Duodenal Trauma Research Articles

Pancreatico duodenal trauma in children: Two-year experience at a regional referral center and tertiary care teaching hospital

Background:Pancreatico-Duodenal injuries, though rare, pose a mighty challenge to the surgeon in both diagnosis and treatment. More so in children, where the patho-physiologic threshold is low. Added to this is the absence of any strong guidelines to guide and ensure standardised care in these children for best outcome.Materials and Methods:The trauma patients' records in the emergency department, operation theatre, inpatient departmrnt, outpatient department (OPD) for the period of December 2016 to December 2018 in the institution were retrospectively reviewed, to find out the cases of pancreaticoduodenal trauma proven radiologically, biochemically and/or on laparotomy. Those cases then studied with respect to diagnosis, treatment and short term outcome.Results:Of the 256 cases of abdominal trauma, suspected pancreatico duodenal (PD) trauma were in nine but on laparotomy actually eight of them had PD trauma. All were blunt abdominal traumas sustained in road traffic accidents. Of these one was combined pancreatico duodenal while three were pure pancreatic and four were pure duodenal. One had associated superior mesenteric vein trauma. All were managed operatively. There were no mortality, one fourth had major complications. Mean hospital stay was 22.25 days. Follow up period varied from six to 32 months.Conclusion:Though PD traumas are rare but are potentially very morbid and may prove fatal. Proactive individualized management, multidisciplinary approach and good perioperative support can yield good results.

Triple tubostomy and its outcome for blunt duodenal injury

Introduction: Blunt duodenal injury in an uncommon form of abdominal injuries, which comprises less than 5% of all injuries. The diagnosis and management are challenging, because of delays in diagnosis due to subtle signs and symptoms in its early stage of presentation. Primary repair along with triple tubostomy (gastrostomy, retrograde duodenostomy and feeding jejunostomy) is a simple and safe method of damage control surgery in this group of patients. This study aims to report our experience in the management of this uncommon procedure.
 Methods: This is a retrospective analysis of the patients undergoing triple tubostomy (TT) for blunt duodenal injury at the Department of Surgery, B.P.Koirala Institute of Health Sciences (BPKIHS), Dharan, over a three and half years. The study included demographics, clinical profile, length of hospital stay, postoperative morbidity (duodenal fistula), rate and timing of spontaneous closure of fistula and mortality.
 Results: Eleven (6.7%) patients out of 164 blunt trauma abdomen had sustained a duodenal injury. Eight patients who underwent TT were included in the study. The mean age of the patient was 31.8 years (range: 18-67), with a male: female ratio of 3:1. The mean time to trauma and presentation was 4.25 days. The most common site of injury was the second part of the duodenum (87.5%), AAST grade III was seen in 62.5%, two (25%) patients were in shock at presentation. Eight patients required primary closure with triple tubostomy. Postoperatively, all patients had a duodenal fistula, which closed spontaneously in 6 (75%) patients at a mean duration of 17 days, with a mean postoperative length of hospital stay of 33.5 days. The remaining two (25%) patients died of an active fistula.
 Conclusion: Blunt duodenal trauma, when presented late can be managed with primary closure and triple tubostomy with acceptable postoperative outcomes.

Surgical management of 86 patients with duodenal injuries

Objective To study the early diagnosis, surgical treatment options, prevention and management of complications in patients with duodenal trauma. Methods All patients with duodenal trauma treated operatively from January 2009 to December 2018 were studied retrospectively. Factors including sex, age, cause of injury, AAST grading, diagnostic method, operative procedure, therapeutic effectiveness, complications, and factors related to death were analyzed. The technique consisting of duodenal decompression and jejunal feeding as recommend by the authors were used in severe cases. Results Blunt trauma occurred in 66 of 86 patients (76.7%). The diagnosis of duodenal trauma was made preoperatively based on abdominal signs, peritoneocentesis, and imaging in 32 patients (37.2%). The remaining 54 patients (62.8%), with duodenal injury was detected during emergency laparotomy. All the 86 patients underwent surgical intervention which included simple suturing, pedicled jejunal flap, segmental resection and anastomosis, Roux-en-Y duodenojejunostomy, diverticularization, and Whipple's procedure using the principle of Damage Control Surgery (DCS). Postoperative morbidity occurred in 15 patients (17.4%). There was a high incidence of duodenal (or pancreatic, biliary) fistulae. The overall mortality rate was 12.8% (in 11 patients). The causes of deaths were mainly massive bleeding and poly-trauma. Conclusions To decrease morbidity and mortality rates, early diagnosis and surgical intervention were critical. The choice of surgical treatment procedures should be based on the duodenal trauma grading and whether there were associated injuries. For patients with a combined pancreaticoduodenal trauma, DCS is a wise procedure to adopt. The double-tube gastrostomy technique as recommended by the authors is beneficial to severe cases in decreasing the incidences of postoperative duodenal and jejunal obstruction. Key words: Duodenum; Wounds and injuries; Digestive system surgical procedures; Decompression, Surgical; Enteral nutrition; Postoperative complications

