Dr. Chow Chi Woo Samuel

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Management of Duodenal Trauma

• Dr. Chow Chi Woo Samuel
• Department of Surgery, Queen Elizabeth Hospital

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Introduction

• Duodenal trauma is uncommon
• 3-5
• D2 most common (35)
• gt D3 gt D4 gt D1
• Penetrating trauma (78)
• Gunshot wounds
• Stab wounds
• Blunt trauma (22)
• Motor vehicle collisions
• Steering wheel
• Seatbelt
• Bicycle handle (paediatrics)

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Introduction

• Associated injuries are common
• Liver
• Pancreas
• Bowel
• Major vessels
• High mortality (17)
• High morbidity (40)
• Duodenal fistula (7)

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Diagnosis

• High index of suspicion
• Symptoms/signs usually not helpful

Penetrating trauma Intra-operative features 1.
Bile staining at retroperitoneum 2. Periduodenal
hematoma 3. Periduodenal crepitus
Blunt trauma Radiological Imaging 1. X-ray 2.
CT scan (IV oral contrast) 3. Fluoroscopy
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Management

• Disease factors
• 1. Severity of injury
• 2. Associated injuries

• Patient factors
• 1. Hemodynamic stability

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Grading of Severity

• Duodenum Organ Injury Scale (OIS) according to
  The American Association for the Surgery of
  Trauma (AAST)

Grade Description Description
I Hematoma Laceration 1 portion of duodenum Partial thickness, no perforation
II Hematoma Laceration gt1 portion of duodenum lt 50 of circumference
III Laceration 50-75 of circumference of D2 50-100 of circumference of D1, 3, 4
IV Laceration gt75 of circumference of D2 Involve ampulla or distal CBD
V Laceration Vascular Duodenopancreatic complex Devascularization of duodenum
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Damage control Control hemorrhage Provisional
repair Temporary abdominal closure ICU
resuscitation
Operative
Unstable
Delayed repair
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Stable
1. Hemorrhage control 2. Decontamination 3.
Repair Associated injuries
Penetrating
Operative
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Non-operative
Intramural hematoma
Blunt
Equivocal
CT scan
Perforation
Stable
1. Hemorrhage control 2. Decontamination 3.
Repair Associated injuries
Operative
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Repair

• Aim
• Close the defect
• Restore continuity
• Always ascertain location of ampulla (D2)
• Options
• Duodenorrhaphy
• Duodenorrhaphy diversion
• Duodenal resection anastomosis
• Jejunal serosal patch
• Pedicled graft
• Whipple operation

Simple
Complex
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Duodenorrhaphy

• 75-85 of duodenal injuries
• Debride non-viable tissue
• Tension-free repair
• Single/double layer closure
• Transverse closure
• lt 50 of circumference

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Duodenorrhaphy Diversion

• Indication
• High risk of suture line dehiscence
• Delayed injury
• Large defect
• Combined injury
• Aim
• Divert gastric secretions
• Promote healing
• Options
• Tube decompression
• Pyloric exclusion
• Duodenal diverticulization

Simple
Complex
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Tube decompression

• External diversion

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Pyloric exclusion

• Internal diversion

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Duodenal Resection Anastomosis

• Large duodenal defects (near-circumferential)
• Duodenal transections
• Segmental resection with end-to-end duodenostomy
• Adequate mobilization, tension-free

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• Antrectomy closure of duodenal stump
  side-to-side gastrojejunostomy
• Inadequate mobilization
• Proximal to ampulla
• Closure of duodenal stump end-to-end
  duodenojejunostomy
• Inadequate mobilization
• Distal to ampulla

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Which repair is the best?
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Which repair is the best?
Low grade injuries
Duodenorrhaphy
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Which repair is the best?
High grade injuries
1. Involve CBD/pancreas 2. Devascularization
Repairable
Non-repairable
1. Damage Control Surgery delayed
reconstruction 2. Duodenorrhaphy diversion
wide drainage Delayed reconstruction 1.
Reimplantation of CBD 2. Hepaticojejunostomy 3.
Whipple operation
1. Duodenorrhaphy diversion 2. Duodenorrhaphy
1. Duodenal Resection anastomosis 2. Jejunal
serosal patch 3. Pedicled graft
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High grade repairable injuries

