 24 hours; and (5) an associated injury to the commonbile duct had occurred. Curiously, in this series the presence of as-sociated pancreatic injury was not found to alter morbidity and mor-tality significantly. This finding is at variance with that of other au-thors who have reported the presence of associated pancreatic in-jury to be a good predictor of increased morbidity and mortal-ity.46, 48, 93, g4 Identification of the presence or absence of such factors allows thesurgeon to assess the injury fully. We recommend that all duodenalinjuries be staged according to some classification scheme so that itmight stratify the injuries according to severity. This recommenda-tion is made with the hope that the most simple and effective surgi-cal technique or techniques will be selected for management of thesimpler injuries and that the most complex techniques will be re-served 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 sorelylacking in trauma surgery. Lucas and Ledgerwood”’ and Adkins andCum- Probl Surg, November 1993 1051
  • 27. TABLE 9. Duodenum organ injury scaleGrade* Injury DescriptiontI Hematoma Involving single portion of duodenum Laceration Partial thickness, no perforationII Hematoma Involv& more than one portion Laceration Disruption <SO% of circumferenceIII Laceration Disruption 50% to 75% circumference of D2 Disruption 50% to 100% circumference of Dl, D3, D4Iv Laceration Disruption >75% circumference of D2 Involving ampulla or‘ distal common bile ductV Laceration Massive disruption of duodenopancreatic complex Vascular Devascularization of duodenumDz, 1st portion duod,enum; 02, 2nd portion duodenum; 03, 3rd portion duodenum; 04, 4th portionduodenum.*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 theirrespective trauma centers, but neither provided statistically signifi-cant 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 knownincidence of complications and each injury is graded on a scale of 1to 5. Duodenal injuries are assigned a risk factor of 5 and are gradedas 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 than50% of the wall, grade 4; and ampullary injuries, grade 5. Multiplica-tion of the grade of injury by the risk factor allows for calculation ofthe 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 withhigher scores. The value of this procedure for quantifying duodenalinjury severity objectively was validated by Ivatury and colleagues,55who 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, ex- perience with the new duodenal organ injury scale is limited, al- though Cogbill and colleagues57 used this scale successfully in a co- operative multicenter trial in which they graded 164 duqdenal inju- ries. 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
  • 28. TABLE 10. Surgical techniques and procedures used for repair of duodenal anduancreaticoduodenal injuriesDuodenorrhaphyDuodenorrhaphy with external drainageDuodenorrhaphy with tube duodenostomy Primary (through duodenum) Antegrade (through pylorusJ Retrograde (through jejunumiTriple ostomy technique (gastrostomy and antegrade and retrograde jejunostomieslJejunal serosal patchJejunal mucosal patchPedicled grafts Ileum Jejunum Stomach (gastric island)Duodenal resection Duodenoduodenostomy DuodenojejunostomyDuodenal diverticulization (vagotomy and antrectomy, gastrojejunostomy, duodenorrhaphy, T-tube drainage and external drainage)Pyloric exclusion With sutures (absorbable and nonabsorbable) StaplesPancreaticoduodenectomy (Whipple’s procedure)nal injury represent only a part of the risk of morbidity and mortal-ity. Approximately 75% to 85% of all duodenal injuries can be repairedsafely using simple surgical techniques. The surgeon must possessthe technical capabilitjr to repair injuries of high severity. Many dif-ferent surgical techniques for the treatment of duodenal injuries havebeen described (Table 10). Basic surgical ptinciples, such as debride-ment of the duodenal injuries to viable tissues and a meticulousdouble-layer technique for closure approximating the innet layer us-ing fine absorbable sutures and a seromuscular closure of iriterruptednonabsorbable Lembert sutures, should be used (Fig. 1). Duodenorrhaphy alone carries a small risk of narrowing the duo-denal lumen. Several technical points must be kept in mind to &voidthis problem when closing duodenal lacerations. These technicalpoints were outlined by Kraus and Condons on the basis of the re-sults of an animal model in which they established that longitudinalduodenotomies can be closed transversely if the length of the duo-denotomy does not exceed one half of the circumference of the duo-denum (Fig. 2). These investigators recommehded that longitudinalclosures be performed if the duodenotomy exceeds one haif of thecircumference of the duodenum. In neither of these closures was theduodenal lumen narrowed. The authors strongly recommendedCurr Probl Surg, November 1993 1053
  • 29. FIG. 1. Most duodenal lacerations can be repaired primarily after meticulous debridementof all damaged tissue. The repair can be accomplished with a double-layer closure, in-cluding an inner layer of fine running absorbable sutures encompassing the entire width ofthe duodenal wall followed by a second layer of fine seromuscular interrupted nonabsorb-able Lembert sutures. Meticulous attention must be paid to imbricate the duodenal mu-cosa because it tends to extrude from suture lines. (From Juan A. Asensio, MD, andRobert 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 theyconsistently showed to narrow the duodenal lumen. The use of drains placed adjacent to duodenal repairs should beconsidered for all duodenorrhaphies. No prospective studies have ad-dressed the risk/benefit ratio. We recommend that drains be usedroutinely, but we strongly emphasize that this drain system shouldbe of the closed-suction type and should not be placed directlyagainst the suture line to avoid duodenal fistula formation. Before discussing the surgical techniques available for repair ofcomplex duodenal injuries, a word of caution is in order. Surgicaljudgment is needed to select the best surgical technique for repairof particular duodenal injuries. The surgeon must consider the ana-tomic extent of the injury; the magnitude of associated injuries, es-pecially those to the biliary tree and pancreas; and the time elapsed1054 Curr Probl Surg, November 1993
  • 30. FIG. 2. Longitudinal duodenotomies can be closed transversely if the length of the duo-denotomy does not exceed one half the circumference of the duodenum.from injury to repair. Finally, the overall condition of the patient mustbe evaluated. Other points to be considered for penetrating injuriesinclude the potential for blast effect. For blunt injuries, the degree ofassociated retroperitoneal and periduodenal inflammatory processesresulting from extruded duodenal contents should be assessed. Af-ter evaluating these factors, the surgeon can choose the proceduresthat are needed to repair or decompress the duodenum, resect de-vitalized areas, buttress the repair, or exclude the duodenum fromthe passage of gastric contents. Controversies surround the use of adjacent maneuvers to safeguard the duodenal closure. One of these maneuvers is the tube duode- nostomy (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 decompressedby 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 ob- scure until 1949, when Welch” described this application in patientsCur-r Probl Surg, November 1993 1055
