1. 372 DUODENAL INJURIES
related to almost half the deaths in this series. In fact, delays 6. Sinha R, Sharma N, Joshi M: Laparoscopic repair of small bowel perfora-
exceeding as little as 8 hours resulted in increased morbidity and tion. J Soc Laparoendosc Surg 9:399–402, 2005.
mortality. 7. Maull KI, Reath DB: Impact of early recognition on outcome in nonpen-
Mortality after penetrating injury is most commonly related to etrating wounds of the small bowel. South Med J 77:1075–1077, 1984.
8. Brasel KJ, Olsen CJ, Stafford RE, Johnson TJ: Incidence and significance
injury to other intraperitoneal and/or retroperitoneal injuries.22 of free fluid on abdominal computed tomographic scan in blunt trauma.
J Trauma 44:889–892, 1998.
9. Malhotra AK, Fabian TC, Katsis SB, et al: Blunt bowel and mesenteric
CONCLUSIONS injuries: the role of screening computed tomography. J Trauma 48:
991–1000, 2000.
Small bowel injuries may follow blunt or penetrating trauma. The 10. Allen TL, Mueller MT, Bonk T, et al: Computed tomographic scanning
major concern in the patient who sustains blunt small bowel injury without oral contrast solution for blunt bowel and mesenteric injuries in
is recognizing the presence of the injury. In patients with associated abdominal trauma. J Trauma 56:314–322, 2004.
injuries requiring operation or in those sustaining gunshot wounds, 11. Gonzalez RP, Ickler J, Gachassin P: Complementary roles of diagnostic
peritoneal lavage and computed tomography in the evaluation of blunt
small bowel injuries are promptly discoverable. The trend toward abdominal trauma. J Trauma 51:1128–1136, 2001.
CT-based nonoperative management and the inaccuracy of early 12. Mitsuhide K, Junichi S, Atsushi N et al: Computed tomography scanning
postinjury CT places patients with isolated blunt small bowel injury and selective laparoscopy in the diagnosis of blunt small bowel injury: a
at risk of delayed diagnosis and increased morbidity and mortality. prospective study. J Trauma 58:696–703, 2005.
The importance of injury mechanism and physical findings is often 13. Brownstein MR, Bunting T, Meyer AA, Fakhry SM: Diagnosis and man-
overlooked. Patients who are neurologically intact will demonstrate agement of blunt small bowel injury: a survey of the membership of the
abdominal tenderness; many will have peritoneal findings at presen- American Association for the Surgery of Trauma. J Trauma 48:402–407,
tation. The presence of a seat-belt contusion should elevate concern. 2000.
Injuries that can be repaired by lateral enterorrhaphy rarely cause 14. Kaban G, Somani RA, Carter J: Delayed presentation of small bowel
injury after blunt abdominal trauma. J Trauma 56:1144–1145, 2004.
postoperative complications, which are more commonly related to 15. Hackam DJ, Ali J, Jastaniah SS: Effects of other intra-abdominal injuries
associated injuries after both blunt and penetrating trauma. Surgical on the diagnosis, management and outcome of small bowel injuries.
judgment is required to ensure early diagnosis and appropriate op- J Trauma 49:606–610, 2000.
erative management. 16. Fakhry SM, Brownstein M, Watts DD, et al: Relatively short diagnostic
delays (Ͻ8 hours) produce morbidity and mortality in blunt small bowel
REFERENCES injury: an analysis of time of operative intervention in 198 patients from
a multicenter experience. J Trauma 48:408–415, 2000.
1. Nance ML, Peden GW, Shapiro MB, et al: Solid viscus injury predicts 17. Fang JF, Chen RJ, Lin BC, et al: Small bowel perforation: is urgent surgery
major hollow viscus injury in blunt abdominal trauma. J Trauma 43: necessary? J Trauma 47:515–520, 1999.