• Optimal repair remains debatable
• Duodenorrhaphy pyloric exclusion
• Classically recommended (Vaughan, Degiannis,
  Cogbill)
• Problems
• Increased operative time and hospital stay, extra
  anastomosis, suture line ulcers
• Role downplayed (Seamon)
• Duodenorrhaphy tube decompression
• Controversial (Stone, Hasson, Ivatury, Girgin)
• Problems
• Increased hospital stay, dislodgement,
  obstruction
• Duodenorrhaphy
• Gaining popularity (DuBose, Velmahos, Siboni)
• Concept of less is better

Pyloric exclusion
Duodenorrhaphy
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What else

• Feeding jejunostomy
• Early enteral nutrition
• Periduodenal drains
• Closed suction drain
• Controlled fistula
• No level I evidence
• Surgeon preference

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Summary

• Duodenal trauma is DEADLY and requires a HIGH
  INDEX OF SUSPICION for diagnosis
• Management depends on HEMODYNAMICS, INJURY
  SEVERITY and ASSOCIATED INJURIES
• DUODENORRHAPHY is good enough for most injuries
  keep it simple, but consider DIVERSION when in
  doubt
• Never forget DAMAGE CONTROL

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References

1. Vaughan GD, Frazier OH, Graham DY, et al.. The
   use of pyloric exclusion in the management of
   severe duodenal injuries. Am J Surg.
   1977134(6)785-90.
2. Degiannis E, Krawczykowski D, Velmahos GC, et al.
   Pyloric exclusion in severe penetrating injuries
   of the duodenum. World J Surg. 199317(6)751-4
3. Cogbill T H, Moore E E, Feliciano D V. et al.
   Conservative management of duodenal trauma a
   multicenter perspective. J Trauma.
   (1990)3014691475.
4. Seamon MJ, Pieri PG, Fisher CA, et al. A ten-year
   retrospective review does pyloric exclusion
   improve clinical outcome after penetrating
   duodenal and combined pancreaticoduodenal
   injuries? J Trauma. 200762(4)829-33.Stone HH,
   Fabian TC. Management of duodenal wounds. J
   Trauma 197919334-9
5. Hasson JE, Stern D, Moss GS. Penetrating duodenal
   trauma. J Trauma. 1984 Jun24(6)471474.
6. Ivatury RR, Gaudino J, Ascer E, et al. Treatment
   of penetrating duodenal injuries primary repair
   vs. repair with decompressive enter-
   ostomy/serosal patch. J Trauma 198525337-41
7. Girgin S, Gedik E, Yagmur Y, et al. Management of
   duodenal injury our experience and the value of
   tube duodenostomy. Ulus Travma Acil Cerrahi Derg.
   200915467-72.
8. Siboni S, Benjamin E, Haltmeier T, et al.
   Isolated Blunt Duodenal Trauma Simple Repair,
   Low Mortality. Am Surg. 2015 Oct81(10)961-4
9. Velmahos GC,Constantinou C,Kasotakis G. Safety of
   repair for severe duodenal injuries. World J Surg
   2008327-12.
10. DuBose JJ, Inaba K, Teixeira PG, et al. Pyloric
    exclusion in the treatment of severe duodenal
    injuries results from the National Trauma Data
    Bank. Am Surg. 2008749259.
11. Ivatury RR, Malhotra AK, Aboutanos MB, et al.
    Duodenal Injuries A Review. Eur J Trauma Emerg
    Surg 200733231-7
12. Ordoñez C, García A, Parra MW, et al. Complex
    penetrating duodenal injuries less is better. J
    Trauma Acute Care Surg. 201476(5)1177-83.

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Question Time
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Radiological Imaging
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Less is better

• Damage control approach
• Duodenorrhaphy is advocated for high grade
  injuries
• Siboni et al. 2015
• 2220 patients with isolated blunt duodenal
  injuries
• No difference in mortality and sepsis
• Shorter hospital stay
• Velmahos et al. 2008
• 50 patients with severe duodenal injuries
• No difference in morbidity/mortality/ICU/hospital
  stay
• DuBose et al. 2008
• 147 patients with severe duodenal injuries
• No difference in survival/outcome
• Shorter hospital stay
• Role of pyloric exclusion downplayed
• Seamon et al. 2007
• 29 patients with duodenal injuries II
• Greater complication rate, pancreatic fistula
  rate and increased hospital stay

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Duodenum

• 25-30cm (12 fingerbreaths)
• 4 parts
• 1st (Superior)
• 2nd (Descending)
• Bile/pancreatic duct opening
• 3rd (Transverse)
• Mesenteric vessels
• 4th (Ascending)
• Retroperitoneal
• Exception 1st part 2cm
• Complex anatomical relations