Outcomes and Complications of Double Roux Loop Reconstruction in Pancreaticoduodenectomy: A Single Center Experience

Background: pancreaticoduodenectomy is associated with higher morbidity and mortality rates. The leak of activated pancreatic enzymes can cause several complications which could be life threatening. One of the suggested methods, which can prevent complications, is double Roux anastomosis technique. Objectives: The aim of this study was to evaluate the outcomes and complications of double Roux anastomosis method. Methods: In this prospective study, patients who underwent pancreaticoduodenectomy with double Roux anastomosis were evaluated from 2013 to 2017. The outcomes and complications such as mortality rate, pancreatic leak or fistula, bile leakage, and abscess formation were evaluated. Results: A total of 12 patients were evaluated. The mean age was 53.08 ± 13.43 (19 - 70). Seven of them were male and five were female. Indications of surgery in the patients were periampullary cancer (6 patients), pancreatic head cancer (4 patients), distal cholangiocarcinoma (1 patient) and duodenal trauma (1 patient). There was no mortality, no pancreatic leak or fistula, no hemorrhage, and no abscess in any of the patient. There was one case of the biliary leakage, which was managed expectantly. Conclusions: The results of this study showed that use of separate double Roux, one for the pancreas and the other one for the stomach and bile duct reduces complications and mortality. Although this method requires more anastomosis and the operating time is prolonged, but ultimate outcome of the patient has great effects.

A remote death following Whipple procedure with significant Forensic pathological dilemmas

Whipple procedure is a major surgical operation to remove the head of the pancreas, duodenum, gallbladder and the bile ducts most commonly performed for malignant tumors involving the head of the pancreas and distal bile ducts. It is also performed following pancreatic or duodenal trauma as well as chronic pancreatitis. The outcome depends on numerous factors. There are few recognized complications among which sepsis stands out prominently. The deceased in this case discussion had undergone Whipple procedure within three months after the onset of initial cluster of symptoms. Abdominal pain had been the most prominent symptom he presented with. The surgery was uneventful. The patient had been discharged on the 8th day following surgery. He had been advised to get the wound dressed every other day and visit the clinic in regular intervals. The deceased had not fully complied with the instructions and after observing a purulent discharge from the skin wound, a wound debridement had been done around the fourteenth day post op. The condition had gradually deteriorated since then and the deceased was re-admitted to the same ward on the eighteenth day following the surgery where he succumbed to death due to sepsis with metabolic acidosis. A judicial autopsy was performed following an inquest to exclude any possible allegations of medical negligence. Mild icterus was noted on external examination. Macroscopic features of sepsis with surgical site infection and generalized peritonitis were observed during dissection. Pancreaticojejunal, hepaticojejunal, gastrojejunal and jejunojejunal anastomosing sites were free of features suggestive of leakage. The cause of death was finalized according to the WHO guidelines. 1.a Septicemia, 1.b Whipple procedure and 1.c Distal cholangiocarcinoma. The difficulty in diagnosis of sepsis at autopsy, identification of exact cause of sepsis in a post-surgical death, the significance of objective recording of the grade of surgical site infection and incorporation of surgical procedure in the wording of the cause of death are some of the forensic pathological issues to be addressed in this case. In addition to arriving at a diagnosis of sepsis, a forensic pathologist also owes an obligation to attempt to find out the root cause/causes for sepsis.

Management of duodenal trauma: A retrospective review from the Panamerican Trauma Society.