618–623, 1997. 18. Bensard DD, Beaver B, Besner GE, Cooney DR: Small bowel injury in
2. Velitchkov NG, Losanoff JE, Kjossev KT, et al: Delayed small bowel injury children after blunt abdominal trauma: is diagnostic delay important?
as a result of penetrating extraperitoneal high-velocity ballistic trauma to J Trauma 41:476–483, 1996.
the abdomen. J Trauma 48:169–170, 2000. 19. Neugebauer H, Wallenboeck E, Hungerford M: Seventy cases of injury of
3. Fakhry SM, Watts DD, Luchette FA: Current diagnostic approaches lack the small intestine caused by blunt abdominal trauma: a retrospective
sensitivity in the diagnosis of perforated small bowel injury: analysis from study from 1970 to 1994. J Trauma 46:116–121, 1999.
275,557 trauma admissions form the EAST multi-institutional HVI trial. 20. Maull KI: Stomach, small bowel and mesentery injury. In Dudley H,
J Trauma 54:295–306, 2003. Carter D, Russell RC, editors: Operative Surgery. London, Butterworths,
4. Shaftan GW: Indications for operation in abdominal trauma. Am J Surg 1989, pp. 401–413.
99:657–664, 1960. 21. Kirkpatrick AW, Baxter KA, Simons RK, et al: Intra-abdominal complica-
5. Chiu WC, Shanmuganathan K, Mirvis SE, Scalea TM: Determining the tions after surgical repair of small bowel injuries: an international review.
need for laparotomy in penetrating torso trauma: a prospective study J Trauma 55:399–406, 2003.
using triple-contrast enhanced abdominopelvic computed tomography. 22. Stevens SL, Maull KI: Small bowel injuries. Surg Clin North Am 70:
J Trauma 51:860–869, 2001. 541–560, 1990.
DUODENAL INJURIES in published reports sustaining penetrating trauma.2 This figure may
primarily be a reflection of the experience of urban trauma centers
Gregory J. Jurkovich where penetrating mechanism are more prevalent, and of academic
centers that publish their results. Penetrating duodenal wounds are usu-
ally rapidly diagnosed as part of a laparotomy and evaluation of the
tract of the offending agent. But blunt duodenal injuries are often more
d
insidious in their presentation, making the initial diagnosis difficult.
uodenal injuries are uncommon, but not so rare as to preclude a Despite this well-known observation, delays in the diagnosis of duode-
comprehensive understanding of treatment strategies by general nal trauma continue to plague trauma surgeons and seriously compro-
surgeons. A 6-year statewide review in Pennsylvania documented a mise patient care.3
0.2% incidence of blunt duodenal injury (206 of 103,864 trauma regis-
try entries), and only 30 of these patients had full-thickness duodenal
injuries.1 Blunt duodenal injuries are the result of a direct blow to the DETERMINANTS OF OUTCOME
epigastria, which in adults is usually from a steering wheel injury in an
unrestrained driver, and in children is the result of a direct blow from a Directly attributable duodenal mortality ranges from 2%–5%, and
bicycle handlebar, fist, or similar mechanism. Penetrating wounds are is the result of the common complications of wound dehiscence,
more common causes of duodenal injury, with about 75% of patients sepsis, and multiple organ failure.4–11 Associated causes of mortality

2. ABDOMINAL INJURIES 373
in patients with a duodenal injury can be garnered from large series portion (and the remainder of the duodenum) is entirely retroperi-
of duodenal injuries reported during the late 20th century. These toneal; this is the segment mobilized by a Kocher maneuver. The
reports demonstrated an average mortality in patients with a duo- transverse or third portion of the duodenum runs 12 cm horizontally
denal injury of 18%, but with great individual report variability, to the left in front of the ureter, inferior vena cava, lumbar column,
ranging from 6%–29%.6,12–14 Morbidity rates after duodenal injury and aorta, and ends at just at the left edge of the third lumbar verte-
range from 30%–63%, although only about a third of these are di- bra. The superior mesenteric artery runs downward over the anterior
rectly related to the duodenal injury itself.6,9,12 Reasons for this vari- surface of the third portion of the duodenum. The ascending or
ability in morbidity and mortality statistics include the mechanism fourth portion of the duodenum runs upward and slightly to the left
of injury, associated injuries, and time to initial diagnosis. For ex- for only a short distance (2–3 cm) alongside the spine to the duode-
ample, Ivatury and colleagues’ review of 100 consecutive penetrat- nal suspensory ligament of Treitz.
