This document summarizes key information about duodenal injuries: - The duodenum is 12 inches long and located retroperitoneally behind the liver and pancreas. It has four parts and is vulnerable to trauma due to its location and proximity to other abdominal organs. - Duodenal injuries can be from penetrating or blunt trauma. Diagnosis involves imaging like CT scans and upper GI series. Management principles involve restoring intestinal continuity, decompressing the duodenum, providing drainage, and nutritional support. - Treatment options depend on the severity of injury and include primary repair, diversion procedures like gastrojejunostomy, or pancreaticoduodenectomy for severe injuries involving other structures. Complications can include

1. Duodenal injuries
Dr. Joe M Das

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

22. Grade 1,2 & 3 duodenal injuries

23. Cattell and Braasch maneuver

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

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

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

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

29. Duodenorrhaphy
(>½ of circumference of duodenum)

30. Duodenorrhaphy
(<½ of circumference of duodenum)

31. Tube duodenostomy

32. Suck-me, feed-me jejunostomy

33. Addition of gastrostomy

34. Serosal patch technique

35. Jejunal mucosal
patch /
pedicled graft

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

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

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

39. Debridement, segmental resection,
EEA

43. Vaughan / Jordan pyloric exclusion
technique

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

45. Triple ostomy

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

47. Pacreaticoduodenectomy

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

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

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