The operative management of duodenal trauma remains controversial. Our hypothesis is that a simplified operative approach could lead to better outcomes. We conducted an international multicenter study, involving 13 centers. We performed a retrospective review from January 2007 to December of 2016. Data on demographics, mechanism of trauma, blood loss, operative time, and associated injured organs were collected. Outcomes included postoperative intra-abdominal sepsis, leak, need for unplanned surgery, length of stay, renal failure, and mortality. We used the Research Electronic Data Capture tool to store the data. Poisson regression using a backward selection method was used to identify independent predictors of mortality. We collected data of 372 patients with duodenal injuries. Although the duodenal trauma was complex (median Injury Severity Score [ISS], 18 [interquartile range, 2-3]; Abbreviated Injury Scale, 3.5 [3-4]; American Association for the Surgery of Trauma grade, 3 [2-3]), primary repair alone was the most common type of operative management (80%, n = 299). Overall mortality was 24%. On univariate analysis, mortality was associated with male gender, lower admission systolic blood pressure, need for transfusion before operative repair, higher intraoperative blood loss, longer operative time, renal failure requiring renal replacement therapy, higher ISS, and associated pancreatic injury. Poisson regression showed higher ISS, associated pancreatic injury, postoperative renal failure requiring renal replacement therapy, the need for preoperative transfusion, and male gender remained significant predictors of mortality. Duodenal suture line leak was statistically significantly lower, and patients had primary repair over every American Association for the Surgery of Trauma grade of injury. The need for transfusion prior to the operating room, associated pancreatic injuries, and postoperative renal failure are predictors of mortality for patients with duodenal injuries. Primary repair alone is a common and safe operative repair even for complex injuries when feasible. Therapeutic study, level IV.

Primary repair of duodenal injuries: a retrospective cohort study from a major trauma centre in South Africa.

The management of duodenal trauma remains controversial. This retrospective audit of a prospectively maintained database was intended to clarify the operative management of duodenal injury at our institution and to assess the risk factors for leak following primary duodenal repair. This was a retrospective study undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. Operative techniques used for duodenal repair were recorded. Our primary outcome was duodenal leak in the postoperative period. Patients from January 2012 to December 2016 were included. All duodenal injuries were graded according to the American Association for the Surgery of Trauma (AAST) grading. Only patients who had a primary repair were included in the final analysis. During the five-year data collection period, a total of 562 patients underwent a trauma laparotomy; of which 94 patients sustained a duodenal injury. A primary pyloric exclusion and gastro-jejunostomy (PEG) was performed in three patients. These three were then excluded from further analysis. Of the 91 primary duodenal repairs, seven (8%) subsequently leaked. These were managed by PEG in three and by secondary repair and para-duodenal drainage in four. The two physiological parameters most associated with subsequent leak were lactate and pH level. There was a significantly higher mortality rate for those who leaked vs those who did not leak. Chi-squared test revealed a significant difference in the leak rate between AAST I (0%), AAST-II (1.6%) and AAST-3 (66.7%) grade injuries (p <0.01). The trend towards primary repair of duodenal injuries appears to be justified. However duodenal leak remains a significant risk in certain high risk patients and strategies to manage injuries in this subset requires further work.

The spectrum and outcome of blunt trauma related enteric hollow visceral injury.

Introduction This audit focused on patients who sustained enteric injury following blunt abdominal trauma. Methods Our prospectively maintained electronic registry was interrogated retrospectively, and all patients who had sustained blunt abdominal trauma between December 2011 and January 2016 were identified. Results Overall, 2,045 patients had sustained blunt abdominal trauma during the period under review. Seventy per cent were male. The median age was 28 years. Sixty patients (2.9%) sustained a small bowel injury (SBI). Thirty-five of these were peritonitic on presentation. All patients with a SBI had a chest x-ray and free air was present in seven. In 18 patients with a SBI, computed tomography (CT) was performed, which revealed isolated free fluid in 12 and free intraperitoneal air in 5. In five cases, the CT was normal. A total of 32 patients (1.5%) sustained blunt duodenal trauma (BDT). All patients with BDT had a chest x-ray on presentation. Free intraperitoneal air was not present in any. CT was performed on 17 patients with BDT. This revealed isolated free fluid or retroperitoneal air in 12. The median delay between injury and presentation for these enteric injures was 15.5 hours (interquartile range [IQR]: 8-25 hours) while between presentation at hospital and operation, the median delay was 6 hours (IQR: 3-13 hours). Conclusions Blunt trauma related enteric hollow visceral injury remains associated with delayed diagnosis and significant morbidity. It can be caused by a disparate array of mechanisms and is difficult to diagnose even with modern imaging strategies.