ing duodenal injuries documented a 25% mortality rate,6 compared The arterial blood supply of the duodenum is derived from the
with mortality rates of 12%–14% in patients with blunt injury pancreaticoduodenal artery. The superior branch comes off the he-
mechanisms.3,9 patic artery, and the inferior branch from the superior mesenteric
Early death from a duodenal injury, particularly with penetrating artery. These two arteries run in a groove between the descending
wounds, is caused by exsanguination from associated vascular, liver, (second) and transverse (third) portions of the duodenum and the
or spleen injuries.15,16 The proximity of the duodenum to other vital head of the pancreas, with well-developed collateralization via a con-
structures makes isolated injuries uncommon, but not unheard of. tinuous marginal artery. The venous drainage parallels the arterial
While exsanguinating hemorrhage and associated injuries are re- supply, with the posterosuperior arcade draining into the portal vein
sponsible for early deaths, infection and multiple-system organ fail- and the anteroinferior arcade draining into the gastrocolic trunk.21
ure are responsible for most late deaths. Up to one-third of patients The duodenal mucosa resembles that of the remainder of the
who survive the first 48 hours develop a complication related to the small bowel, with the characteristic histologic feature of the submu-
duodenal injury. Anastomotic breakdown, fistula, intra-abdominal cosal Brunner’s glands in the most proximal (first) portion. The vis-
abscess, pneumonia, septicemia, and organ failure are the common cous, mucoid, alkaline secretion of these glands probably affords
complications. Late deaths in patients with a duodenal injury typi- some protection to the duodenum from gastric acid and serves to
cally occur 1–2 weeks or more after the injury, with about one-third begin neutralization of this acid. The mixing of pancreatic and bile
of the late deaths attributable to the injury itself.9,12 juices with the gastric efflux also normally occurs in the duodenum.
The time from injury to definitive treatment is also an important The duodenum sees an average of 2500 ml gastric juice, 1000 ml of
factor in the development of late complications and subsequent bile, 800–1000 ml of pancreatic juices, and 800 ml of saliva, for a
mortality. Roman and colleagues17 identified 10 patients in whom total of about 5 liters of combined flow through the duodenum per
the diagnosis of duodenal injury was delayed over 24 hours; 4 of the day. Such massive flow volumes make it clear that duodenal integrity
10 died, and 3 of the 10 had duodenal fistulas. In a true trauma clas- is crucial, and help to explain why duodenal fistulae can be such a
sic report, Lucas and Ledgerwood18 demonstrated the remarkable difficult complication of injury to this organ.
importance (and frequency) of a delay in diagnosis of duodenal in-
jury. In their report, a delay in diagnosis of more than 12 hours oc-
curred in 53% of their patients, and a delay of more than 24 hours in DIAGNOSTIC ADJUVANTS
28%; mortality was 40% among the patients in whom the diagnosis
was delayed greater than 24 hours, as opposed to 11% in those un- The radiologic signs of duodenal injury on the initial plain abdomi-
dergoing surgery within 24 hours. Snyder and coworkers9 confirmed nal or upright chest radiograph are often quite subtle, with mild
these observations, noting that of the four patients with blunt duo- spine scoliosis or obliteration of the right psoas muscle being occa-
denal trauma in their series in whom the diagnosis was delayed, two sionally all that suggests a retroperitoneal duodenal injury. The pres-
died and the other two developed duodenal fistula. Cuddington and ence of air in the retroperitoneum is a clear sign of duodenal injury,
associates3 also noted that 100% of the deaths directly attributable to but this is often difficult to distinguish from the overlying transverse
duodenal injury occurred in patients in whom there was a delay in colon. Computed tomography (CT) at the current time is the best
diagnosing such injury. method of early diagnosis of a duodenal injury, but it is not infallible.
