EL-MINIA MED. BULL. VOL. 22, NO. 1, JAN., 2011
Wagdy et al
DUODENAL INJURIES: 60 CASES IN 7 YEARS IN THREE
LARGE SURGICAL CENTERS
By
Mohammed Ashraf Wagdy, Abd El-Fatah Saleh Abd El-Fatah Abo Zeid,
and Emad El-Deen Mohamed El-Sager Osman
Department of General Surgery, Al-Minia University
ABSTRACT:
Objective: To evaluate underlying mechanisms, diagnosis, management and final
outcome of duodenal injuries over a period of 7 years.
Patients and methods: The study done in 3 different centers, between 2002 and 2009.
Laparotomy was the surest diagnostic tool when duodenal injuries were suspected.
Cattle-Braach technique allowed full exposure of the whole viscus. exploratory
laparotomy was mandatory for associated intra-abdominal injuries. Primary repair of
the duodenum after debridement of the perforation edges was possible. The author
favors pyloric exclusion.
Results: The study included 60 patients, 29(38.3%) males and 31(51.6%) were
females. Most patients (39 cases; 65%) had duodenal injuries by penetrating trauma.
The second part of duodenum was the most commonly injuried (38 cases; 63.3%).
The most common operative procedure performed was primary repair (83.3%). The
mortality rate was 30% (18 patients).
Conclusion: Exploratory laparotomy remains as the ultimate diagnostic test for
duodenal traumatic injuries. Surgical management is variable.
KEYWORDS:
Duodenal injury
Surgical management.
Trauma
In this study, the underlying
mechanism of duodenal injuries, the
diagnosis, the management and the
final outcome are all discussed.
INTRODUCTION:
Because of its retroperitoneal
location, injuries to the duodenum are
relatively uncommon, occurring in
only 3 to 5% of all abdominal
injuries1,2. It is associated with high
mortality and morbidity especially
when missed for more than 24 hours3.
PATIENTS AND METHODS:
This study has been performed
in 3 different centers, Al Helal hospital
in Cairo, Al Agouza hospital in Giza
and Al-Minia University hospital in the
period between 2002 and 2009.
The majority of duodenal
injuries are caused by penetrating
trauma that requires immediate
exploratory laparotomy4. The vast
majority of duodenal injuries can be
managed by simple repair2. Early
diagnosis and appropriate surgical
repair are the keys to good outcome
and improved survival5.
Diagnosis of duodenal injuries
was generally made during laparotomy,
however, a clinical index of suspicion
was based on the epigastric or right
hypochondrial pain and tenderness. A
plain X-ray may show obliteration of
the right psoas shadow or the presence
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EL-MINIA MED. BULL. VOL. 22, NO. 1, JAN., 2011
of air under diaphragm. CT scan with
contrast may show contrast leakage,
however, CT scan was negative in
many cases (9 cases). The use of DPL
was useful for associated injuries (e.g.
liver) but not conclusive in duodenal
injuries. Laparotomy was the surest
diagnostic tool when duodenal injuries
were
suspected
when
central
retroperitoneal air, blood or bile was
present. This mandated full mobilezation of the duodenum, Kocher’s
maneuver only expose the second part
of the duodenum while Cattle-Braach
technique allowed full exposure of the
whole viscus in order not to miss a
hidden
duodenal
injury
which
happened in 2 cases. Moreover, the last
technique was helpful in complex
pancreatic duodenal injuries.
Wagdy et al
A diversion procedure is
mandatory to protect the site of repair
till healing becomes complete. The
author favors pyloric exclusion more
than duodenal diverticularization, the
former being easy, quick and more
physiologic for diversion of the gastric
secretions away from the site of the
injury. As described previously by
Vaughn6, through gastrotomy the
pyloric inlet was closed by 3
concentric purse strings Vicryl sutures
or by stapling and the gastrotomy
incision was for gastrojejunostomy.
The pyloric inlet reopens again within
2 weeks up to 2 months, with no need
for vagotomy.
RESULTS:
The study included 60 patients
of variable sex and age, 29 (38.3%)
were males and 31 (51.6%) were
females [Table 1]. All age groups were
involved: 10 children (5-10 years old),
12 teenagers (11-19 years old), 20
young adults (20-30 years old), 11
adults (31-49 years old), and the
remaining 7 patients were 50 years old
or more [Table 1].
Not all duodenal injuries were
managed similarly. The operator had
the remedial surgical procedures
accordingly. In cases with intramural
duodenal
hematoma,
exploratory
laparotomy was mandatory for
associated intra-abdominal injuries
through which careful exploration of
the duodenum was done through a
distant duodenotomy to be sure no
perforation occurred followed by
nasogastric
decompression
postoperatively.
Most patients (39 cases; 65%)
had duodenal injuries by penetrating
trauma due to stabs (23 cases; 38.3%)
and gunshots (16 cases; 26.6%) [Table
2]. Only 4 cases (6.6%) of duodenal
injuries were iatrogenic during E.R.C.P.
