Duodenal Trauma Research Articles

Pancreaticoduodenectomy in high-grade pancreatic and duodenal trauma

IntroductionHigh-grade pancreaticoduodenal injuries are highly morbid and may require complex surgical management. Pancreaticoduodenectomy (Whipple procedure) is sometimes utilized in the management of these injuries, but guidelines on its use are lacking. This paper aims to present our 14-year experience in management of high-grade pancreaticoduodenal injuries at our busy, urban trauma center. MethodsA retrospective review was performed on patients (ages >15 years) presenting with high-grade (AAST-OIS Grades IV and V) injuries to the pancreas or duodenum at our Southeastern Level 1 trauma center. Inclusion criteria included high-grade injury and requirement of Whipple procedure based on surgeon discretion. Patients were divided into two groups: (1) those who underwent Whipple procedures during the index operation and (2) Whipple candidates. Whipple candidates included patients who received Whipples in a staged fashion or who would have benefited from the procedure but either died or were salvaged to another procedure. Demographics, injury patterns, management, and outcomes were compared. Primary outcome was survival to discharge. ResultsOf 66,272 trauma patients in this study period, 666 had pancreatic or duodenal injuries, and 20 met inclusion criteria. Of these, 6 had Whipples on the index procedure and 14 were Whipple candidates (among whom 7 had staged Whipples, 6 died before completing a Whipple, and 1 was salvaged). Median (IQR) age was 28 (22.75–40) years. Patients were 85 % male, 70 % Black. GSWs comprised 95 % of injuries. All patients had at least one concomitant injury, most commonly major vascular injury (75 %), colonic injury (65 %), and hepatic injury (60 %). In-hospital mortality among Whipple patients was 15 %. ConclusionsComplex pancreaticoduodenal injuries requiring pancreaticoduodenectomy are rare but life-threatening. In such patients, hemorrhage was the leading cause of death in the first 24 h. Approximately half underwent damage control surgery with staged Whipple Procedures. However, pancreaticoduodenectomy at the initial operation is feasible in highly selective patients, depending on the extent of injury, physiologic status, and resuscitation.

Use of jejunal serosal patch and pyloric exclusion in the management of complex duodenal injury.

Duodenal injuries are relatively rare but remain a management challenge with a high incidence of postoperative complications. Guidelines from the World Society of Emergency Surgery and American Association for the Surgery of Trauma favour a primary repair for less-complex injuries, but the management of more complex duodenal trauma remains controversial with varying techniques supported, including pyloric exclusion, omental or jejunal patch closure, gastrojejunostomy and pancreatoduodenectomy. We describe the techniques used in one case of complex duodenal trauma. The duodenum is approached via a standard laparotomy with Kocherisation. Primary repair of the duodenal perforations is performed using a 3/0 polydioxanone suture (PDS), followed by mobilisation of a loop of mid-jejunum against the area of duodenal trauma over the primary repair as a jejunal serosal patch. The antimesenteric jejunal serosal border is sutured to the serosa of the duodenum (serosa only) using a 3/0 PDS. Pyloric exclusion is then performed through an anterior gastrostomy, to control the volume of gastric juice entering the duodenum. The pylorus is sutured closed using an absorbable suture followed by closure of the anterior gastrostomy using a GIA stapling device.

Is pyloric exclusion the best surgery for lesions of the duodenum D3 and D4?

Due to its retroperitoneal location, injuries to the duodenum are relatively rare. As a result, many general surgeons have limited experience of duodenal trauma, which is particularly the case in countries with a small population. The use of primary repair in the treatment of duodenal injuries is rising with the existing trend of a move away from surgical treatment towards less invasive procedures, and the role of pyloric exclusion has become controversial. We present two cases with lesions to D3 and D4 of the duodenum, treated by pyloric exclusion.