  • 31. 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 duodenos-tomy. This tube should be brought out through an area of uninjured duodenum rather thanthrough 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 de-scribed 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 seriesof 44 patients with tenuous duodenal stump closures, only two com-plications occurred. Antegrade decompression of the duodenal closure by passage of anasogastric tube through the pylorus beyond the point of injury ap-pears to have been used first by Smith and colleagues45 in 1971 andlater by McInnis and coworkers46 in 1975. Retrograde duodenostomywas first used at the Grady Memorial Hospital in 1962,50 and de-scribed in the literature by Stone and Garonil’l in 1966 (Fig. 4). Twoseparate tubes can be placed by way of two separate jejunal sites.The proximal tube is threaded retrograde past the duodenal junc-tion and placed on suction to decompress the duodenum while thedistal tube is used as a feeding jejunostomy. This system has beentermed the “suck-me, feed-me jejunostomy.” This system is also ad-1056 Curr Probl Surg, November 1993
  • 32. FIG. 4. This variation of the tube duodenostomy adds a feeding jejunostomy for early in-stitution of enteral feeding. It has been dubbed the “suck-me, feed-me jejunostomy.” Theproximal tube that acts to decompress the duodenum and protect its suture line is usuallyplaced at a point beyond the duodenal-jejunal flexure and generally requires a longer tubesuch as a Baker tube.vacated by Corley and co11eagues,47 who recommend the addition ofa gastrostomy tube to achieve better decompression (Fig. 5). Addition of tube decompression for duodenorrhaphy is controver-sial; opinions are strongly divided between those who staunchly sup-port its routine use, such as Corley and colleagues,47 Stone and col-leagues,50’101 and Hasson and colleagues,1o2 and those who advocateagainst its use, including Ivatury and co11eagues55’ lo3 and Kashuk andcolleagues.104 Stone and Fabian” reported a high rate of duodenalcomplications in 8 of 44 duodenal wounds closed without tube de-compression, with three subsequent deaths attributed to duodenalcomplications before the routine use of decompressive techniquesthat began in 1962. These investigators reported only one duodenalCurr Probl Surg, November 1993 1067
  • 33. FIG. 5. In this variation of tube duodenostomy, a gastrostomy has been added to furtherdivert the gastric stream and increase protection of the duodenal suture line. (From JuanA. Asensio, MD, and Robert F. Buckman, MD, Duodenal Injuries, Shackleford’s Surgery ofthe 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 inju-ries and found a 2.3% rate of fistula formation in decompressed re-pairs compared with an 11.8% rate in patients without decompres-sion. Contrasting data are presented by Ivatury and colleagues55, lo3 intwo separate papers in which they evaluated patients who sustainedduodenal injuries and associated injuries of comparable severity, asanalyzed by the PAT1 and DIS. These investigators found consistentlyhigher duodenal morbidity rates in the form of duodenal fistulas andabdominal sepsis as well as higher mortality rates in the grouptreated with duodenal repair and decompression. Snyder and associates5’ did not find any statistically significant dif-ference between 101 patients treated with duodenorrhaphy and de-compression (nine fistulas, 9%) and 89 patients treated with duode-norrhaphy alone (five fistulas, 6%). Most other series in the literatureadvocate the use of decompression in a selective fashion.43’ 51-53 Flintand colleagues51 recommend the selective use of decompressive1058 Curr Probl Sur5 November 1993
  • 34. techniques only when the duodenal laceration involves more than20% of the luminal circumference. Ten patients with lacerations in-volving more than 20% of the duodenal circumference underwentduodenorrhaphy and decompression with no suture line leaks; onthe other hand, 23 patients with similar lacerations underwent pri-mary repair with no decompression, and suture line leaks developedin 7 patients (30%). Four of these patients subsequently died. Recently, Griffin and co11eagues1o5 described a simplified techniquefor gastric and duodenal decompression for duodenal injuries by wayof a Moss esophagogastric decompression tube inserted through agastrostomy to provide decompression of the stomach and duode-num through a single tube. The authors described their experiencewith two patients and indicated that complications with decompres-sive tube duodenostomies and long-term nasogastric tube drainagecan be avoided. In a recent multicenter cooperative study in which they reported164 duodenal injuries, Cogbill and colleagues57 stated that on the ba-sis of their data no apparent role exists for tube duodenostomy. Theseinvestigators cited I2 patients in whom a duodenostomy tube wasplaced: 7 patients (58% 1 had duodenal-related complications, includ-ing intraabdominal abscess in 5 patients (42%), duodenal fistula in 3patients (25% ), and duodenal dehiscence in 1 patient (8% 1. These au-thors concluded that the tube duodenostomy is neither necessarynor effective in preventing duodenal-related complications. We ad-vocate individualization of treatment with regard to decompressivetechniques and agree strongly with Kelly and colleagues that “treat- ment 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 sub- ject 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 duode- num 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 theCurr Probl Surg, November 1993 1059
  • 35. FIG. 6. Injuries In which loss of duodenal wall has occurred that cannot be repaired pri-marily without severe narrowing of the lumen may be repaired by use of a serosal patchtechnique. 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 lumenrapidly undergoes complete mucosal resurfacing. (From Juan A. Asensio, MD, and RobertF. Buckman, MD, Duodenal Injuries, Shackleford’s Surgery of the Alimentary Tract, GeorgeD. 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 thejejunal serosa at 8 weeks with no narrowing or dbstruction of thiz duo-denal lumen. This method was also studied and performed clinicallyby 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 mu-cosal patch or pedicled graft. Meticulous attention must be paid to preserving the bloodsupply of the pedicled graft. The segment of jejunum from which the graft has been takenis 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
  • 36. See opposite page for legend.&UT P&Z Surg, November 1993 1061
  • 37. forations, 8 of whom were treated with primary closure protected bya serosal patch of a Roux-en-Y jejunal loop. One of the patients un-derwent reexploration for persistent postoperative fever, and at thattime the patch was inadvertently pulled off the duodenum and notrepaired. Postoperatively, a duodenal fistula developed and the pa-tient died as the result of the complication. These authors warn ofthe consequence of this type of surgical mishap. Jones and col-leaguesll’ criticized the technique of using a separate Roux-en-Y loopof jejunum to cover duodenal defects because it creates a new su-ture line. For larger defects, the ingenious techniques of a jejunal mucosalpatch were described by Jones and Joergensonlll and later modifiedto 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 itsvascular pedicle. The antimesenteric border of the jejunum can thenbe split longitudinally and anastomosed using a double-layer tech- nique to the duodenum to close the defect. This technique has alsobeen used successfully by several other authors.106,113 Other tech- niques used for closure of duodenal wall defects include pediclegrafts of the stomach, otherwise known as gastric island flaps.l14These 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 gastroepiploicvessels. 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 mobili- zation 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 ortransection of the duodenum has occurred (A), the technique of debridement, segmentalresection, and end-to-end duodenoduodenostomy (6) may be used. Limited mobilizationis possible in the descending portion of the duodenum because of the shared blood sup-ply of the pancreas and duodenum. Meticulous dissection must be carried out so that theblood supply is not compromised. Furthermore, care must be taken to avoid injury or ob-struction 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.)1062 Curr Probl Surg, November 1993