The implication of these observations is that the first priority in In a 1997 report describing a 6-year statewide experience with
managing duodenal trauma should be control of hemorrhage. The duodenal injuries, Ballard et al.1 reported that of 30 documented
next priority is limiting bacterial contamination from colon or other blunt duodenal injuries, the initial CT scan missed 27%. The (CT)
bowel injury to prevent late infections. A clear identification of the scan must be performed with both oral and intravenous contrast
extent of the duodenal injury should follow as the next priority, with (Figure 1). The exam must be interpreted with great suspicion for
an emphasis on determining the status of the pancreas as well, as this injury, and uncertainty in interpretation is adequate justification for
affects definitive treatment plans.13,19 operative exploration. False-negative exams are known to occur.22 In
one careful study of the accuracy of CT in diagnosing duodenal and
other small bowel injuries, only 59% (10 of 17) scans were prospec-
ANATOMY AND PHYSIOLOGY tively (preoperatively) interpreted as suggestive for bowel injury,
which increased to 88% (15 of 17 injuries) when evaluated retrospec-
The duodenum is the first portion of the small intestine, beginning tively.23 These investigators emphasized that using CT for the diagno-
just to the right of the spine at the level of the first lumbar vertebra sis of blunt bowel rupture requires careful inspection and technique
and extending from the pyloric ring to the duodenojejunal flexure, to detect the often-subtle findings.
commonly known as the ligament of Treitz. The duodenum is named A more cumbersome alternative to CT is upper gastrointestinal
from the Latin word duodeni, which means “twelve each,” because it series with water-soluble contrast medium followed by barium if the
is in total 25 to 30 cm, or about 12 fingerbreadths, in length. For initial exam is negative. Some have advocated this study if the initial
convenience of description, the duodenum is arbitrarily divided into CT is difficult to interpret, but I would argue that subtle findings on
four divisions, differentiated by the alteration in direction of the CT are adequate justification for operative exploration. In a series of
organ.20 The superior or first portion of the duodenum passes back- 96 patients with CT findings suspicious for duodenal injury, the
ward and upward toward the neck of the gallbladder, and most sensitivity of a subsequent duodenography was 54% with a specific-
of this portion is intraperitoneal. The descending (vertical) or second ity of 98%.24 For those injuries requiring operative repair, the sensi-
portion forms an acute angle with the first portion and descends tivity was only 25%, with a 25% false-negative rate. Allen et al.25
7–8 cm. It contains the bile and pancreatic duct openings. This demonstrated that 83% of the patients with a delay in the diagnosis

3. 374 DUODENAL INJURIES
A B
Figure 1 Duodenal perforation. Nineteen-year-old female dropped a 185-lb barbell on abdomen, presented to emergency department
4 hours later with mild abdominal pain and nausea. Afebrile, hemodynamics stable, persistent epigastric tenderness without peritoneal signs,
WCC 16 K, amylase 114. Arrow points to nonluminal air in the retroperitoneum and free extravasation of contrast.
of blunt duodenal injury had subtle CT findings, including pneumo- Table 1: Determinants of Duodenal Injury Severity
peritoneum, unexplained fluid, and unusual bowel morphology
that were dismissed. These authors emphasized the point that subtle Mild Severe
findings of duodenal injury on abdominal CT should mandate Determinants of Injury Severity
laparotomy.
