Blunt Duodenal Injury

A fifty-one year old female presented to after a she fell from her scoter and it fell onto her abdomen. She had no other injuries, was hemodynamically stable. Her exam was significant for a circular imprint on her anterior abdomen above the umbilicus. She was tender in all four quadrants but not peritonitic. We obtained a CT scan of her abdomen and pelvis.

Imaging demonstrated a small amount of focal fluid and edema in the small bowel mesentery located near the junction of the second and third portion of the duodenum, but no evidence of free air.

And a right-sided Spigalien hernia containing mesenteric fat, patient notes a three-year history of a bulge.

With hemodynamic stability and no evidence of free perforation we elected to observe her and perform serial abdominal exams. Over the next few hours she continued to have abdominal pain, this progressively worsened and after four hours she had diffuse peritonitis. We at that time took her to the OR and encountered the following.

On entry we found succus in all quadrants, and a hematoma around the ligament of treitz, which extended into the right retroperitoneum. On further exploration it was obvious the duodenum at D3 had a 50% blow-out perforation. This was well away from the ampulla and we primarily repaired the injury.

We drained her internally with an NG Tube and externally with a JP drain, a post-injury dobhoff tube was placed for feeding access. We then studied her on post operative day five. There was easy passage of contrast and no evidence of extravasation.

She tolerated the initiation and advancing of her diet and was discharged to home.

Duodenal trauma:

Duodenal trauma represents a significant surgical challenge. Its location deep and central in the abdomen means it’s rarely injured in isolation. Also the anatomic and physiologic factors of the associated organ systems means complications are high and morbidity can present weeks to months after. Larger trauma centers in the 1960-80’s reported only 10-20 injuries a year. Recent series would place the incidence at 0.2-0.3% of app trauma cases. In these series there are a large number of associated injuries; major vascular 48%, liver in 44%, colon 31%, pancreas 30%. Over all mortality is approximated at 17%, death is from hemorrhage in the early phase accounts for 73% of that mortality and sepsis and multisystem organ failure in 27%.

Treatment is summarized in this algorithm

Our patient sustained a Grade 2 injury and was therefore treated with a primary repair. If this injury was more proximal to the ampulla or of a greater circumference our institutions preference is for exclusion with gastrojejunostomy reconstruction and feeding jejunostomy, as shown in the following figure.

Over all isolated duodenal injuries are rare, and their diagnosis requires a low index of suspicion.  This patient offered a unique look at the management of isolated duodenal injuries.

Resources:

-- Snyder WH III, Weigelt JA, Watkins WL, Bietz DA. The surgical management of duodenal trauma. Arch Surg. 1980;115:422–429.

-- Ivatury RR, Nallathambi M, Gaudino J, Rohman M, Stahl WM. Penetrating duodenal injuries: analysis of 100 consecutive cases. Ann Surg. 1985;202:153–158.

-- Shorr RM, Greaney GC, Donovan AJ. Injuries of the duodenum. Am J Surg. 1987;154:93–98.

-- Cogbill TH, Moore EE, Feliciano DV, et al. Conservative management of duo- denal trauma: a multicenter perspective. J Trauma. 1990;30: 1469–1475.

-- Kao LS, Bulger EM, Parks DL, Byrd GF, Jurkovich GJ. Patterns of morbidity after traumatic pancreatic injury. J Trauma. 2003;55:898–905.
-- Velmahos GC, Tabbara M, Gross R, et al. Blunt pancreatoduodenal injury: a multicenter study of the research consortium of New England centers for trauma (ReCONECT). Arch Surg. 2009;144:413–419.

from Dr. John Kubasiak