Management of duodenal injuries

Abstract

Injuries to the duodenum pose a diagnostic and therapeutic challenge to the surgeon. Due to the intraand extra-peritoneal location of the duodenum, the presentation can be overt or occult, and delay in diagnosis is associated with an increased mortality rate. A range of interventions have been described and this article reviews the relevant literature, highlights the salient points and suggests a treatment algorithm.

Concomitant Occult Post-traumatic Pancreatic Transection and Duodenal Contusion: a Case Report

“…However, distal duodenal obstruction is a fairly common complication of duodenal contusions and haematomas, particularly in the subacute stage after the initial trauma, when insertion of a nasojejunal feeding tube may be required. 5,18,19 In our patient, imaging features of duodenal contusion and distal duodenal obstruction were only manifested on serial CT and delayed fluoroscopic evaluation.…”

“…Blunt pancreatic and duodenal trauma is relatively uncommon, and accounts for less than 2% of all abdominal injuries. [2][3][4][5][6] Direct impact to the upper abdomen by a steering wheel during a road traffic accident, or bicycle handlebars are the typical mechanisms of trauma recorded with injury to the pancreas and / or the duodenum, which may also involve the left hepatic lobe, stomach, or spleen.…”

“…Patients with pancreatic or duodenal injuries may complain of epigastric or vague abdominal pain and vomiting, which are fairly non-specific. [2][3][4][5][6] In addition, blunt pancreatic and duodenal injury can occur in the setting of polytrauma, and such patients may have undergone intubation or received sedatives, precluding accurate assessment of the patient's signs and symptoms. Raised serum amylase and lipase levels may be present, although these levels may lie within normal or nearnormal levels at the time of initial presentation, 7,8 as seen in our patient.…”

A modified approach to decompression of primary repair of the duodeno-jejunal flexure transection after blunt trauma

“…The treatment of DJ flexure transection was traditionally by pyloric exclusion (PE) and gastrojejunostomy (GJ) but more recently evidence has suggested that primary closure or end-to-end anastomosis may be effective; 7 protection of the DJ anastomosis is by antegrade or retrograde i.e. external tube duodenostomy.…”

“…Timely resuscitation with rapid procedures like primary closure with an appropriate technique for decompression and protection of the suture line in case of isolated DJ flexure or associated multiple injuries reduces the rate of further complication, 7 and we propose a modification that avoids external tube duodenostomy.…”