Diagnostic peritoneal lavage (DPL) is unreliable in detecting iso- Agent Stab Blunt or missile
lated duodenal and other retroperitoneal injuries. Nevertheless, DPL Size Ͻ75% wall Ն75% wall
is often helpful because approximately 40% of patients with a duo- Duodenal site 3, 4 1, 2
denal injury have associated intra-abdominal injuries that will result
in a positive peritoneal lavage. The findings of amylase or bile in the
Injury-repair Ͻ24 Ն24
lavage effluent are more specific indicators of possible duodenal in- interval (hr)
jury. Serum amylase levels are nondiagnostic as well, but if elevated Adjacent injury No CBD CBD
additional investigation (CT or celiotomy) for the possibility of pan- No pancreatic injury Pancreatic injury
creatic or duodenal injury is warranted. At celiotomy, the presence of Outcome
any central upper abdominal retroperitoneal hematoma, bile stain-
ing, or air mandates visualization and a thorough examination of the Mortality (%) 6% 16%
duodenum. Asensio and colleagues26 have published the technical Duodenal 6% 14%
details of exposing the entire duodenum and pancreas. morbidity (%)
CBD, Common bile duct.
TREATMENT
Treatment principles are governed by the severity of duodenal injury
and the likelihood of postrepair complications. Approximately 70% rithm approach to the management of duodenal injuries is provided
of duodenal wounds can be safely repaired primarily, and the re- in Figure 2.27 A classification system for all organ injuries has been
maining 30% are “severe” injuries that require more complex proce- developed by the American Association for the Surgery of Trauma
dures. Snyder and colleagues9 are credited with cataloging the factors (AAST) and is known as the Organ Injury Scale (OIS).28 This classi-
that determine whether a duodenal wound can be primarily repaired. fication for duodenal wounds is listed in Table 2, with duodenal
In their review of 247 patients treated for duodenal trauma, they re- injuries graded from I to V, minor to major injury. In a review of
ported an overall duodenal fistula rate of 7% and a mortality rate of 164 duodenal trauma patients managed at eight trauma centers and
10.5% in the 228 patients surviving for greater than 72 hours. These to whom the AAST/OIS classification scheme was applied, there were
investigators felt that five of the factors listed in Table 1 most signifi- 38 class I, 70 class II, 48 class III, four class IV, and four class V inju-
cantly correlate with the severity of duodenal injury and subsequent ries. Primary repair alone was performed in 71% (117) of all cases.4
morbidity and mortality. A more recent addition, as noted in the Primary duodenal repair was performed in 90 of 108 patients with
table, is the presence of a pancreatic injury, a significant predictor of class I or II injuries. More complex duodenal treatment strategies,
late morbidity and mortality. Each of these factors, either individu- including pyloric exclusion, duodenoduodenostomy, duodenojeju-
ally or in combination, has been used to develop a variety of duode- nostomy, or pancreatoduodenectomy, were employed in 26 of
nal injury classification systems. Snyder and colleagues9 demon- 56 (46%) patients with class III to V injuries, or 29% of the total
strated that patients with “mild” duodenal trauma had 0% mortality population.
and 2% duodenal fistula rate, as compared with 6% mortality and Primary repair is usually the simplest, fastest, and most appropri-
10% fistula rate among those with severe duodenal injuries. In gen- ate way to manage duodenal injuries.29 Primary repair is appropriate
eral, patients with a “mild” duodenal injury and no pancreatic injury for complete transection of the duodenum if there is little tissue loss,
can be primarily repaired. Patients with more severe duodenal inju- if the ampulla is not involved, and if the mucosal edges can be de-
ries may require more complex treatment strategies. A useful algo- brided and closed without tension. The repair is done as with any

4. ABDOMINAL INJURIES 375
F
Detected at Evacuation of
laparotomy hematoma
Hematoma G
A NG suction
Detected non-
TPN
History and physical examination operatively
Observation
Abdominal trauma
H
Grade I/II simple
Suture closure Pyloric exclusion
laceration
E J
Duodenal Inspection at Primary repair or
Injury laparotomy Proximal to antrectomy
ampulla Gastojejunostomy
I
Stump closure
Grade III laceration
Primary repair or
B Distal to
Labs Roux-en-Y
ampulla
Abdominal x-ray C duodenojejunostomy
Contrast studies
D
K Complex biliary
reconstruction
Grade IV/V laceration
or destruction
Pancreatico-
duodenectomy
Figure 2 Algorithm for the management of duodenal injuries. (From Jurkovich G: Duodenal injury. In McIntyre R, Van
Stiegmann G, Eiseman B, editors: Surgical Decision Making, 5th ed. Philadelphia, Elsevier, 2004, pp. 512–513.)