Management of pancreatic and duodenal trauma in childhood: a university hospital experience over a 10-year period

PurposeDuodenal/pancreatic injuries occur in less than 10% of intra-abdominal injuries in pediatric blunt trauma. Isolated duodenal/pancreatic injuries occur in two-thirds of cases, while combined injuries occur in the remaining. This study aimed to investigate pediatric patients with pancreatic and duodenal trauma.MethodsData from 31 patients admitted to Atatürk University, Medical Faculty, Department of Pediatric Surgery for pancreatic/duodenal trauma between 2010 and 2019 were retrospectively analyzed. Age/gender, province of origin, duration before hospital admission, trauma type, injured organs, injury severity, diagnostic and therapeutic modalities, complications, hospitalization duration, blood transfusion requirement, and mortality rate were recorded.ResultsTwenty-four patients were male, and 7 were female. The mean age was 9 years. The leading cause was bicycle accidents, with 12 cases, followed by traffic accidents/bumps, with 7 cases each. Comorbid organ injuries accompanied 18 cases. Duodenal trauma was most commonly accompanied by liver injuries (4/8), whereas pancreatic injury by pulmonary injuries (7/23). Serum amylase at initial hospital presentation was elevated in 83.9% of the patients. Thirty patients underwent abdominal CT, and FAST was performed in 20. While 54.8% of the patients were conservatively managed, 45.2% underwent surgery.ConclusionBecause of the anatomical proximity of the pancreas and the duodenum, both organs should be considered being co-affected by a localized trauma. Radiologic confirmation of perforation in duodenal trauma and an intra-abdominal pancreatic pseudocyst in pancreatic trauma are the most critical surgical indications of pancreaticoduodenal trauma. Conservative management’s success is increased in the absence of duodenal perforation and cases of non-symptomatic pancreatic pseudocyst.

Development of a gastrocutaneous fistula from a marginal ulcer after repair of duodenal injury with pyloric exclusion

Duodenal trauma is rare but can be associated with significant morbidity and mortality (Pandey et al., 2011) [1]. Adjunct procedures, such as pyloric exclusion, can be performed to assist in surgical repair of these injuries. However, pyloric exclusion can lead to severe long-term complications associated with significant morbidity that can be difficult to repair. A 35-year-old man with a history of duodenal trauma from a gunshot wound (GSW) status post pyloric exclusion and Roux-en-Y gastrojejunostomy presented to the Emergency Department (ED) with complaints of abdominal pain and leakage of food particles and fluid from an open wound around his surgical scar. Computed tomography (CT) scan on admission showed a tract extending from the gastrojejunostomy anastomosis to the skin representing a fistula. Esophago-gastro-duodenoscopy (EGD) reconfirmed a large marginal ulcer that had fistulized to the skin. After nutritional repletion, the patient was taken to the operating room (OR) for takedown of the enterocutaneous fistula and Roux-en-Y gastrojejunostomy, closure of gastrostomy and enterotomy, pyloroplasty and feeding jejunostomy tube placement. The patient was re-admitted after discharge with abdominal pain, vomiting and early satiety. EGD showed gastric outlet obstruction and severe pyloric stenosis which was managed with endoscopic balloon dilation. This case represents the severe and potentially life-threatening complications that may occur after pyloric exclusion with Roux-en-Y gastrojejunostomy. Gastrojejunostomies are prone to marginal ulceration which can perforate if not adequately treated. Free perforations cause peritonitis, but if the perforation is contained it can erode through the abdominal wall creating the rare complication of a gastrocutaneous fistula. Even after restoration of normal anatomy with a pyloroplasty, patients may suffer additional complications such as pyloric stenosis requiring continued intervention.

Blunt traumatic isolated duodenal perforation treated by multimodal endoscopic approach.

Duodenal trauma usually consists of retroperitoneal lesions, which represent a small percentage of abdominal injuries. These injuries are difficult to manage by surgery, so endoscopy can be an useful alternative [1] [2] [3].