  • 38. See opposite page for legend.Curt- Probl Surg, November 1993 1063
  • 39. section and primary end-to-end duodenoduodenostomy are possiblein the second portion. In cases where the duodenal wound is immediately adjacent to theampulla of Vater, extreme caution must be exercised to preserve theintegrity of this structure. In such cases, a choledochostomy is neces-sary, with the passage of a probe to identify the ampulla and keep it inview during the creation of the anastomosis. Avulsions of the ampullaof Vater have been treated successfully by duodenorrhaphy and im-plantation of the ampulla into a Roux-en-Y limb of jejunum, as re-ported by Fish and Johnson.116 Similarly, avulsions of the commonbile duct resulting from lacerations of the second portion of the duo-denum have been repaired successfully with common bile duct reim-plantation, as reported by Lee and associates117 and Longmire andMcArthur.‘l’ If an end-to-end anastomosis cannot be performed with-out tension, a Roux-en-Y duodenojejunostomy may be performedand the distal portion of the duodenum oversewn (Fig. 9) .ll’, lzoFIG. 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.)1064 Curr Probl Surg, November 1993
  • 40. Patients with severe duodenal injuries should be considered ascandidates for more complex duodenal repairs such as duodenal di-verticulization or pyloric exclusion.g5 Such injuries include thosecaused by blunt trauma or missiles, those involving more than 75%of the wall, those involving the first and second portions of the duo-denum, those associated with a delay in repair of more than 24 hours,and those with associated injuries to the pancreas, common bileduct, or both. Injuries described as grades 3 and 4 by PATIg8 and asgrades III and IV of the Duodenum Organ Injury Scalelzl can also beconsidered for these repairs. Other criteria that may lead the surgeon to consider one of thesemore complex surgical procedures include compromised blood sup-ply to the duodenum and associated injury to the head of the pan-creas without disruption of the main pancreatic ductlo We considerinjuries involving more than 50% of the circumference of the duode-nal wall, whether associated with pancreatic injuries or not, to behigh-risk injuries amenable to repair by one of these two procedures.The main purpose of these procedures is to exclude the duodenumfrom the passage of gastric contents to allow time for the duodenalrepair to heal and to prevent suture line dehiscence. We emphasizethat these procedures can only be used if the duodenal injury is ame-nable to primary repair. The original duodenal diverticulization (Fig. 10) was described byBerne and colleaguesl” in 1968 and was aimed at decreasing the highrate of morbidity and mortality in patients with combined duodenaland pancreatic injuries. In a previous study by this same group in1966, these investigators reported a mortality rate of 5% in 20 patientswith duodenal perforation and no associated pancreatic injury.123However, they noted a mortality rate of 33% in nine patients withassociated pancreatic injuries. These investigators also noted thehigh morbidity present in these patients, with complications includ-ing lateral duodenal fistula, pancreatitis, pancreatic fistula, intraperi-toneal abscess, secondary hemorrhage, duodenal obstruction, andmajor wound infection. Prompted by unacceptably high complica-tion rates, the authors devised the duodenal diverticulization proce-dure with the goal of excluding the duodenum from the passage ofgastric contents. This concept was not new, having been first sug-gested by Summers7 This procedure was performed by Berglz4 in1907, who stated that a gastrojejunostomy with the stomach and duo-denum in continuity did not provide the total diversion necessary toachieve healing from a duodenal fistula. As such, he treated two pa-tients by side-to-side gastroenterostomy and pyloric occlusion, whichwas achieved in the first patient with a large silk ligature and in thesecond with an occlusive tape. The procedure by Berne and colleagueslz5 included antrectomy,debridement, and closure of the duodenum, tube duodenostomy, va-Curr Probl Surg, November 1993 1065
  • 41. FIG. 10. Severe combined duodenal and pancreatic injuries demand diversion of gastriccontents away from the duodenal repair, provided the duodenal injury is amenable to safeprimary closure. This procedure was originally described by Berne and colleagues125 asthe duodenal diverticulization procedure. The original procedure consists of primary duo-denorrhaphy, truncal vagotomy, antrectomy with gastrojejunostomy, tube choledochos-tomy, and external drainage of the duodenal repair. Indications for this procedure are nowlimited to severe injuries of the first portion of the duodenum and/or pyloric channel or an-trum 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’sSurgery 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 pro-cedure was performed in 16 patients with severe duodenal-pancreatic injuries. Three of the 16 patients died because of profoundirreversible shock; their deaths were not related directly to this pro-cedure. In this series, only three duodenal fistulas developed, andthese healed promptly. The morbidity and mortality rates for thesepatients were markedly decreased. Interestingly, of the original 16 pa-tients, only 8 underwent vagotomy; the remaining patients did not.In most instances, this decision reflected pressure to terminate theoperation quickly in these critically ill patients. The authors also rec-ommend that the vagi be sectioned if the surgeon believes the con-dition of the patient is stable. Also interestingly, biliary tract drainagewas carried out in 7 of the 16 patients whose indications included1066 Curr Probl Surg, November 1993
  • 42. injuries to the extrahepatic biliary tract, severe pancreatic injury, orperiampullary duodenal injury. In 1974, Berne and colleagues1z5 again reported 34 patients inwhom this operation had been performed for severe duodenal orcombined duodenal-pancreatic injury. These 34 patients were addedto the 16 from the original report. An overall mortality rate of 16%was reported. In this series, associated injuries to major vessels andthe colon proved more deadly than the duodenal and pancreatic in-juries. The operation of duodenal diverticulization appeared to re-duce morbidity and mortality when compared with other proce-dures. The overall mortality rate of 16% compared favorably with a35% 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, anoverall mortality rate of 4% was reported.lz7 Twelve of the 105 survi-vors underwent duodenal diverticulization; three of these patientsdied. Two of the patients had duodenal fistulas and died as a resultof septic complications and multisystemic organ failure, for a mor-tality rate of 17%. The third patient died from complications of mas-sive transfusion. Duodenal diverticulization is a time-consuming and often compli- cated surgical procedure that many critically ill patients cannot tol- erate. An alternate means of securing exclusion of the duodenal su- ture line and diversion of the gastric contents using a simpler, less time-consuming technique was devised by George Jordan and re- ported 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 tis- sue 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 re- ported by Berne and colleagues.125 Gastrojejunostomy without a va- gotomy is suspected as being an ulcerogenic procedure by many sur- geons. The authors of this study investigated 25 patients in whom the pyloric exclusion procedure was performed by upper gastroin- testinal studies after periods ranging from 2 months to 3 years after the operations. All these patients demonstrated a functioning pylo- rus 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 gas- tric physiologic and gastrointestinal anatomic functions. These pa-Cur-r Probl Surg, November 1993 1067
