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with wounds to the duodenum are caused by associated injuries. Duodenal injury itself is the cause of death in the minority of cases (6 to 12%).1 • 1 • 1 • 1 • Early death after duodenal injury is most often due to exsanguination from associated major vascular injury.1 • 1 • 1 • Several series have reported that fully half of patients who die present in shock.1 • 1 • Mortality rates are also influenced by wounding mechanism, with a slightly higher reported mortality rate for blunt versus penetrating trauma (20% versus 15%, respectively).

The presence of associated major pancreatic and bile duct injury carries a mortality risk twice that of isolated duodenal injury alone.1 • 1 • 1 • Delay in the diagnosis of duodenal injuries beyond 24 hours has historically been reported to increase mortality rates to 40%.1 • 1 • Reports have suggested that there is no increase in mortality rates caused by delay in surgery up to 24 hours after injury.1 • 1 • [26]

Diagnosis

Penetrating Injuries

The diagnosis of penetrating injuries to the duodenum is most often made at surgery. Knife or gunshot tracts that pass near the duodenum require meticulous visualization and thorough exploration of the entire duodenum to exclude the possibility of full-thickness injury. Blunt Injuries

The diagnosis of blunt duodenal injury is more difficult to make than the diagnosis of penetrating injury; illustrating this is the observation made in numerous reported series of blunt duodenal injury that the diagnosis of blunt injury is often delayed, despite appropriate work-up of patients with potential injury and careful monitoring of such patients by experienced surgeons.1 ' 1 ' 1 ' 1 ' A careful history of the injuring event is required. Blunt rupture of the duodenum is most commonly caused by the transmittal of significant force to the anterior abdomen, as often experienced by an unrestrained driver in a motor vehicle accident who comes into contact with the steering column. A considerable number of blunt fli [40] [74] [77]

duodenal injuries can, however, be caused by far less violent mechanisms, such as falls, assaults, and handlebar contact.1 ' 1 ' 1 ' 1 ' Adding to the difficulty of diagnosis is the fact that patients with blunt duodenal injury often have mild or subtle symptoms and physical findings. Vague complaints of abdominal pain and unimpressive physical examination can occur in the presence of a full-thickness duodenal

perforation confined to the retroperitoneum. Similarly, absent a major associated abdominal catastrophe, patients can present and remain stable.1 •

Routine laboratory tests are nonspecific for duodenal injury. Especially in cases of contained rupture, serum amylase, white blood cell count, and hematologic parameters may be normal or only slightly elevated.1 • 1 • Similarly, plain films of the abdomen may be nondiagnostic. Free air is an unusual finding that is seen in less than 10% of cases, and evidence of retroperitoneal air may be absent in more than 50% of

patients with duodenal rupture.1 • 1 • DPL is a very insensitive test for the diagnosis of retroperitoneal injuries.1 • 1 • 1 • A positive DPL is most often due to the presence of associated intraperitoneal injuries, not the duodenal injury itself.1 • 1 •

CT scanning probably is the most accurate adjunctive test for the specific diagnosis of blunt duodenal rupture.1 • 1 • 1 • 1 • 1 • 1 • CT scanning is more sensitive than plain radiography for the detection of retroperitoneal air, duodenal thickening, and extravasation of contrast material from the injured duodenum. Its use is, however, limited to hemodynamically stable patients. Reliance on CT findings for the exclusion of duodenal injury remains problematic. In a statewide study of more than 200 patients with blunt duodenal injury, Ballard et al.[ ] reported that pathognomonic signs of true full-thickness perforation (retroperitoneal air or contrast extravasation) were present in only 26% of studies in patients with subsequent documentation of full-thickness duodenal perforation. In addition, 27% of studies in this patient group

were interpreted as "normal." Thus, the initial CT scan in cases of documented blunt duodenal rupture was as likely to be interpreted as normal as it was to be interpreted as "pathognomonic" for injury.1 ' Operative Management

Suspected or proved full-thickness perforations of the duodenum require urgent laparotomy. Exploration of the entire abdomen is facilitated by a long midline incision. Immediate control of life-threatening hemorrhage and leakage of enteric contents must be accomplished. A systematic exploration of all hollow viscera follows. If a duodenal injury is suspected, the entire duodenum must be thoroughly visualized. Suspicion of duodenal injury is raised by the presence of bile staining, periduodenal crepitation, or hematoma. The first and second portions of the duodenum are readily visible, whereas inspection of the third and fourth portions requires reflection of the hepatic flexure of the colon and division of the ligament of Treitz. Alternatively, the entire duodenum can be exposed by performing the Cattell-Braasch maneuver. Inspection of the posterior aspect of the duodenum requires a Kocher maneuver. The duodenum must be fully mobilized and inspected to rule out the presence of injury. Periduodenal hematomas must be meticulously explored to exclude an underlying injury.