Table 2: AAST-OIS Grading of Duodenal Injury
Severity
Grade Type Description
I Hematoma Single portion of duodenum
Laceration Partial thickness
II Hematoma More than one portion
Laceration Ͻ50% circumference
III Laceration 50%–75% D2
50%–100% D1, D3, D4
IV Laceration Ն75% D2
Involves ampulla or distal CBD
V Laceration Massive disruption of duodeno-
pancreatic complex
Devascularization Figure 3 Extensive disruptions of the duodenum may be treated by
resection with end-to-end Roux-en-Y duodenojejunostomy. (From
AAST-OIS, American Association for the Surgery of Trauma Organ Injury Asensio J, Feliciano D, Britt L, Kerstein M: Management of duodenal injuries.
Severity scoring system. Curr Probl Surg 11, 1993, p. 1064, figure 9.)
Modified from American Association for the Surgery of Trauma (AAST).
small bowel repair. I prefer a two-layer closure, but a watertight, ing a duodenal wound. In this report of 60 patients with penetrating
serosa-approximating single layer repair is equally acceptable. How- duodenal injuries, there was a 64% incidence of abdominal sepsis
ever, if adequate mobilization for a tension-free repair is impossible, and a 27% death rate in 11 patients with duodenal gunshot wounds,
or if the injury is very near the ampulla and mobilization risks com- compared with a 7% abdominal sepsis and 0% mortality in
mon bile duct injury, a Roux-en-Y jejunal limb anastomosis to the 30 patients who had either primary repair of Roux-en-Y anastomotic
proximal duodenal injury with oversewing of the distal duodenal repair of similar injuries. In 17 patients from that same series with
injury is the most reasonable option (Figure 3). Mucosal jejunal duodenal stab wounds, the complication rate was also higher if the
patch repair as depicted in Figure 4 is rarely, if ever, used, and was not “sucker patch” repair of a duodenal wound was used. It is usually
used in any patient in the most recent multicenter trial in which only preferable to fully debride the wound and transect the duodenum,
five patients (3%) had duodenoduodenostomy or duodenojejunos- mobilize the edges, and perform a direct end-to-end duodeno–
tomy repairs.4 While historically utilized, a 1985 report by Ivatury duodeno anastomosis. Because the duodenal mesentery is short, this
et al.30 demonstrates why this is generally a poor solution to manag- is usually readily accomplished. Pancreatoduodenectomy is only

5. 376 DUODENAL INJURIES
required for duodenal injuries if there is uncontrollable pancreatic
hemorrhage or combined duodenal and distal common bile duct or
pancreatic duct injury. Most often this represents the completion of
a debridement initiated by the injury forces.
Several techniques may help protect a tenuous duodenal repair.
Buttressing the repair with omentum (my preference) or a “serosal
patch” from a loop of jejunum seems logical, although the benefit of
such techniques is unproven.6,31 Diversion of gastric contents is an-
other option, most commonly accomplished by the Vaughan/Jordan
pyloric exclusion technique.32 Probably first described by Summers in
1904 as an adjunct to treatment of duodenal wounds,33 pyloric exclu-
sion is a less disruptive procedure than true duodenal “diverticuliza-
tion” advocated by Berne and Donovan and colleagues34,35 (Figure 5).
