Complex Duodenal Injuries

Abstract

Most duodenal injuries are due to penetrating trauma, usually gunshot wounds. In penetrating trauma, there are often multiple associated abdominal injuries and are more likely to prompt immediate surgical exploration, and the diagnosis is usually made intraoperatively. In blunt trauma, the injury often involves the retroperitoneal part of the duodenum, and the initial clinical examination may be unreliable due to subtle signs. Computed tomography with intravenous contrast and in the appropriate cases with oral contrast, remains the cornerstone of diagnosis of blunt duodenal injuries. Prompt diagnosis and surgical intervention are critically important for patients with duodenal trauma. Delay of the operation increases serious complications and mortality. Exposure and repair of the duodenal injury may need a Kocher or Cattell–Braasch maneuver, depending on the anatomical site of the injury. In minor or moderate severity injuries of the duodenum, debridement to healthy tissues and simple, tension-free primary repair is the procedure of choice. The current trend in the management of severe duodenal injuries favors an approach with simpler techniques and avoidance of complex procedures, such as pyloric exclusion or major resections. In very rare cases with destructive injuries to the duodenum or in the presence of severe associated trauma to the head of the pancreas, a pancreaticoduodenectomy (Whipple procedure) may be needed. In the presence of severe hemodynamic instability, a damage control operation during the index surgery and definitive reconstruction at a second semi-elective operation, after patient stabilization, should be considered.