If suspicion of duodenal injury remains despite careful inspection, a helpful adjunct is the installation of methylene blue dye via the nasogastric tube. The appearance of periduodenal dye staining after several minutes of dwell time proves the presence of a full-thickness breach of the duodenal wall that might be obscured by surrounding hematoma or too small to visually identify. Duodenal injuries can easily be overlooked in cases of massive associated injuries, especially if the injuries are vascular. Attempts at surgical control of associated vascular injuries may render portions of the duodenum ischemic and prone to delayed perforation. Thus, after the repair of associated injuries, careful reinspection of the duodenum is indicated.

Once a duodenal wound is identified, several factors must be considered when choosing an operative repair strategy: extent of injury, presence of associated injuries to the pancreas or bile ducts, time from injury to repair, and physiologic condition of the patient. Although most duodenal wounds are simple, some may be extremely severe, requiring extensive surgery for repair or reconstruction. The presence of associated injuries not only complicates repair but also directly increases morbidity and mortality rates. In cases in which a delay in diagnosis has produced significant intra-abdominal soilage or sepsis or when the physiologic condition of a patient is tenuous due to sepsis or shock, consideration must be given to abbreviated or staged procedures.

Techniques of Repair

Most duodenal injuries, especially those caused by stab wounds, are amenable to simple débridement and two-layer repair with a running, full-thickness, absorbable suture followed by the placement of Lembert sutures ( Fig. 9-1 ). The edges of gunshot wounds or blunt ruptures should be débrided back to healthy tissue.

Figure 9-1 Most simple duodenal lacerations can be closed primarily. Lacerations along the axis of the duodenum may be closed longitudinally or transversely. The transverse closure is preferred, if significant narrowing would result from longitudinal closure.

Figure 9-2 Transection of the duodenum may be treated by debridement and end-to-end repair. Limited mobilization is possible in the descending portion of the duodenum due to the dependence of the duodenum on vessels from the pancreas. Care must be taken to avoid injury to, or obstruction of, the ampulla of Vater.

Figure 9-3 Extensive disruptions of the duodenum may be treated by resection with end-to-end Roux-en-Y duodenojejunostomy.

Figure 9-4 Duodenal Injuries that cannot be repaired primarily without severe narrowing of the lumen may be repaired by the use of a serosal patch technique. The serosa of a loop of jejunum is sutured to the edges of the duodenal defect. Experimental studies have shown that the serosa exposed to the duodenal lumen becomes covered with epithelium.

Figure 9-5 An alternative to the use of a serosal patch in severe duodenal injuries is the use of a pedicled graft (A to D). Such grafts may be taken from the body of the stomach or from the jejunum. Large duodenal defects may be closed in this fashion (E). The segment ofjejunum from which the graft has been taken is repaired by end-to-end anastomosis.

Figure 9-6 Anatomically severe duodenal wounds often require adjunctive procedures to protect the anastomosis. The simplest of these is a tube duodenostomy. This should be brought out through a portion of uninjured duodenum, rather than through the duodenal repair. Although decompressing the duodenum may provide some protection for the duodenal repair, tube duodenostomy does not totally divert the stream of

Figure 9-7 The treatment of severe duodenal wounds by primary repair, gastrostomy, retrograde duodenostomy, and feeding jejunostomy has been associated with a very low incidence of duodenal fistula.

Figure 9-8 Severe duodenal and combined pancreaticoduodenal injuries often require the diversion of the gastric contents away from the duodenal repair. This may be permanently accomplished by the so-called duodenal diverticularization. This consists of antrectomy with gastrojejunostomy, truncal vagotomy, tube duodenostomy, and external drainage of the duodenal repair. Tube choledochostomy may be added if the duodenal injury is in the region of the ampulla.

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