A case series on diagnosis, management and outcome of second part of duodenum perforation

Duodenal injuries are uncommon after Blunt and penetrating trauma to abdomen and are potentially life threatening. Iatrogenic injuries caused by interventional procedures like endoscopic retrograde cholangiopancreatography (ERCP) is only 1%. Duodenal trauma can often pose diagnostic and therapeutic challenges due to its subtle clinical features as 2nd part of duodenum being a retroperitoneal organ and its rarity to get injured following blunt trauma, and hence diagnosis and treatment are often delayed. These injuries are potentially life threatening because D2 being a high output zone, managing these injuries are very difficult and more complex surgery are warranted. Here we discussed about the outcomes of D2 perforation in blunt trauma, pathological D2 perforation, iatrogenic while attempting ERCP and also based on the time of presentation to casualty from the time of perforation and also comparing the size of perforation in trauma, iatrogenic, pathologic injuries and also different types of procedures they underwent Based on the severity of injuries, we conclude that time of presentation is the foremost factor in deciding the outcome of the patient with D2 perforation which was often delayed due to its anatomic location being retroperitoneal organ and D2 being a high output zone, often makes the surgical procedures unsuccessful with high risk of postoperative leaks and makes duodenal injuries as life threatening injuries. Thus careful monitoring and computed tomography (CT) abdomen for all suspicious blunt trauma abdomen cases can help in early identification of D2 injuries and immediate surgical intervention procedures with T tube diversion, tube duodenostomy, pyloric exclusion to decompress the high output D2 based on the size, site, output and time of perforation will improve the overall outcome of the patient.

Isolated Duodenal Perforation at D3 Following Blunt Abdominal Trauma, a Challenging Diagnosis and Management: A Case Report

Introduction: Isolated duodenal rupture following blunt abdominal trauma is rare. We here report a case of isolated duodenal perforation treated by suture, pyloric exclusion and side-to-side gastrojejunostomy in order to discuss its diagnostic, therapeutic, and evolutionary features. Observation: A 46-year-old man, victim of a physical aggression, consulted ten hours after the trauma for diffuse abdominal pain associated with vomiting. The physical examination revealed a febrile patient at 38.2°C, hemodynamically stable with generalized abdominal defense. The abdominal CT revealed parietal defect of the 3rd duodenum (D3), pneumoperitoneum, intra and retroperitoneal fluid effusion without adjacent organ involvement. The patient underwent emergency surgery. Intraoperatively, a centimetric perforation of D3 on the anterior wall was found. The lacerated edges were repaired with interrupted sutures. A pyloric exclusion and side- to-side gastrojejunostomy are performed. Postoperative course of patient was unremarkable. Isolated duodenal injuries are rares in blunt abdominal trauma because the duodenum is located in a deep anatomical position. Duodenal injuries secondary to blunt trauma can range in severity from intramural hematoma to a complete transection and devascularization of the duodenum. There is no consensus on the surgical procedure. Options range from primary suture to complex duodenopancreatic resections based on the severity of the lesions. Conclusion: Isolated duodenal trauma is unusual following blunt trauma. Prompt diagnosis and management is the key to prevent morbidity and mortality.

Duodenal Trauma in Children: What is the Status of Non-Operative Conservative Treatment?

Conservative treatment of duodenal trauma in children has long been the first line of treatment for duodenal wall hematomas. However, it has rarely been described in duodenal perforations. Our purpose is to highlight the possibility of conservative treatment in selected cases of duodenal perforation. In the period between 2009 and 2022, 6 children were treated for duodenal injury following abdominal blunt trauma in the pediatric surgical emergency department. The clinical presentation, diagnosis and treatment are reported and analyzed. Three patients presented with duodenal hematomas, they were treated non-operatively with hospital stays between 12 and 20 days and good clinical outcome. One child presented with duodenal hematoma and retroperitoneal air bubbles; non-operative conservative treatment was carried with favorable results. The fifth patient had a duodenal perforation; he underwent a primary duodenal 2-layers closure. The last patient had a combination of duodenal hematoma and perforation involving 75% of the duodenal diameter for which he underwent a gastro-jejunostomy with pyloric exclusion. An isolated duodenal lesion can be subject to a conservative treatment whenever allowed by a stable clinical condition and the availability of appropriate clinical and radiological monitoring.