ПОВРЕЖДЕНИЯ ДВЕНАДЦАТИПЕРСТНОЙ КИШКИ: ВОПРОСЫ ДИАГНОСТИКИ И ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ

Injuries of the duodenum can arise as a result of the action of a variety of factors and differ by localization and the extent of its damage. Diagnosis of injuries of the duodenum, especially of retroperitoneal ones, is difficult, which requires the use of a comprehensive algorithm for examining the victims. The main method of treatment of duodenal trauma is timely and earliest possible surgical intervention, the nature of which depends both on the etiologic cause of the trauma and anatomical features of the damage to the intestine and adjacent organs.

Penetrating injuries to the duodenum: An analysis of 879 patients from the National Trauma Data Bank, 2010 to 2014.

Despite wide belief that the duodenal Organ Injury Scale has been validated, this has not been reported in the published literature. Based on clinical experience, we hypothesize that the American Association for Surgery of Trauma Organ Injury Scale (AAST-OIS) for duodenal injuries can independently predict mortality. Our objectives were threefold: (1) describe the national profile of penetrating duodenal injuries, (2) identify predictors of morbidity and mortality, and (3) validate the duodenum AAST-OIS as a statistically significant predictor of mortality. Using the Abbreviated Injury Scale 2005 and International Classification of Diseases-9th Rev.-Clinical Modification (ICD-9-CM) E-codes, we identified 879 penetrating duodenal trauma patients from the National Trauma Data Bank between 2010 and 2014. We controlled patient-level covariates of age, biological sex, systolic blood pressure (SBP), Glasgow Coma Scale (GCS) score, pulse, Injury Severity Score (ISS), and Organ Injury Scale (OIS) grade. We estimated multivariable generalized linear mixed models to account for the nesting of patients within trauma centers. Our results indicated an overall mortality rate of 14.4%. Approximately 10% of patients died within 24 hours of admission, of whom 76% died in the first 6 hours. Patients averaged approximately five associated injuries, 45% of which involved the liver and colon. Statistically significant independent predictors of mortality were firearm mechanism, SBP, GCS, pulse, ISS, and AAST-OIS grade. Specifically, odds of death were decreased with 10 mm Hg higher admission SBP (13% decreased odds), one point higher GCS (14.4%), 10-beat lower pulse (8.2%), and 10-point lower ISS (51.0%). This study is the first to report the national profile of penetrating duodenal injuries. Using the National Trauma Data Bank, we identified patterns of injury, predictors of outcome, and validated the AAST-OIS for duodenal injuries as a statistically significant predictor of morbidity and mortality. Epidemiologic/Prognostic, level IV.

Duodenal trauma

Duodenal trauma represents a unique challenge to the surgeon due to its relative rarity, anatomic location, and often the difficulty in diagnosing and managing these injuries. Despite these challenges, significant advances have been made over the previous century, and mortality has fallen to as low as 17%. The CT scan is the primary modality for diagnosis in the blunt trauma patient, and thorough surgical exploration at laparotomy is the mainstay for penetrating injuries. Management is guided by the grade of injury, with low-grade hematomas managed by observation, intermediate grade injuries by primary repair, and high-grade injuries with a damage control surgery approach. While pyloric exclusion remains the most common technique to augment primary repair in intermediate and higher grade injuries, the utility of this procedure has come into question in current literature, and an overall ‘less-is-more’ surgical approach has been advocated in recent publications. Complications following duodenal trauma are common and include fistulae, duodenal obstruction, and infectious complications. However, the overall morbidity and mortality have improved with these injuries. Future investigation is needed to determine the optimal management approach for these challenging patients.