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• Blood supply
• Arterial
• Pancreaticoduodenal artery
• Superior (GDA)
• Inferior (SMA)
• Retroduodenal artery
• Supraduodenal artery
• Venous
• Posterosuperior arcade ? portal vein
• Anteroinferior arcade ? SMV
• Physiology
• Conduit for mixing of gastric juice/bile/pancreati
  c secretions
• 10L/day

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Fluoroscopic studies

• Gastrograffin/barium follow through
• Features
• Leakage of contrast
• Stacked coin sign (intramural hematoma)
• Limitation
• Timaran CH et al.
• Sensitivity 54, specificity 98
• Difficult to interpret

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Delayed treatment

• Complex duodenal injury
• Inflammed and unhealthy tissue
• Retroperitoneal abscess
• Drainage of abscess
• Retroperitoneal laparostomy
• Pyloric exclusion duodenostomy
• Controlled fistula
• Feeding jejunostomy

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Non-operative
Intramural hematoma
Stable
CT scan
Perforation
Operative
Reconstruction
Blunt Injury
Unstable
Operative
Damage control
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Management Algorithm
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Intramural hematoma

• More common in children
• Obstruction within 48 hours
• Coiled spring/stacked coin sign
• NG tube suction TPN
• Desai et al
• Success rate 89
• Czyrko et al
• Success rate 83
• Failed conservative (2-3 weeks) ? exploration

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Intramural hematoma

• If detected intra-operatively
• Evacuate hematoma and repair wall
• Partial tear ? full thickness tear
• Explore and exclude perforation, leave hematoma
  intact, nasogastric tube suction

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Morbidity

• Asensio et al.
• Duodenal fistula
• 7
• Intra-abdominal abscess
• 11-18
• Pancreatitis
• 3-15
• Duodenal obstruction
• 1-2
• Bile duct fistula
• 1

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Mortality

• Overall
• 17
• Disease-specific
• 6.5-12.5
• Risk factors
• Delayed diagnosis
• Associated injuries

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Jejunal Serosal Patch
Pedicled graft

• Buttress duodenal defect with serosa of jejunum
• Large defects
• Unproven efficacy

• Graft
• Jejunum
• Vascular pedicle
• Large defects
• Unproven efficacy

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Grading of Severity

• Duodenal Severity Scale

Mild Severe
Determinants of injury severity Determinants of injury severity Determinants of injury severity
Agent Stab Blunt/Missile
Size lt75 wall 75 wall
Duodenal site 3, 4 1, 2
Injury-repair interval (hr) lt24 24
Adjacent Injury No CBD No pancreatic injury CBD Pancreatic injury
Outcome Outcome Outcome
Mortality 0 6
Morbidity 2 10
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Plain radiograph

• Retroperitoneal gas
• Free gas under diaphragm
• Obliteration of right psoas muscle

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Computerized Tomography

• Contrast extravasation
• Pneumoperitoneum
• Retroperitoneal hematoma
• Unusual bowel morphology
• Unexplained periduodenal fluid

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Computerized Tomography

• Mainstay of evaluation for blunt trauma
• Limitations
• Allen et al.
• Diagnostic delay in 20
• Ballard et al
• Diagnostic delay in 27
• Importance of re-evaluation CT or exploration

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Operative Exposure
Laparotomy
Kocher Maneuver
Transection of Ligament of Treitz
Cattel and Braasch Maneuver
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Whipple procedure

• Pancreatico-duodenectomy
• Indications
• Uncontrolled peripancreatic hemorrhage
• Extensive injury to proximal pancreatic duct,
  distal common bile duct and ampulla
• Combined devascularizing injuries to duodenum and
  head of pancreas
• High mortality rate
• Velmahos et al
• 33
• 2-stage vs 1-stage

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Jejunal Serosal Patch
Pedicled graft
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Duodenal diverticulization

• Berne 1968
• Procedure
• Duodenorrhaphy
• Gastric antrectomy
• Vagotomy
• Tube duodenostomy
• T-tube common bile duct drainage
• End-to-side gastrojejunostomy
• Complicated
• Out-of-date

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Damage control

• Hemorrhage control
• Provisional repair
• closure of perforation
• resection without anastomosis
• Temporary abdominal closure
• Intensive care unit resuscitation