Repair by Primary Closure of Traumatic Blunt Duodenal Injuries: Simple is Not Always Safe

IntroductionRecent literature on managing traumatic duodenal injuries suggests the superiority of primary repair. We hypothesized that duodenal trauma repair by primary closure might not be a safe strategy in an environment dealing predominantly blunt injuries with limited resources. MethodsData analysis was done from the prospectively maintained trauma registry. The study period chosen was from January 1, 2014 to December 31, 2018. Data of 63 patients were analyzed for demographics, injuries, management, and outcome. Logistic regression was used to identify mortality predictors. ResultsThe most common mechanism of injury was blunt (56/63, 88.9%). Forty (63.5%) patients had associated intraabdominal injuries. The most common American Association for the Surgery of Trauma grade of injury to the duodenum was three in 21 patients. Univariate analysis showed that mortality was associated with hypotension on presentation, higher duodenal grade, associated abdominal vascular injuries, primary closure, and duodenal leak. Logistic regression showed associated associated abdominal vascular injuries, primary closure, and leak remained significant predictors of mortality. ConclusionsPrimary repair was found to be an independent predictor of mortality. A patient's physiology is a critical determinant of the outcome. Liberal use of tube duodenostomy over primary repair seems reasonable for blunt duodenal injury management.

Duodenal Trauma

Duodenal trauma is rare enough to prevent most surgeons from having extensive experience with its management, but not so unusual as to be ignored. The challenges are not simply in the operative decision-making, but also in the timely diagnosis. The duodenum accounts for only 5% of intra-abdominal traumatic injuries, likely owing to its deep, mostly retroperitoneal location. Fully three-quarters of duodenal injuries reported in the world’s literature are from penetrating wounds, and nearly all (90%) will have associated intra-abdominal injuries. Hemorrhage control, halting contamination, and definitive repair of the duodenal injury are the hallmarks of good management. The grade or severity of the duodenal injury will direct the appropriate surgical repair technique. Timely diagnosis is imperative, for a delay will increase mortality four-fold. This review contains 7 figures, 5 tables, and 25 references Keywords: Duodenum, pylorus, injury, trauma, pyloric exclusion, amylase, lipase, tube-duodenostomy, whipple procedure, retroperitoneum

Duodenal Trauma

Duodenal trauma is rare enough to prevent most surgeons from having extensive experience with its management, but not so unusual as to be ignored. The challenges are not simply in the operative decision-making, but also in the timely diagnosis. The duodenum accounts for only 5% of intra-abdominal traumatic injuries, likely owing to its deep, mostly retroperitoneal location. Fully three-quarters of duodenal injuries reported in the world’s literature are from penetrating wounds, and nearly all (90%) will have associated intra-abdominal injuries. Hemorrhage control, halting contamination, and definitive repair of the duodenal injury are the hallmarks of good management. The grade or severity of the duodenal injury will direct the appropriate surgical repair technique. Timely diagnosis is imperative, for a delay will increase mortality four-fold. This review contains 6 figures, 2 tables, and 24 references. Key Words : Duodenum; Pylorus; Injury; Trauma; Pyloric exclusion; Amylase; Lipase; tube-duodenostomy; Whipple procedure; Retroperitoneum