On the other hand, 17 cases (28.3%) of
duodenal injuries were due to blunt
trauma, as a result of falling from
height (7 cases; 11.6%), a blow or kick
to the epigastric (3 cases; 4.9%), runover accidents (4 cases; 6.6%), lap belt
injury (2 cases; 3.3%), handlebars of
bicycle (1 case; 1.6%) [Table 2].
The author think duodenotmy
directly into the site of hematoma is
not only confusing but also fear of
conversion of a partial tear into a full
thickness tear. Primary repair of the
duodenum after debridement of the
perforation edges was possible, and it
was performed in either single or
double layers using absorbable sutures
and external drainage was done
through a simple soft silicone suction
drain that placed not in direct contact
with suture line.
The second part of duodenum
was the most commonly injuried (38
cases; 63.3%) due to its easy compressi-
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EL-MINIA MED. BULL. VOL. 22, NO. 1, JAN., 2011
bility. They rarely occur as isolated
injuries. Most injuries associated with
other organ injuries: liver (12 cases),
pancreas (10 cases), small bowel (9
cases), colon (4 cases) and vascular
injuries involving I.V.C, portal vein and
aorta (7 cases) [Table 3].
Wagdy et al
In one of these 2 cases debridement
and primary repair without tension was
possible, while in the other case the
distal duodenum stump was closed and
the proximal was anastomosed by a
Roux-en Y duodenojejunostomy.
In this study, the mortality rate
was 30% (18 patients). Eight patients
succumbed either intra or shortly
postoperatively, and 10 patients died
due to uncontrolled sepsis and
associated intra or extra abdominal
injuries (e.g. head injuries, chest
injuries). The dismal outcome is
essentially related to: 1) associated
pancreatic injury; 2) involvement of
more than 75% of the duodenal
circumference; 3) gunshot injuries
more than blunt injuries or penetrating
stabs; 4) associated common bile duct
injuries; 5) injury to the first and
second part of duodenum more than
injury of 3rd and 4th parts; and 6)
missed duodenal injuries for more than
24 hours.
Intramural duodenal hematoma
was found in 5 pediatric cases (8.3%),
either due to child abuse (2 cases) or
handle bars injuries during cycling (3
cases). In these cases, a distant
duodenotomy was done for exploration
only without a duodenal procedure
followed by nasogastric decompression
postoperatively. Primary repair was
done in 50 cases (83.3%) [Table 4].
Three patients (5%) died during
laparotomy with incomplete surgical
intervention. In one case, we were
obliged to do pancreaticoduodenectomy when massive combined
injuries to the duodenum and head of
pancreas. In 2 cases, complete
transection of the duodenum was found.
Table 1: Patient characteristics
No. of patients
Percentage
29
31
38.3%
51.6%
10
12
20
11
7
16.67%
20%
33.33%
18.33%
11.67%
Sex:
Male
Female
Age:
Children (5-10 years)
Teenagers (11-19 years)
Young adults (20-30 years)
Adults (31-49 years)
More than 50 years
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EL-MINIA MED. BULL. VOL. 22, NO. 1, JAN., 2011
Wagdy et al
Table 2: Modes of duodenal injury
Penetrating trauma
Stabs
Gunshots
Iatrogenic during E.R.C.P
Blunt trauma
Falling from height
Blow or kick to the epigastric
Run-over accidents
Lap belt injury
Handlebars of bicycle
No. of patients
39
23
16
4
17
7
3
4
2
1
Percentage
65%
38.3%
26.6%
6.6%
28.3%
11.6%
4.9%
6.6%
3.3%
1.6%
No. of patients
12
10
9
4
7
Percentage
20%
16.67%
15%
6.67%
11.67%
No. of patients
5
50
1
1
3
Percentage
8.3%
83.3%
1.6%
1.6%
5%
Table 3: Associated other organ injuries
Liver
Pancreas
Small bowel
Colon
Vascular injuries
Table 4: Types of surgical procedures
No duodenal procedure
Primary repair
Pancreaticoduodenectomy
Roux-en Y duodenojejunostomy
Died intraoperatively
penetrating injuries. This is consistent
with other studies carried out
previously9,10. Blunt injury of the
duodenum is both less common and
difficult to diagnose than penetrating
injury. It usually occurs from crushing
of the duodenum between spine and
steering wheel, handlebar or some
other force applied to the anterior
aspect of the abdomen11. In this study,
the most common segment of
duodenum injured was second part due
DISCUSSION:
Duodenal injuries are rare1,2,
and collection of data regarding
incidence and management is time
consuming, in this study we share our
surgical experience of 60 consecutive
cases over period of 7 years. Most of
patients in our study was males with
common age group between 21 and 30
years old, as in other studies on
trauma7,8. The leading cause of
duodenal trauma in current study was
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EL-MINIA MED. BULL. VOL. 22, NO. 1, JAN., 2011
to its easy compressibility. This is in
accordance to previous reports9,12.
Wagdy et al
curred. Many authors have advocated
the use of pyloric exclusion and have
considered it to be the procedure of
choice for patients with severe
duodenal trauma 17-19.