  • 43. FIG. 11. Pyloric exclusion procedure is useful in the management of severe pancreati-coduodenal injuries provided the duodenal injury can safely be closed primarily. The py-lorus is occluded with nonabsorbable suture material through a gastrotomy in the depen-dent 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 ofthe 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 werewithin normal range, as well as gastric analysis. The acid secretoryrates were within the normal range of 1 to 3 mEq/hr in 8 patients.Two patients, however, had elevated acid secretory rates ranging from6 to 7 mEq/hr. All patients underwent upper gastrointestinal endos-copy that confirmed the radiologic findings of a patent pylorus. Nosignificant pyloric abnormality was noted in any of these patients.One significant finding among these patients was development ofthree marginal ulcers at periods of 4 months to 2 years after the op-erations. One of the patients had a history of previous duodenal ul-cer despite normal gastric adid levels. This patient was treated con-servatively, and the ulcer was found to heal spontaneously. The othertwo patients had gastric hypersecretion, and both were treated sur-gically. One patient was treated simply by takedown of the gastroje-junostomy, and the other patient was treated by vagotomy and gas-tric resection. In a more recent series, Graham and colleaguess4 reported 68 pa-1068 Curr Probl Surg, November 1993
  • 44. FIG. 12. An alternate method of pyloric exclusion is represented in which the proximalduodenum is stapled distal to the pylorus. A gastrojejundstomy is then performed.tients who sustained combined pancreaticoduodenal injuries, 32 ofwhich 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 of6.9%. 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 beenpopularized by Kelly and colleagues4’ (Fig. 12). Martin and col-leaguesl” reported a follow-up study describing an expanded expe-rience with pyloric exclusion in which 128 of 313 patients (41% 1 whosustained duodenal injuries vere treated with this procedure; a 5.5%duodenal fistula rate was seen. In this study, 42 patients underwentupper gastrointestinal tract examination after their operations. In pa-tients examined 21 days or more after their operations, 94% had apatent pylorus. Marginal ulceration was infrequent and reported inonly four of these patients, thus confirming the efficacy of this surgi-cal procedure. These authors also advocated the use of nonabsorb- able monofilament polypropylene sutures or absorbable polyglycolic acid sutures. Other authors have supported the use of the pyloricexclusion procedure and recommended the use of polygalactin su-tures to occlude the duodenum.1zs,130Curr Probl Surg November 1993 1069
  • 45. FIG. 13. Pancreaticoduodenectomy is reserved for the most severe combined pancreati-coduodenal injuries. It has a high mortality rate. Technical difficulties with this procedureinclude creation of a choledochojejunostomy because the common bile duct is usually smalland 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 holdsutures well. These technical difficulties may predispose to fistula formation. Recently, Buck and colleagues131 described a series of 17 patientswith severe pancreaticoduodenal injury, 15 of whom survived longenough to undergo pyloric exclusion with gastrojejunostomy as partof their initial treatment. Of the remaining 15 patients, 2 died within48 hours. Eight of the surviving patients underwent a vagotomy inaddition to pyloric exclusion. Three patients experienced complica-tions related to the pyloric exclusion; two had marginal ulcers thateither perforated or bled and required additional operations. One ofthese patients required vagotomy and antrectomy for severe bleed-ing, and the other required a takedown of the gastrojejunostomy forperforation. These authors reported a 33% incidence of marginal ul-cerations on the basis of their data, a rate significantly higher thanreported previously. They therefore recommended the addition of va-gotomy to pyloric exclusion at the time of the initial procedure if thepatient’s condition permits. This report is at variance with a greaterexperience of Martin and colleagues1zg and Feliciano and col-leagues.13’1070 Curr Probl Surg November 1993
  • 46. 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 reportedtheir experiences in the management of pancreaticoduodenal inju-ries. These investigators concluded that well-defined protocols, withcareful selection of surgical procedures according to the grade of in-jury, yield much better outcomes. They also concluded that tech-niques such as pyloric exclusion should be reserved for the infre-quent complex injuries that involve both the pancreas and duode-num. Pancreaticoduodenectomy was first suggested by Thal and Wil-son134 in 1964 as a treatment for patients sustaining severe blunttrauma to the head of the pancreas (Fig. 13). These authors reportedon three patients who underwent pancreaticoduodenectomy, two ofwhom also had massive accompanying duodenal injuries.: Indica-tions for pancreaticoduodenectomy were outlined by Foley and col-leagues13” in 1969 (Table 111. Pancreaticoduodenectomy is clearly aformidable procedure in critically ill patients. A review of 52 series reported in the literature from 1964 to 1990yielded a total of 170 patients who underwent pancreaticoduodenec-tomy (Table 12).* Fifty-six of these patients subsequently died. Thetabulated mortality rate for all the series reviewed was 33%, which isnot at variance with the range of 30% to 40% reported in the litera-ture.* Two of the largest series in the literature are those of Yellin andRos~ff~~~ and Oreskovich and Carrico.161 The Oreskovich series is re-markable because no deaths occurred in 10 patients. However, in thisseries radiologic confirmation of contrast extravasation was used asan indication of significant pancreatic ductal disruption, whichpointed to the need for pancreatic resection. This represented a lib-eral indication and is at variance with the indications reported bymost authors.MORTALITY Duodenal injuries, as a whole, carry a significant mortality rate. Theoverall mortality rates as reported in several recent large series rangefrom 5.3% to 30% .41-43J45-54The lower overall mortality rate cited here *References 14,43,45, 50, 53-55, 64, 76, 92, 93,125,X29,134-173Curr Probl Surg, November 1993 1071
  • 47. TABLE 12. Pancreaticoduodenectomy for traumaAuthor Year No. of patients DeathsThai and Wilsor? 1964 2 1Walter et alT3” 1966 1 0Thompson and 1966 2 1 Hindshawx3’Salyer and McClellandx3’ 1967 1 0Sawyers et alT3’ 1967 1 0Wilson et al.14’ 1967 2 0Brawler et al?41 1968 3 1Werschky and Jordan14’ 1968 1 1Pantazelos et al.‘43 1969 1 0Halgrimson et alT4 1969 3 0Foley et al.‘35 1969 3 0Gibbs et al?” 1971 1 0Bach and Frey145 1971 3 0Nance and DeLoach146 1971 5 2Jones and Shires14’ 1971 (Recorded in other series.1Smith et al.45 1971 5 2Salam et alF4a 1972 4 1Anderson et al.lz6 1973 2 1White and Benfields 1972 5 0Owens and Wolfman 1973 3 1Steele et al?” 1973 3 3Strum et al.1’l 1973 5 2Yellin and Rosoi? 1975 10 6Ananeh-Sefahs3 1975 6 0Chambers et alT5a 1975 1 0Heitsch et al.ls4 1976 2 2Lowe et al?55 1977 6 0Karl and Chandler*‘” 1977 1 1Hagan et alT5’ 1978 2 2Grahan? 1979 6 3Stone and Fabian” 1979 3 3Majeski and Tyle?s 1980 1 0Cogbill et al?” 1982 1 0Levinson et al.43 1982 1 1Henarejos et al?a’ 1983 1 0Oreskovich and Carrlco’G1 1984 10 0Adkins and Keyse? 1984 5 1Moore and Moots? 1984 1 0Fabian et alF4 1984 1 1Sims et al?“’ 1984 2 0Donahue et al.‘” 1985 1 1JonesxG3 1985 12 7 (including studies in 1971 and 19781Ivatury et al? 1985 7 3Smego et al.‘“a 1985 1 0Wynn et all”’ 1985 3 2Walke? 1986 1 0Feliciano et alT3’ 1987 13 6Melissas et al?a’ 1987 1 0 Continued.
