Overview
Definition:
Duodenal injuries, often secondary to blunt or penetrating trauma, pose significant management challenges due to the duodenum's retroperitoneal location and its critical role in digestion
Repair strategies aim to restore luminal continuity and prevent leakage, with primary repair and pyloric exclusion being two major surgical approaches.
Epidemiology:
Duodenal injuries account for approximately 1-2% of all abdominal trauma cases
Penetrating injuries are more common than blunt trauma
High-velocity impact, deceleration injuries, and direct blows to the abdomen are typical mechanisms for blunt duodenal trauma
Associated injuries to adjacent organs like the pancreas, stomach, and major vessels are frequent.
Clinical Significance:
Undetected or inadequately repaired duodenal injuries can lead to severe complications including duodenal fistula, peritonitis, sepsis, intra-abdominal abscess formation, and high mortality
Prompt and appropriate surgical intervention is crucial for patient survival and optimal recovery, making this a high-yield topic for surgical trainees.
Indications
Indications For Repair:
All significant duodenal injuries require surgical exploration and repair
Factors influencing repair choice include the size and location of the injury, degree of duodenal devascularization, presence of associated pancreatic injury, patient's hemodynamic stability, and surgeon's experience.
Indications For Primary Repair:
Suitable for smaller, superficial lacerations or perforations, especially in the anterior duodenal wall with minimal tissue loss and good vascularity
Injuries less than 2 cm in length are often amenable to primary repair.
Indications For Pyloric Exclusion:
Reserved for extensive injuries involving more than 50% of the circumference, significant tissue loss, major devascularization, severe contamination, or when primary repair would lead to undue tension or stenosis
Often indicated in injuries associated with pancreaticoduodenectomy or complex duodenal reconstruction.
Preoperative Preparation
Resuscitation:
Aggressive fluid resuscitation, blood transfusion, and correction of coagulopathy are paramount
Assess and manage hemodynamic instability.
Diagnostic Workup:
Initial assessment with FAST scan or diagnostic peritoneal lavage
CT scan of the abdomen and pelvis with IV contrast is crucial for identifying duodenal injuries and associated organ damage
Oral contrast studies (e.g., Gastrografin) may be considered if suspicion for perforation is high but CT is equivocal.
Antibiotics:
Broad-spectrum intravenous antibiotics covering aerobic and anaerobic organisms are essential to prevent infection and sepsis
Prophylactic antibiotics should be continued postoperatively.
Nasogastric Tube:
Insertion of a nasogastric tube for gastric decompression is recommended prior to definitive management.
Surgical Management Options
Primary Repair Techniques:
Lacerations can be repaired primarily using sutures, typically in two layers, with the inner layer absorbing sutures and the outer layer non-absorbable
Transverse closure is preferred to minimize the risk of stenosis
Mobilization of the duodenum (e.g., Kocherization) may be necessary to achieve tension-free closure.
Pyloric Exclusion Procedure:
This involves diverting gastric contents away from the repair site
The common method is a "antrectomy with truncal vagotomy and Roux-en-Y gastrojejunostomy." The pylorus is surgically excluded, and a gastrojejunostomy is created, bypassing the duodenum
This reduces the intraluminal pressure and digestive enzyme activity at the repair site, promoting healing.
Other Reconstructive Options:
For extensive injuries, more complex reconstructions like duodenal diverticulization, segmental duodenectomy with end-to-end anastomosis, or even pancreaticoduodenectomy (Whipple procedure) may be necessary
These are reserved for specific, severe injury patterns.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and abdominal distension is crucial
Serial abdominal examinations to detect signs of peritonitis or dehiscence.
Drainage:
Placement of surgical drains around the repair site to monitor for leakage of duodenal contents
Drains are typically removed when output is minimal and non-bilious.
Nutrition:
Early enteral nutrition is preferred if possible
If the repair is tenuous or significant duodenal reconstruction has been performed, parenteral nutrition may be required
Nasojejunal feeding tubes can be used for enteral feeding distal to the repair.
Pain Management:
Adequate pain control with analgesics, including epidural analgesia if appropriate, to facilitate early mobilization and reduce splinting.
Antibiotic Therapy:
Continued intravenous antibiotics based on intraoperative findings and culture results, typically for 5-7 days or longer if infection is present.
Complications
Early Complications:
Duodenal fistula formation (the most feared complication), intra-abdominal abscess, peritonitis, sepsis, wound infection, dehiscence of the repair, hemorrhage, pancreatitis.
Late Complications:
Duodenal or gastric outlet obstruction due to stenosis, prolonged ileus, adhesions leading to bowel obstruction, malnutrition, vitamin deficiencies.
Prevention Strategies:
Meticulous surgical technique, tension-free repair, adequate drainage, early nutritional support, judicious use of pyloric exclusion in appropriate cases, and early recognition and management of suspected leaks.
Key Points
Exam Focus:
Understand the indications for primary repair versus pyloric exclusion
Recall the surgical steps for pyloric exclusion (antrectomy, vagotomy, gastrojejunostomy)
Recognize the high morbidity and mortality associated with duodenal fistulas.
Clinical Pearls:
In penetrating duodenal injuries, visualize the entire duodenum by Kocherizing it
Consider pyloric exclusion for injuries >50% circumference or if primary repair would be under tension
High index of suspicion for pancreatic injury in duodenal trauma.
Common Mistakes:
Inadequate assessment of the extent of duodenal injury
Overly aggressive primary repair in the face of significant devascularization or contamination
Failure to consider associated pancreatic injuries
Delayed diagnosis of duodenal leaks leading to sepsis.