MANAGEMENT                    OF DUODENAL                          INJURIESIN BRIEF    With most of the duodenum          ...
occur with a frequency of 14%, resulting in greater technical chal-lenges to the surgeon.    Successful diagnosis of a duo...
When a duodenal         injury is detected intraoperatively,         the surgeonmust be aware of factors that increase the...
Juan A. Asensio,         MD, graduated           with a BS degree from the                       University     of Illinoi...
L. Delano   Britt, MD, received        his BA degree from the Uni-versity of Virginia,     his MD degree from the Harvard ...
MANAGEMENT                           OF DUODENAL            INJURIESINTRODUCTION   The duodenum       is the epitome of an...
HISTORIC         PERSPECTIVE   There is a scarcity of well-documented         historic accounts regard-ing the management ...
utensil was filled with it in a few minutes. On the iifth day, an alvine evacu-ation, equally copious     took place, proc...
TABLE      1. American   military    experience   with   duodenal    injuriesConflict                    Author           ...
and its multiple anatomic variations. The duodenum                constitutes thebeginning of the small bowel and measures...
perior surface of the duodenum         under its second portion and entersthe pancreas just below and opposite the common ...
breach in the duodenal wall occurs. Escape of duodenal contents intothe free peritoneal cavity or retroperitoneum      inc...
TABLE      2. Mechanism         of iniurv   in duodenal      iniuries                                                     ...
TABLE        3. Penetrating         injuries-wounding                      agents                                         ...
Crushing injuries usually occur when a direct force is appliedagainst the abdominal wall and transmitted        to the duo...
TABLE      6.   Associated       injuries,         bv organ                                                               ...
TABLE 7.      Associated       injuriesOrgan                                           No. of injuries                    ...
TABLE         8. Anatomic     location       of duodenal   injury        (blunt      and    penetrating1                  ...
Patients who have sustained blows to the midepigastrium                     must beevaluated thoroughly.        Even an im...
who had elevations of their serum amylase levels between 4 and 12times normal during a period of observation.             ...
taken   either     in the oblique      or lateral  position,        may        demonstrate            a sinus       lead-i...
and his coworkers stated that air in the transverse mesocolon is oc-casionally misread as a mixture of air and feces in th...
abdominal trauma as the diagnostic method of choice in patients sus-pected of having duodenal injury. If the CT scan ident...
lowed by thin barium. Additionally,              in patients in whom no conclu-sion could be reached from both the contras...
Nichols and colleaguesgl that cefoxitin provides ample coverage ini-tially.   Abdominal      injuries should be explored t...
surgeon’s attention from the duodenum.          If findings such as minimalhematoma or insignificant      edema are deemed...
TABLE      9.   Duodenum         organ   injury    scaleGrade*              Injury                        DescriptiontI   ...
TABLE          10. Surgical      techniques       and    procedures       used    for repair     of duodenal        anduan...
FIG. 1. Most    duodenal          lacerations     can be repaired           primarily     after meticulous      debridemen...
FIG. 2. Longitudinal         duodenotomies       can be closed     transversely   if the   length   of the duo-denotomy   ...
FIG. 3. Adjunct           techniques       in management         of anatomically       severe duodenal          wounds    ...
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
Mx duod injuries curr probl surg
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Mx duod injuries curr probl surg

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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