  • 48. TABLE 12. (cont.)Author Year No. of patients DeathsMcKonek et aI?” 1988 5 0Eastlick et al?71 1990 1 0Gentile110 et aI?” 1990 3 1Heimonsohn et aI? 1990 6 0TOTAL 170 56Average mortality rate 33.0%was reported by Adkins and Keyser53 in their 1984 series in which 3of 56 patients died. Although this figure is quite remarkable, it is atvariance with most other figures of overall mortality rates reportedin the literature41‘43’ 45-52J and definitely at variance with a calcu- 55lated averaT mortality rate of 17% from the review of these series(Table 13) .4 -43J45-58 Remarkable improvements have occurred since 1876 when Otis4 re-ported a 100% mortality rate during the American Civil War. Subse-quent decreases in mortality rates have been reported in each ofAmerica’s major wars (see Table 1). Recently, several authors have evaluated the overall mortality ratesreported in their series separate from the mortality rates caused ex-clusively by duodenal injuries. They found mortality rates in theTABLE 13. Mortabty rate associated with duodenal injuries Mortality by mechanism of injury OverallAuthor and year mortalitv rate Penetrating BluntMorton and Jordan, 196S41 21.0 22.0 14.0Smith et al., 1~71~~ 21.0McInnis et al., 1975@ 14.0Corley et al., 197447 23.5 20.0 35.0Lucas and Ledgerwood, 197548 19.4Matolo et al., 197549 9.3Kelly et aI., 197S4’ 14.0Stone and Fabian, 197S5’ 14.0 13.0 15.0Flint et al., 197S51 19.0 11.0 20.0Snyder et al., 19805’ 17.4Levinson et al., 198243 18.0Adkins and Keyser, 198453 5.3Fabian et al., 19&ls4 30.0Ivatury et al., 198555 25.0Bostman et al., 198g5” 5.5Cogbill et al., 19905’ 18.0 14.4 3.6Cuddington et al., 19905’ 14.0Average mortality rate 17.0 16.0 17.5All numbers expressed as percentages.Curr Probl Sur. November 1993 1073
  • 49. range of 6.5% to 12.5% .42,43J 52, 54,lz8 These figures were confirmed 5oJin an excellent review of duodenal injuries by Weigelt and Borman4’ Mortality can be analyzed using several variables. It can be reviewedon a temporal basis and subdivided into early and late mortality. Mostearly deaths are caused by exsanguination, usually resulting from as-sociated major vascular injuries. This finding is repeatedly borne outin the literature. Morton and Jordan41 reported that 55% of the earlydeaths they studied occurred in patients initially in shock. Stone andFabian5’ reported that 46% of the early deaths they studied occurredin patients of similar clinical diagnosis. McInnis and colleagues46 re-ported a 100% mortality rate for all patients with shock.46 Further-more, several authors reported that early mortality rates associatedwith shock, prolonged bleeding, and the sequelae of massive bloodreplacement 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. 40,42,43,52,55,128These 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 fail- ure. Other methods for analyzing mortality include examination of se- lective mortality related to the mechanism of injury. Five authors pre- sented a breakdown of mortality according to mechanism of in- juTy.41,47,50,51,57 Duodenal death caused by penetrating trauma aver- aged 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 mor- tality associated with duodenal injury is the delay in time from rec- ognition 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 op- erations more than 24 hours after injury, whereas those patients op- erated 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 mortal- ity rates have also been reported by Flint and colleagues51 and Cleve- land and Waddell,” whereas Cocke and Meyer” reported a 71% mor- tality 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 41-43,45,47-50,52,53,57,58.1074 Cur-r Probl Surg, November 1993
  • 50. MORBIDITY Just as duodenal injuries are associated with high rates of death,they are also associated with very high rates of morbidity. Twelve re-cent series in the literature were selected and reviewed because theyclearly outlined morbidity figures.* Overall, morbidity rates rangedfrom 38% to 125%) with an average morbidity of 63.7%. The lowestmorbidity rate, 38%, was reported by Kelly and colleagues.42 In thisseries 19 major complications were reported in 12 of the 32 survivingpatients, 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 fistulaformation resulting from failure of surgical repair because of sutureline dehiscence and is represented occasionally by duodenal ob- struction. Other complications are commonly related to associatedinjuries. In 15 recent series reviewed, a total of 82 duodenal fistulaswere 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 intheir series, whereas Corley and coworkers47 reported 14 duodenalfistulas 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% ofthe patients.3s, 43,50, 52 Other important complications caused by associated injuries in- clude intraabdominal abscess, 10.9% to 18.4%; recurrent pancreati-tis, 2.5% to 14.9% ; and bile duct fistula, 1.3% .3s,43P 52 50, *References 41-43,45,47-50,52,53,57,58.TABLE 14. Overall morbidity associated with duodenal injuriesAuthor and year No. of patients Complication rate (o/a)Morton and Jordan, 196841 131 64.0Smith et al., 197145 26 58.0Corley et al., 197447 98 63.0Lucas and Ledgerwood, 197P 36 72 .OMatolo et al., 197.? 32 47.0Kelly et al., 197S4’ 34 38.0Stone and Fabian, 197g5’ 302 124.5Synder et al., 19805’ 228 63.0Levinson et al., 198P 93 49.0Adkins and Keyser, 19S453 56 39.2Cogbill et al., 19905’ 139 100.0Cuddington et al., 1990s8 36 47.2Average morbidity rate 63.7Cur-r Probl Surg, November 1993 1075
  • 51. TABLE 15. Duodenal fistulas after traumaAuthor and year No. of duodenal fistulas Duodenal fistulas (% iMorgan and Jordan, 196S4* 8 6.1Smith et al., 197145 1 3.8McInnis et al., 19754” 2 9.0Corley et al., 197447 14 14.2Lucas and Ledger-wood, 197548 4 11.1Matolo et al., 197549 1 3.1Kelly et al., 197S4’ 2 5.8Stone and Fabian, 197g5’ 9 2.9Flint et al., 197g51 0 0.0Snyder et al., 19805’ 16 7.0Levinson et al., 198243 5 6.bAdkins and Keyser, 198453 3 5.6Ivatury et al., 1985” 3 4.0 Cogbill et al., 19905’ 6 4.3 Cuddington et al., 199058 6 16.6 Average 6.6%SPECIAL SITUATIONSBLUNT DUODENAL RUPTURE Diagnosing blunt injuries of the duodenum is difficult. All sizableseries of blunt duodenal injuries include multiple instances in whichthis diagnosis was delayed.16’ 43J 60,83, 174 In many cases, the delays 48Jin diagnosis occurred while the patient was under the observationof 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 andWaddell” reviewed 37 patients with blunt rupture of the duodenum.These authors found instances of delays in six patients ranging from2 l/2 days to 7 months. In 1964, Cocke and Meyer?’ reviewed 48 casesfrom the literature and found that 15% of the patients having sus-tained blunt duodenal injuries had not undergone an operation orhad not had the injury diagnosed at laparotomy; 71% of these pa-tients died. In 1974, Corley and colleagues, noting the 35% mortality rate withblunt duodenal rupture in the Cook County series, wrote: The clinical manifestations may be unimpressive early in the post-injuryperiod. . . . These injuries test the diagnostic capabilities of the most astutesurgeon. Early treatment is the exception rather than the rule.47 Lucas and Ledgerwood4’ reported an experience with 28 blunt rup-tures of the duodenum encountered over a 14-year period. In 10 pa-tients, the diagnosis was delayed beyond 24 hours; 4 of these 10 pa-tients subsequently died. Flint and colleaguessl reported 19 patients1076 Cum Probl Surg, November 1993