ТРУДНОСТИ ДИАГНОСТИКИ И ЛЕЧЕНИЯ ПОВРЕЖДЕНИЙ ДВЕНАДЦАТИПЕРСТНОЙ КИШКИ У ДЕТЕЙ

Objective: To study the clinical presentations and diagnosis of injuries to the duodenum in children. Methods: The study analyses the diagnosis and treatment of duodenal injuries in 14 children admitted to pediatric surgery departments at the Bashkir State Medical University, Ufa, Russia and Saint-Petersburg State Pediatric Medical University, Russia, between 2000 and 2020. The clinical presentations of duodenal injuries, diagnostic challenges and preoperative and intraoperative errors were evaluated. Results: High diagnostic error rates were observed since practitioners have a knowledge gap regarding the clinical presentation and surgical treatment principles of duodenal trauma among affected children. The authors believe that the presence of one of the symptoms (retroperitoneal hematoma, emphysema, yellowish green staining of the retroperitoneum and tissues is an indication for inspection of the retroperitoneal part of the duodenum, performed according to Kocher manoeuvre. Conclusion: Damage to the duodenum in children presents considerable difficulties in diagnosis and treatment. In this regard, imaging studies should be employed for diagnosis. Diagnostic laparoscopy is considered the gold standard for preoperative clinical evaluation. Retroperitoneal hematoma and/or emphysema, and yellow-green staining of the retroperitoneum and tissues, are indications for inspection of the retroperitoneal part of the duodenum, performed according to Kocher manoeuvre. Keywords: Duodenum, trauma, diagnosis, surgical treatment.

Surgical management of complex duodenal trauma using laterolateral duodenum enteroanastomosis: A case report.

Introduction and importanceDuodenal trauma is rare, however, it has high morbidity and mortality rates. Surgical treatment modalities are employed depending on severity, ranging from simple sutures to complex pancreaticoduodenectomy cases.Case presentationA male patient had a circular saw accident, leading to evisceration in an extensive wound from the thoracoabdominal transition to the inguinal region, with 75% laceration of the second duodenal portion circumference, laceration in hepatic segments, section from right mesocolon to transverse colon, and multiple perforations in small bowel loops between 70 and 90 cm from the angle of Treitz. Laterolateral duodenum enteroanastomosis was performed with proximal jejunum and gastroenteroanastomosis with the distal loop of the small intestine at 90 cm from the Treitz angle, and a termino lateral enteroanastomosis between food and the biliary loop at 20 cm from the gastroenteroanastomosis.Clinical discussionThis report presents a new surgical technique for patients with penetrating duodenal trauma associated with liver and intestinal injuries, to avoid the need for more complex procedures. In addition, it demonstrates postoperative management of complications, including confection of the enteroatmospheric fistula for feeding.ConclusionThe technique described in this article proved to be a good option for treating these lesions, as evidenced by optimal postoperative results.

Damage control in penetrating duodenal trauma: less is better - the sequel.

The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of “Less is Better”. Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.

The Roux-en-Y Lateral Duodenojejunostomy: an Elegant Solution for Traumatic Pediatric Duodenal Disruption

Duodenal trauma is rare in children and its diagnosis and management often pose a challenge. In complex duodenal injuries, primary closure may not be feasible and complications are prone to occur in the post-operative period. Herein, we share our experience of such a case managed by an infrequently utilized technique, Roux-en-Y lateral duodenojejunostomy.

Pancreas-preserving total duodenectomy: a systematic review

Introduction: The management of the pancreas in patients with duodenal trauma or duodenal tumors remains a controversial issue. Pancreas-preserving total duodenectomy is a procedure that requires a meticulous surgical technique as well as a thorough and detailed knowledge of peripancreatic anatomy. The most common indication is familial duodenal adenomatous polyposis. The aims of this study are to carry out a systematic review of the literature on the indications for pancreas-preserving total duodenectomy, to highlight the risks and benefits, and to demonstrate the significant reduction in mortality compared with other aggressive surgical techniques. Methods: Regulated systematic literature review following PRISMA recommendations of all studies published in PubMed, Embase, and Cochrane library with no limits on year of initial publication until 31 May 2019. A total of 30 articles describing 211 patients that met the inclusion criteria were chosen. Results: The mean age was 48 years. Seventy-five per cent of patients presented an initial surgical indication of familial adenomatous polyposis (98% Spigelman stages III-IV). The mean operating time was 329 minutes, and mean intraoperative bleeding 412 ml. Postoperative morbidity rate was 49.7% (76% with Clavien-Dindo < IIIa) and mortality rate 1.4%. The mean hospital stay was 22 days. Overall survival at 1-3-5 years was > 97.8%. Conclusions: Pancreas-preserving total duodenectomy is indicated for patients with benign and premalignant duodenal lesions without involvement of the pancreatic head. It is a safe and feasible procedure that reduces risks and increases peri-operative benefits compared to other aggressive surgical techniques. Mortality is below 1.5%.