Duodenal Trauma: Incidence and Management in Penetrating and Blunt Abdominal Trauma

ABSTRACT Rationale Duodenal injuries are rare and most common due to penetrating abdominal trauma, especially gunshot wounds, with greatest prevalence among young men. Achieving simpler and more effective surgical procedures also contributes to the reduction of mortality and morbidity rates. Objective Review cases of penetrating and blunt duodenal trauma, the complexity of the injuries, incidence, management as well as morbidity and mortality. Materials and methods At Grajaú General Hospital, between January 2010 and May 2014, a retrospective analysis of 1,039 patients’ medical records who had undergone emergency exploratory laparotomies was done. From these cases, 298 were caused by blunt and penetrating abdominal traumas, and 11 suffered duodenal traumas. Results It was observed that there was a predominance of young adults (mean age 26.48 years) and all patients were males (100%), of which one injury was from blunt abdominal trauma, three from stab wounds, and seven caused by firearm. Most of the duodenal injuries were classified as grade II injuries and most commonly involved the fourth portion of the duodenum. We emphasize the association with injuries to other organs, especially the liver and the small intestine. In the cases we analyzed, we highlight the importance of time between entry of service and surgery in all patients being less than 6 hours. The most common surgery performed to repair these injuries was duodenorrhaphy (90.9%). In this series, there were four deaths. Postoperative complications included duodenal fistulae with spontaneous resolution. Conclusion Duodenal injuries are rare, and are most commonly due to penetrating abdominal trauma, especially gunshot wounds, with the greatest prevalence among young men. There is a need for early diagnosis and rapid surgical intervention, shortened and effective surgical procedures, due to the morbidity/mortality and high complexity of these injuries. This emphasizes the importance of early intervention in the short time before surgical procedure takes place. How to cite this article Ribeiro MAF Jr, Rosa OM, Filho OC, Santin S, Fonseca AZ, Alvarez BE, Parra MW. Duodenal Trauma: Incidence and Management in Penetrating and Blunt Abdominal Trauma. Panam J Trauma Crit Care Emerg Surg 2017;6(1):13-16.

Review of Pancreaticoduodenal Trauma with a Case Report.

Complex anatomical relation of the duodenum, pancreas, biliary tract, and major vessels plays to obscure pancreaticoduodenal injuries. Causes of pancreaticoduodenal injuries are blunt trauma (traffic accidents, sport injuries) in 25% of cases and penetrating abdominal injuries (stab wounds and firearm injuries) in 75% of cases. Duodenal injuries are reported to occur in 0.5 to 5% of all abdominal trauma cases and are observed in 11% of abdominal firearm wounds, 1.6% of abdominal stab wounds, and 6% of blunt trauma. Retroperitoneal and deep abdominal localization of duodenum as an organ contribute to the difficulty in diagnosis and treatment. There are three important major points regarding treatment of duodenal injuries: (1) operation timing and decision, (2) Intraoperative detection, and (3) post-operative care. Therefore, it is difficult to diagnose and treat duodenal trauma. We would like to present a 21-year-old male patient with pancreaticoduodenal injury who presented to our emergency service after firearm injury to his abdomen and discuss his treatment with a short review of related literature.

Pancreatic and Duodenal Trauma in Children.

Trauma is the leading cause of death in children of all ages. The most common site of injury in pediatric patients is the head followed by the extremities and the abdomen. Though less than 10% of admissions to the hospital are secondary to intra-abdominal injuries, mortality related to these injuries is not insignificant. Pancreatic and duodenal trauma occurs in 3 to 12% of the patients with abdominal injuries and can be associated with significant morbidity. The management of pancreatic and duodenal trauma in children is based mostly on adult data, but there is an increasing volume of research on the subject.

Pancreatico duodenectomy for pediatric combined duodenal, pancreatic and biliary trauma

Pancreaticoduodenal trauma in children is uncommon but carries high morbidity and mortality rates, especially when the diagnosis is delayed. A case of combined pancreatico duodenal and bile duct injury following blunt abdominal trauma is described which presented two days after injury. It highlights the extremes of surgical procedures that may be needed in massive blunt trauma.

Duodenal Injuries Due to Trauma: Review of the Literature

Duodenal injuries constitute a challenge to the trauma surgeon, mainly due to their retroperitoneal location. When identified, they present associated with other abdominal injuries. Consequently, they have an increased morbidity and mortality. At best estimates, duodenal lesions occur in 4.3% of all patients with abdominal injuries, ranging from 3.7% to 5%, and because of their anatomical proximity to other organs, they are rarely an isolated injury. The aim of this paper is to present a concise description of the anatomy, diagnosis, surgical management and treatment of complications of duodenal trauma, and an analysis of complications and mortality rates of duodenal injuries based on a 46-year review of the literature.