  • 52. with blunt duodenal rupture. In two of these patients, the diagnosiswas delayed beyond 24 hours; both of these patients died. In the largeseries by Snyder and colleagues5’ of 48 blunt duodenal injuries overan lb-year period, delays in diagnosis averaged 8 hours and rangedup to 7 days. Talbot and Shuck176 reported a series of 8 patients withretroperitoneal duodenal injury from blunt trauma in whom 5 werenot readily identified as having duodenal injury. These authors foundthat frequent physical examination was the most reliable diagnostictechnique. Levinson and colleagues43 reported that of 17 patients with bluntduodenal injuries evaluated initially by the trauma service at SanFrancisco General Hospital, 10 were explored immediately becauseof shock, free intraperitoneal air, or a positive diagnostic peritoneallavage. Seven other patients, including several with negative resultsfrom peritoneal lavage, were admitted for observation. Four of thesepatients had delays in diagnosis of more than 24 hours. Of these,two patients had delays from 4 to 10 days after injury. Anotherpatient had a duodenal injury that was overlooked at the initialoperation, Adkins and Keyser53 reported 17 patients with blunt duodenal in-juries, of which 1.2 were transmural perforations. The average timefrom injury to operation was 16 hours. Two of the 12 injuries werenot diagnosed for more than 2 days. Fabian and colleagues54 reported 10 cases of duodenal disruptioncaused by blunt trauma, with a 30% mortality rate. The serum amy-lase level was elevated in seven patients (70% ). In this series, a 30%mortality rate was reported. The average interval from injury to op-eration was 9.3 hours for survivors and 16.3 hours for nonsurvivors.These findings support the concept that early surgical interventionimproves outcome and demonstrate that the critical delay period isless than the classically reported 24 hours. The frequent difficulty with diagnosis of blunt rupture of the duo-denum and the extreme danger posed by the delayed recognitionmerit special discussions of the diagnostic features of these injuries.The most common cause of blunt rupture of the duodenum is im-pact of the epigastrium of an unrestrained driver against the steeringwheel of an automobile. A variety of other blows to the abdomen mayalso 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 nohistory. Frequently the patient is inebriated, causing a delay inseeking medical attention immediately after the accident. In addi-tion to these historic factors, the symptoms are often extremelymild.48 In the early stages after injury, the patient may have onlyvague epigastric or right upper quadrant pain, although the painmay occasionally be manifested in the right lower quadrant, withCur-r mob1 Surg, November 1993 1077
  • 53. radiation to the back or flank. Pain rarely has been reported toradiate to the testicles61 or neck.60 Frequent serial physical examina-tions performed by the same observer, ideally an experiencedsurgeon, coupled with the high index of suspicion in the presenceof the patient having sustained upper abdominal trauma, have beenfound by Talbot and Shuck176 to be one of the more reliable ways tomake this diagnosis. Often, none of the classic signs of an acute abdominal catastropheare present. Because the retroperitoneal duodenal injury is often iso-lated, or at least not accompanied by any significant intraperitonealinjury, the patient may be perfectly stable. Over a period of hours todays, the abdominal symptoms and physical findings become morepronounced even if the injury remains confined to the retroperito-neum. If the rupture gains entry into the free peritoneal cavity, signsof localized or generalized peritonitis may develop. This change incondition may be sudden. In cases of early retroperitoneal rupture of the duodenum, andwhile the process remains confined to the retroperitoneum, it is no-toriously difficult to detect by history and physical examinationalone. In addition, standard laboratory tests may provide little help.The serum amylase level may or may not be elevated. In the earlystages, the white blood cell count may be normal or only slightly el-evated. Hematuria may indicate the severity of the blow to the kid-neys but provide no specific information about the status of the duo-denum. Plain films of the abdomen are useful only if they are posi-tive. Only in the vast minority of cases is the classic radiographic find-ing of retroperitoneal air outlining the right upper pole of the kidneyor obliterating the right psoas shadow present. Furthermore, thepresence of free air is rare in these cases. The best way to establishthe diagnosis is by CT scan with both oral and intravenous contrastor by the upper gastrointestinal series. The ultimate diagnostic test in blunt abdominal trauma remainsthe exploratory laparotomy. Because no noninvasive test is com-pletely accurate, patients having met the clinical profile describedpreviously and who have persistent or increasing abdominal pain 6hours after injury, especially if accompanied by increased abdomi-nal tenderness or rising white blood cell count or serum amylaselevel, should be considered candidates for exploratory laparotomy.The devastating consequences of duodenal rupture, coupled withmortality rates ranging from 40% to 71% 16’ 43J 52, 60,70,g7 and the high 48Jincidence of fistula formation in survivors as high as 50% ,43J 83 war- 52,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 over-looked at the operation.12J I’, 41,45Jloo, 1771078 Curr Probl Surg, November 1993