Surgical Decision Making in Pancreatic and Duodenal Trauma

Introduction: Pancreatic and duodenal injuries occur uncommonly but may cause significant morbidity and mortality. This study focuses on factors that may influence surgical decision making in this patient group. Method: A retrospective review of patients admitted with pancreatic and/or duodenal injuries from 2000 - 2017 to a level 1 trauma service was undertaken. Demographic, injury and management data were collected. The grade of pancreatic or duodenal injury was considered to be low (AIS 1-2) or high (AIS 3-5). Patients were analysed in two groups according to whether they were managed operatively or non-operatively. The operative group was then divided into patients managed with damage control versus those who had definitive surgery. Univariate and multivariate analysis were performed to identify factors which differentiated between these groups. Results: 148 patients sustained pancreatic and/or duodenal injuries. Non-operative management was undertaken in 119 patients (80.4%). On multivariate analysis, injury to four or more abdominal organs was the only factor associated with requiring operative management (OR 1.87 (95%CI 1.29-2.71, p=0.01). 45 of the 119 patients (37.8%) required damage control surgery. On multivariate analysis, shock (OR 17.57 (95%CI 3.58-86.15, p=0.0000)) and major vessel injury (OR 3.14 (95%CI 1.25-7.92, p=0.02)) were associated with requiring a damage control approach. Conclusion: Pancreatic and duodenal injuries are uncommon. Injury to multiple abdominal organs is associated with operative treatment of the pancreatic or duodenal injury. In patients with shock or major vessel injury, damage control surgery is likely to be required.

Treatment experience of a patient with duodenal trauma

A case of combined duodenal trauma in the 11-year-old patient is described. Complications of pre-operative and intraoperative diagnosis as well as complicated postoperative period are emphasized to be a cause of high mortality risk in this pathology. The disconnection of proximal and distal parts of duodenum was performed; anastomoses were placed between the common bile and pancreatic ducts and small intestine, and gastroenteroanastomosis was performed on a short loop. Follow-up traced for 10 months: recovery.

Prognosis of mortality and evolution in pancreatoduodenal trauma in patients with wound by projectile of firearm.

The wounds caused by the firearm projectile are published to date in a public health problem in the world. As an example, we mentioned the injuries caused by firearms are the first cause of death in the age group between 1 to 19 years in the United States, as in Mexico. Analysis of the prognostic factors of mortality and evaluation of the evolution in patients with TPD due to abdominal HPPAF. Retrospective, observational, descriptive study. Helped by 49 clinical files of patients who were admitted to the department of surgery of the University Hospital José Eleuterio González, between 2011 to 2015 and whose diagnosis was due to pancreatic trauma (TP), duodenal trauma (TD) or pancreatoduodenal trauma (TPD) by wounds caused by the firearm projectile. During a collection period of 5 years, a total of 49 clinical records applicable to the study were obtained according to the inclusion criteria, of which 36 (73%) suffered only from TD, 37 (75%) from TP and 24 (49%) about TPD. Significant differences were obtained for mortality associated with TD and TPD, but not for TP. The most affected organ as a lesion associated with a TPD was the liver, followed by thoracic structures and the stomach. The most significant risk factor for mortality was a prolonged stay in the intensive care unit. Data obtained are consistent with those consulted, providing new reproducible statistics for future studies regarding the increasing violence in our country and around the world.