The management of duodenal
injuries remains controversial, and this
field lacks a consensus regarding what
the optimal treatment should be. In our
study, the primary repair was
performed in 83.3% of cases. This is
agreed with data in literature as
approximately 70% to 85% of all
duodenal injuries can be repaired
safely by primary repair2,13,14. Patients
with severe duodenal injuries should
be considered candidates for more
complex duodenal repairs. However,
there is no clear definition regarding
when these procedures should be
indicated and which duodenal injuries
should be considered severe. Certain
factors may lead surgeons to consider
an injury severe and order a complex
procedure, including blunt trauma or
bullet wounds, delay to repairs
exceeding 24 hours, injury of the first
or second portions of the duodenum,
duodenal injuries of AAST-OIS grade
≥ III, associated injuries to the
pancreas or common bile duct (or both)
and compromised blood supply to the
duodenum 13,15,16.
The mortality rate in our study
was 30%. This is in upper limit of the
range reported in literature by Cogbill
et al.13, and others9,20, ranging from 1030% and can be attributed to severe
duodenal or associated injuries,
delayed
hospitalization
due
to
unapparent clinical feature particularly
in cases of blunt trauma, or
presentation in shock, peri-operataive
sepsis and organ failure, and not
particularly procedure related.
In conclusion, the duodenal
trauma is an uncommon injury
associated with
the
significant
morbidity and mortality. Their
detection can be challenging due to the
retroperitoneal location. Exploratory
laparotomy remains as the ultimate
diagnostic test, even in the face of
absent or equivocal radiographic signs.
Treatment of injured duodenum varies,
according to severity of injury, degree
of contamination of the peritoneal
cavity, associated organs injury and
duration before diagnosis. Detailed
knowledge of the available operative
choices and their correct application is
important. Therefore early diagnosis
and appropriate surgical repair are the
keys to good outcome and improved
survival.
In this study, we favor the use
of pyloric exclusion rather than the use
of diverticulization which is much
more complex and time consuming as
it involves primary repair of the
duodenal wound, vagotomy, antrectomy and end-to-side gastrojejunostomy (Billroth II) and T-tube drainage
of the common bile duct to completely
divert gastric and biliary contents away
from the repaired duodenum. The
decision to use pyloric exclusion to
repair a duodenal injury is multifactorial. This procedure appears to offer
the best combination of limited surgery
in cases of severely injured patients,
with effective exclusion of the
duodenum until after healing has oc-
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Ospina JA. Prognostic factors and
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Trauma.
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15- Weigelt JA. Duodenal injuries.
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‫‪EL-MINIA MED. BULL. VOL. 22, NO. 1, JAN., 2011‬‬
‫إصابات االثنى عشر‪ :‬تقييم ‪ 60‬حالة في ‪ 3‬مراكز جراحية كبرى خالل ‪ 7‬سنوات‬
‫محمد أشرف وجدى و عبد الفتاح صالح عبد الفتاح و عماد الدين محمد الصغير‬
‫الهدف ‪:‬‬
‫أجريت هذه الدراسة لتقييم اآلليات الكامنة‪ ،‬والتشخيص‪ ،‬والعالج‪ ،‬والنتيجة النهائية إلصابات‬
‫االثني عشر خالل فترة ‪ 7‬سنوات‬
‫المرضى واألدوات ‪:‬‬
‫أجريت الدراسة في ‪ 3‬مراكزجراحية مختلفة ‪ ،‬بين عامي ‪ 2002‬و ‪ .2009‬كان استكشاف‬
‫البطن أضمن أداة تشخيصية عند وجود اشتباه إصابات باالثنى عشر‪ .‬وكان غلق الجرح أوليا‬
‫بعد التنضير من حواف الثقب ممكناً‪.‬‬
‫النتائج ‪:‬‬
‫شملت الدراسة ‪ 60‬مريضا‪ )٪ 38.3( 29 ،‬من الذكور و ‪ )٪ 51.6( 31‬من اإلناث‪ ،‬ومعظم‬
‫المرضى (‪ 39 ٪ 65‬حالة) كان يعاني من إصابة االثنى عشر الناتجة عن أدوات حادة‪ .‬وكانت‬
‫إصابة الجزء الثاني من االثني عشر األكثر شيوعا( ‪ 38‬حالة ؛ ‪ .)٪ 63.3‬وكان اإلجراء األكثر‬
‫شيوعا المنطوق إجراء الترميم األولى للجروح (‪ .)٪ 83.3‬وكان معدل وفيات المرضى ‪٪ 30‬‬
‫(‪ 18‬مريضا)‪.‬‬
‫الخالصة ‪:‬‬
‫يبقى استكشاف البطن جراحيا ً هووسيلة التشخيص النهائي في حاالت إصابة االثني عشر‪ ،‬كما‬
‫أن العالج الجراحي في مثل هذه اإلصابات متغير حسب نوع اإلصابة‪.‬‬
‫‪61‬‬