  • 54. DUODENAL HEA4ATOMA Another type of duodenal injury that requires special considerationand judgment is the intramural duodenal hematoma. The manage-ment of this entity, first described in 1838, remains a subject of con-troversy.17’ Duodenal hematomas are usually caused by blunt ab-dominal trauma and can occur in any part of the duodenum. Al-though most cases have been documented in normal persons (in-cluding many children), their occurrence has been associated withclotting disorders, anticoagulant therapy, and alcoholism.*7g Intramural hematomas of the duodenum are believed to be the re-sult of shearing forces that rupture vessels within the duodenalwal1.18o 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 gas-trointestinal obstruction after trauma. Copious bilious vomiting afterblunt abdominal trauma should raise the suspicion of the evaluatingphysician. Often, a symptom-free interval of several hours occurs. Inthe series by Janson and Stockinger,17’ 76% of patients had symp-toms of upper intestinal obstruction and another 22% had abdomi-nal pain. Physical examination usually discloses mild epigastric ten-derness. A history of trauma may not be obtainable. An abdominalmass is rarely palpable. Laboratory values may show a mild elevation in the white bloodcell count and, occasionally, an elevation of the serum bilirubin oramylase level. Profound fluid and electrolyte disturbances may bepresent if the obstruction has been long-standing, but this is rare.The basic findings on plain films of the abdomen often are gastricdistention, sometimes dilation of the proximal duodenum, an airfluid level in the duodenum, and absence of the right psoasshadow.181 Diagnostic peritoneal lavage will be negative unless an as-sociated intraperitoneal injury is present. The diagnostic test ofchoice is an upper gastrointestinal series using water-soluble con-trast material. This technique may demonstrate the classic “coiledspring” deformity of the duodenal mucosa known as Felson’s sign71or the “stacked coin” sign.” This radiographic finding reflects muco-sal dissection of the hematoma. The obstruction is usually partial. Ifno duodenal perforation is observed, superior detail may be seen byrepeating the upper gastrointestinal series using thin barium. Evi-dence of duodenal perforation must be sought diligently. If the se-rum amylase level is elevated, it is wise to obtain an abdominal CTscan or ultrasound image to look for an associated pancreatic injury.The CT scan may also detect peritoneal air or extravasated contrastmaterial in occult perforations. Although some authors have recommended operative interventionfor duodenal hematoma,*82~18s the consensus expressed in the litera-Curr Probl Surg, November 1993 1079
  • 55. ture is to avoid surgical intervention because most patients can betreated successfully without operations.1g0-1g3 Nasogastric suctionand parenteral or hyperalimentation should be instituted. Careful at-tention should be paid to the fluid and electrolyte balance. If the pa-tient exhibits no sign of increase in abdominal pain or tenderness,then nonoperative therapy should be continued until the obstruc-tion 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 perfo-ration The appearance of increased abdominal pain or tendernesson clinical examination, or retroperitoneal gas on follow-up of plainabdominal films, mandates immediate surgical intervention. The se-rum amylase and lipase values should be observed closely. A risingserum amylase level may indicate significant pancreatic injury ortraumatic pancreatitis.“, 48 Although some authors have recom-mended operation if the serum amylase level continues to rise dur-ing a period of 6 hours, the evidence for this approach is not clear.48Approximately 3% of the patients with duodenal hematoma have oc-cult duodenal perforations.17s Some authors have recommended that an obstructing duodenalhematoma be evacuated through a seromuscular incision if one isdiscovered at the time of laparotomy for trauma.182~18s If this evacu-ation cannot be accomplished, performance of a gastrojejunostomyhas been recommended”; however, most authors would not recom-mend intervention and would prefer to leave the duodenal hema-toma undisturbed and allow for a period of 2 to 4 weeks for itsresolution.180~1s0~1s3 After this time has elapsed, and if the duodenalhematoma is not resolved, surgical intervention is then recom-mended for evacuation. Evacuation after this time may be technicallyeasier. The evacuation is carried out by way of a seromuscular inci-sion, avoiding penetration into the duodenal lumen. The seromus-cular layer is then approximated with Lembert sutures of nonabsorb-able materials. Recently, Jewett and colleaguesls4 reviewed the English literature and collected 182 cases of intramural hematoma of the duodenumin the pediatric population. Apparently, this injury is one of the leastcommonly encountered in children. Given the rarity of this problem,little consensus has existed regarding the relative merits of operativeversus nonoperative management. Of these 182 patients, 121 weretreated 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 duo- denum was not suspected in 26 of the patients. In the same surgicalgroup, 83 patients underwent surgery on a delayed basis (later than1080 Curr Probl Surg, November 1993
  • 56. 24 hours after admission), and 26 had a delay in diagnosis. In thesurgical group, 18 complications occurred. No complications oc-curred in the nonsurgical, conservatively managed group. In this se-ries, patients who underwent surgical management were exposed toa 16% risk of having serious complications. Simple evacuation of thehematoma resulted in only a 5% complication rate, whereas someform of bypass procedure carried an excessively high rate of 40%. Theauthors concluded that, in the pediatric population, intramural duo-denal hematoma is the least common intraabdominal injury result-ing from blunt trauma. A higher rate of suspicion of this injury will result in fewer unnec-essary operative procedures. Jewett and co11eagues1g4 recommendedconservative 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 car-ries a higher complication rate and results in an appreciably longerhospital stay. These authors recommended that surgery should bereserved for those cases complicated by perforation or a severelydamaged duodenum. They also recommended hematoma evacua-tion, rather than bypass operations, for those few cases in which per-foration or severe injury to the duodenum occurred.UNUSUAL DUODENAL INJURIES Rare forms of duodenal injury include iatrogenic injuries occurringduring surgical procedures such as nephrectomies or abdominal aor-tic aneurysm repair. Duodenal injuries can also occur after endo-scopic procedures such as flexible endoscopy and endoscopic retro-grade cholangiopancreatography. Bleeding from the papilla of Vaterafter endoscopic sphincterotomy may occur and, although rare, mayrequire operative intervention. In general, duodenal injuries after en- doscopic procedures are rare. Endoscopic perforations are treatedas any other transmural duodenal injuries of the same anatomic se-verity, and they are repaired using an inner layer of absorbable su-ture material followed by seromuscular Lembert sutures of nonab- sorbable material. Bleeding from the papilla of Vater is controlled by suturing the edges of the sphincterotomy through a duodenotomyin the second portion of the duodenum. Zinelis and colleagues1g5 recently reported what they believed tobe the first case of an intramural duodenal hematoma after uppergastrointestinal endoscopic biopsy. This hematoma caused total ob- struction 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 submu- cosal vascular plexus were the crucial factors in the development of this complication.Cum Probl Surg, November 1993 1081
