Recent Trends in Management of Duodenal Injuries

Abstract

Blunt abdominal injuries such as direct blow to the epigastrium result bowel trauma, and they account for 25% of all duodenal traumas, while the remaining 75% of duodenal trauma are due to penetrating trauma. Isolated blunt duodenal injuries are very rare since they are commonly associated with lesions of other abdominal or thoracic organs, including major vessels. Considering the deep and relatively protected anatomical site of the duodenum, it is likely that when the situation of the trauma is able to injury the duodenum, other intraabdominal organs are usually involved. Thus, if any traumatic lesion of the duodenum is detected, injuries to other structures have to be ruled out. . Delay in diagnosis and management clearly increases the morbidity and mortality. Sonography can be performed initially to rule out injuries of the intraabdominal organs and vessels, but it is inadequate to detect lesions in the pancreaticoduodenal area. Thus, computed tomography (CT) scan with both oral and intravenous contrast medium is of paramount importance; in this way it may be possible to demonstrate the extravasation of oral or intravenous contrast medium in the presence of a laceration. The development of multidetector CT has improved the ability to examine and detect duodenal injuries. However, in some cases finding on CT scan can be negative at admission, or subtle because of small amount of unexplained fluid existed and unusual bowel morphology, duodenal injury can be underestimated and dismissed. For these reasons, subtle findings on abdominal CT should be an indication for laparotomy or explorative laparoscopy. The surgical management of duodenal injuries is verified depending on the number of basic criteria: the anatomical relationship to the ampulla of Vater; the characteristics of the injury (simple laceration or wall destruction); the involved circumference; and associated injury to the biliary tract, pancreas, or other major structure. In operative terms, the duodenum can be divided into two parts; an upper part, with the complex anatomical structures within it (the common bile duct and sphincter) and the pylorus, and a lower part. The lower part can be treated like small bowel; diagnosis and operative management are relatively simple, including debridement, closure, resection, and reanastomosis of the bowel. Although most duodenal injuries can be managed with primary repair, a certain subset of high-risk patients are more at risk of duodenal dehiscence. Approximately 80% of duodenal injuries can be safely primarily repaired, while the remaining usually requires more complex procedures, such as pyloric exclusion, duodenoduodenostomy, and duodenojejunostomy. Pancreaticoduodenectomy is rarely and it might be performed in case of massive disruption of the duodenopancreatic complex. Unfavorable prognostic factors of duodenal injury are the involvement of common bile duct and pancreas, blunt duodenal trauma, and an involvement of more than 75% of the duodenal circumference. Additional unfavorable prognostic factors were represented by delay of treatment after the first 24 hours from onset of the trauma, and lesions located in the first and second portions of the duodenum.