1. The document presents a treatment algorithm for grading duodenal injuries from Grade I to Grade V based on the severity of the injury. 2. Mild injuries like hematomas or partial-thickness lacerations are often observed or treated with closure. More severe injuries may require primary closure, resection, or bypass procedures like Roux-en-Y reconstruction. 3. For Grade III injuries, 2-layer closure is appropriate if the mesentery is intact, while more severe injuries may require resection and anastomosis or bypass depending on the extent of injury to surrounding structures.

1. Duodenal Injury Treatment Algorithm 1.0 www.SurgicalReview.net Version 1.01

2. Duodenal Grading system * Progress one grade if there are multiple lesions, up until grade III. AAST: American Association for the Surgery of Trauma. AIS- Abbreviate Injury Scale: www.surgicalreview.net 4 Extensive (>50%) rupture; stomach devascularized V 3 Large laceration involving vessels on greater or lesser curvature IV 3 Large (> 3cm) Laceration III 2 Intramural hematoma >3cm; small (<3 cm) laceration II 2 Intramural hematoma <30 cm; partial-thickness laceration I AIS-90 Score Injury Characteristics AAST Grade*

3. Duodenal Injury : Treatment by Grade Grade I: Single Segment hematomas: Treat Expectantly Partial-thickness laceration: Treat with closure of the seromuscular layer Grade II: Multisegment hematomas : Can be observed for 7 days. May repeat CT with oral contrast . If obstruction continues for more than 10 days, then surgical evacuation of hematoma is indicated (antimesenteric longitudinal incision) Lacerations : <50% of the total circumference of the duodenal segment treat with 2-layer transverse closure Grade III: Intact mesentery: 2 –layer transverse closure is appropriate (refer to diagram for grade III) Ragged Transected duodenum: Distal end of duodenum should be over sown and anastomosed to proximal end of jejunal loop. If lumen has high risk of being compromised with a primary closure then utilized retro colic Roux-en-Y jejunal limb. Grade IV: With intact ampullla and mesentery treat with primary closure If risk of luminal compromise with primary closure and bile duct and ampulla intact then perform Roux en Y duodenojejunostomy If the ampulla is disrupted but there is an uninjured pancreas . Reimplant distal bile duct and pancreated duct into posterior duodenal wall, and use pyloric exclusion Note: If ampulla and pancreatic duct are injured in the head of pancrease consider “trauma Whipple” Grade V: IF the duodenum is viable: treat with primary closure with either duodenal diverticularization or pyloric exclusion. OR consider pancreatico-duodenectomy IF evidence that the entire head of pancrease and duodenum are devascularized. Treat with Trauma whipple www.surgicalreview.net