Isolated Duodenal Trauma following Cricket Ball Injury

ABSTRACTA fifteen years old boy presented to the emergency department with blunt trauma abdomen following cricket ball injury. At the time of presentation, patient was hemodynamically stable with diffuse abdominal tenderness and right hypochondrial guarding. On exploratory laparotomy, he was found to have isolated duodenal laceration and underwent pancreas preserving total duodenectomy with ampullojejunostomy. In the postoperative period, patient developed fever with respiratory tract infection and eventually succumbed to multiorgan dysfunction. To the best of our knowledge, this is the first case report describing isolated duodenal injury resulting from blunt abdominal trauma due to cricket ball.How to cite this articleKrishnamurthy G, Kumar H, Das R, Gupta R. Isolated Duodenal Trauma following Cricket Ball Injury. J Postgrad Med Edu Res 2015;49(4):213-215.

Хирургическая тактика при закрытой дуоденальной травме

Relevance Among closed injuries of the abdominal cavity trauma duodenum (KDP) holds a special place due to the rare, large traumatic severe complications in 50-70% of operated patients. To date, there is a high mortality rate (30 to 60%) due to develop complications and failure at the seams or phlegmon - up to 100%. The purpose of the study The aim of the study was choice of the method of surgical treatment and analysis results of surgical treatment in patients with closed trauma of the KDP. Materials and methods The paper analyzes results of treatment 35 patients with a closed duodenal injury. The most common cause of damage KDP was closed to road traffic injury (17 pers. - 48.6%), resulting in katatravmy in 6 (17.1%) patients. In 5 (14.3%) patients injury was received in the workplace, in 1 - sports injury in 6 - home injury. Results and their discussion Depending on the timing of the victims to the hospital after the injury, the size of the defect duodenal wall, level of injury, associated injuries pancreatoduodenal zone defines the principles of surgical treatment for injuries of the duodenum. For the prevention and treatment of retroperitoneal phlegmon used 5% glucose solution ozonated, which reduced the number of complications from 52.3% in the control group to 33.3% - in the main group and reduced the risk of an adverse outcome, ie, reduce mortality C60% to 33.3%. Conclusion 1. The volume of surgery at closed duodenal injury must be selected individually, depending on the severity of the injury and status of victim. 2. In the postoperative period is mandatory drug suppression of secretion digestive tract and the appointment of broad-spectrum antibiotics against background of infusion-transfusion therapy. Key words Closed duodenal trauma, surgical technique, complications, mortality

Lesiones duodenales secundarias a traumatismo: revisión de la literatura

Duodenal injuries constitute a challenge to the Trauma Surgeon, mainly due to their retroperitoneal location. When identified, they present associated with other abdominal injuries. Consequently, they have an increased morbidity and mortality. At best estimates, duodenal lesions occur in 4.3% of all patients with abdominal injuries, ranging from 3.7% to 5%, and because of their anatomical proximity to other organs, they are rarely an isolated injury. The aim of this paper is to present a concise description of the anatomy, diagnosis, surgical management and treatment of complications of duodenal trauma, and an analysis of complications and mortality rates of duodenal injuries based on a 46-year review of the literature.

Is there a role for pyloric exclusion after severe duodenal trauma?

Duodenal trauma is an infrequent injury, but linked to high morbidity and mortality. Surgical management of duodenal injuries is dictated by: patient's hemodynamic status, injury severity, time of diagnosis, and presence of concomitant injuries. Even though most cases can be treated with primary repair, some experts advocate adjuvant procedures. Pyloric exclusion (PE) has emerged as an ancillary method to protect suture repair in more complex injuries. However, the effectiveness of this procedure is debatable. The "Evidence Based Telemedicine - Trauma & Acute Care Surgery" (EBT-TACS) Journal Club performed a critical appraisal of the literature and selected three relevant publications on the indications for PE in duodenal trauma. The first study retrospectively compared 14 cases of duodenal injuries greater than grade II treated by PE, with 15 cases repaired primarily, all of which penetrating. Results showed that PE did not improve outcome. The second study, also retrospective, compared primary repair (34 cases) with PE (16 cases) in blunt and penetrating grade > II duodenal injuries. The authors concluded that PE was not necessary in all cases. The third was a literature review on the management of challenging duodenal traumas. The author of that study concluded that PE is indicated for anastomotic leak management after gastrojejunostomies. In conclusion, the choice of the surgical procedure to treat duodenal injuries should be individualized. Moreover, there is insufficient high quality scientific evidence to support the abandonment of PE in severe duodenal injuries with extensive tissue loss.