  • 57. Sarr and colleagues1s6 reported on a series of 254 patients who hadcomplications related to therapeutic endoscopic sphincterotomy andrelated procedures on the ampulla of Vater. Of 254 patients, 5 patientshad duodenal (peri-Vaterian) perforation and 6 patients had clinicallysignificant pancreatitis. Most patients were not suspected of having asignificant complication the night of the procedure, despite abdomi-nal pain. CT scan proved to be the most accurate radiographic studyfor establishing the existence of a significant complication. A peri-duodenal collection of fluid (abscess) without significant pancreaticenlargement was the most common complication in patients withduodenal perforation. In patients who had pancreatitis after peri-Vaterian procedures, generalized pancreatic enlargement and pan-creatic edema were most prominent. Four of the five patients withduodenal perforation required surgical drainage, and all recovered. Incontrast, four of the six patients with pancreatitis had medicaltherapy. One patient with pancreatitis died after multiple pancreaticdebridements were performed. A second patient with pancreatitiswho underwent exploration recovered eventually. Pancreaticoduode-nal complications after a therapeutic endoscopic sphincterotomyand related procedures are difficult to diagnose early. These compli-cations should be suspected early and approached aggressively tolimit morbidity and death. Booth and colleagueslg7 reviewed 574 cases of endoscopic sphinc-terotomy. In this group, 56 precut papillotomies were performed.Complications were identified in 16% of these patients, with perfora-tion present in 9%, pancreatitis in 5%, bleeding in 2%, and pancre-atic abscess in 2%. Duodenal perforation accounted for more thanhalf of all major complications. Five patients had duodenal perfora-tions, and in two patients the perforation was diagnosed immediatelyafter sphincterotomy. Both patients underwent operations within 8hours and required only simple closure; these patients survived andwere discharged within 10 days. Three patients had delayed diagno- sis 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 fromtheir review of the literature that duodenal perforation has been re-ported in 1% to 7% of patients who undergo endoscopic sphincter- otomy 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-1082 Curr Probl Surg, November 1993
  • 58. fice of the papilla and the true or Vaterian sphincter located moreproximally. When only one papillary sphincter is cut, the procedureshould be called an endoscopic papillotomy. When both sphinctersare divided, the procedure is known as endoscopic sphincterotomy.The authors concluded that endoscopic sphincterotomy remains avaluable additional method of treatment of several disease processesof the ampulla of Vater. Precut papillotomy carries a significantlyhigher complication rate than conventional sphincterotomy, and the complications occurring from the latter procedure are much moreserious than those with sphincterotomy. The authors also recom-mended that duodenal perforations be repaired immediately, andthey strongly supported the concept that duodenal perforations should not be managed conservatively. Bell and colleagues”’ de-scribed eight proven perforations of the duodenum that occurred in441 patients who underwent endoscopic sphincterotomy. This com-plication developed with a frequency of 1.8% in this series. These au-thors reported that physical laboratory findings were of little diag- nostic value, whereas plain abdominal radiographs showed evidence of perforation in 86%. Two of the eight patients underwent opera- tions within 8 hours of the diagnosis and recuperated. Six patients underwent operations between 24 hours and 120 hours after endo- scopic sphincterotomy (mean, 43 hours). Three of the six patients re- quired 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 per-forations (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 vaginawere repaired. When bile drained from suction catheters, reexplora- tion disclosed an injury to the duodenum and diaphragm. The au- thors stated that, in general, vaginal injuries that occur from penetrat- ing 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 duode- num; this situation is usually prevented by spasm of the pylorus. In those rare cases in which transmural duodenal necrosis has oc- curred, resection will usually be required. Sarfati and colleagueszo2Cur-r Probl SW.. November 1993 1083
  • 59. recently reviewed their experience with 484 adults with caustic in-gestion injury and documented a very high mortality rate of patientswith this type of injury. The authors are indebted to Mrs. Dolores Williams for her help in assemblingthis manuscript. The authors also thank Mrs. Gae Decker for her help in compilingthis manuscript. REFERENCES 1. Loria F. Historical aspects of abdominal injuries [Introduction]. Springfield, Ill.: Charles C. Thomas, 1968:lO. 2. Loria F. The era of surgical controversy: historical aspects of abdominal in- juries. Springfield, Ill.: Charles C. Thomas, 1968:45-7. 3. Larrey Baron DJ. Memoirs of military surgery and campaigns [Translated from the French by R.W. Hall]. Vol. 3. Baltimore: Joseph Cushing, 1814:309- 89. 4. Otis GA. Medical and surgical history of the war of rebellion. Part 2, Vol. 2. Washington, DC: Government Printing Office, 1876:158-61. 5. Herczel. Cit. Nach. Jahresber Hildebrands, 1896:691. Cited by Meerwein. 6. Moynihan BGA. A case of gastro-jejunostomy for complete rupture of the intestine at the duodeno-jejunal flexure. BMJ 1901;1:1136. 7. Summers JE. The treatment of posterior perforations of the fixed portions of the duodenum. Ann Surg 1904;39:727-32. 8. Godwin HJ. A case of traumatic rupture of the duodenum and jejunum; op- eration; recovery. Lancet 1905;2:1108-9. 9. Meerwin H. Duodenal verlezungen duodenal stumpfe gewalt. Beitr Z Kbn Chir 1907;53:556-78. 10. Kanavel AB. The duodenum: mobilization, traumatic rupture and toxemia. Tr West Surg Assoc 1914,1913;221-31. 11. Lee BG. Medical department, U.S. Army in World War. Vol. 2. Surgery, Part 1. Washington, DC: Government Printing Office, 1927:443. 12. Cave WH. Duodenal injuries. Am J Surg 1946;72:26-31. 13. Sako Y, Artz P, Howard JM, et al. A survey of evacuation and mortality in a forward surgical hospital. Surgery 1955;37:602-11. 14. Halgrimson GG, Trimble C, Gale S, et al. Pancreaticoduodenectomy for trau- matic lesions. Am J Surg 1969;118:877-82. 15. Hirsch JE, Arhens EH Jr, Blankehorn DH. Measurement of the human intes- tinal length in vivo and some causes of variation. Gastroenterology 1956;31:274-84. 16. Cocke WM Jr, Meyer KK. Retroperitoneal duodenal rupture: proposed mechanism. Review of the literature and a report of a case. Am J Surg 1964;108:834-9. 17. Haley JC, Peden JK. The suspensory muscle of the duodenum. Am J Surg 1943;59:546-50. 18. Michaels NA. Variational anatomy of the hepatic, cystic and retroduodenal arteries. Arch Surg 1953;66:20-32. 19. Michaels NA, ed. Blood supply to the pancreas and duodenum. In: Blood supply and anatomy of the upper abdominal organs with a descriptive at- las. Philadelphia: JB Lippincott, 1955236-47.1084 Cur-r Probl Surg, November 1993
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