Duodenal “diverticulization” employs primary closure of the
duodenal wound, antrectomy, vagotomy, end-to-side gastrojeju-
nostomy, T-tube common bile duct drainage, and lateral tube duo-
Figure 4 Injuries in which loss of duodenal wall has occurred that denostomy. The concept is to completely divert both gastric and
cannot be repaired, primarily without severe narrowing of the lumen, biliary contents away from the duodenal injury, provide enteral
may be repaired by use of a serosal patch technique. The serosa of a nutrition via the gastrojejunostomy, and convert a potential un-
loop of jejunum is sutured to the edges of the duodenal defect. controlled lateral duodenal fistula to a controlled fistula. A less
Experimental studies have demonstrated that the serosa exposed to formidable and less destructive alternative is the “pyloric exclu-
the duodenal lumen rapidly undergoes complete mucosal sion,” which does not employ antrectomy, biliary diversion, or
resurfacing. (From Asensio J, Feliciano D, Britt L, Kerstein M: Management vagotomy32,34,36,37 (Figure 6). This procedure is performed through
of duodenal injuries. Curr Probl Surg 11, 1993, p. 1060, figure 6.) a gastrotomy and consists of grasping the pylorus with a Babcock
clamp and suturing closed the pylorus with absorbable size 0 poly-
glycolic acid or polyglactin, or Maxon® (polyglyconate) or PDS®
(polydioxanone) suture and construction of loop gastrojejunos-
A tomy. This diverts gastric flow away from the duodenum for sev-
B eral weeks while the duodenal and pancreatic injuries heal. The
pylorus eventually opens (2 weeks to 2 months) and the gastroje-
junostomy functionally closes. Fang and colleagues38 at Chang-
Gung Memorial Hospital in Taiwan have described a technical
method of a controlled release of the pyloric exclusion knot and
thereby timing the opening of the pyloric occlusion. Marginal ul-
ceration at the site of gastrojejunostomy has been reported in
5%–33% of patients, prompting some to add truncal vagotomy to
the procedure.14,32,36,38 Most surgeons do not add a truncal vagot-
omy to pyloric exclusion, however, because nearly all of the pyloric
closures open within a few weeks, regardless of the type of suture
material used, and the occasional marginal ulcer can be medically
managed in the interim. The data supports the use of pyloric ex-
clusion and gastrojejunostomy in “severe” duodenal injuries7,14 or
in cases of delayed diagnosis,36 although no prospective, random-
ized trial has proven the true benefit of gastric diversion. In addi-
Figure 5 (A) Berne diverticulization and (B) pyloric tion, the added operating time and the extra anastomosis suggest
exclusion. (From Jurkovich GJ: Duodenum and pancreas. In Moore EE, a good deal of selectivity should be applied to its use.
Feliciano DV, Mattox K, editors: Trauma, 5th ed. New York, McGraw-Hill, Mortality directly related to the duodenal injury is the result
2004, p. 717.) of duodenal dehiscence, uncontrolled sepsis, and subsequent
C
A
B
Figure 6 Pyloric exclusion technique.

6. ABDOMINAL INJURIES 377
multiple-system organ failure. Knowledge of the lethal nature
of duodenal dehiscence and duodenal fistula certainly tempts the
operating surgeon to add pyloric exclusion, anastomosis buttress-
ing, and duodenostomy to the repair of class III or IV duodenal
injuries. As noted previously, concomitant pancreatic injury should
also be included as a high-risk confounder that might warrant
pyloric exclusion added to the duodenal repair. In one report of
40 patients with penetrating duodenal injuries, there were 14 pa-
tients with combined duodenal and pancreatic wounds. Five
patients with this combination of injuries had primary duodenal
repair alone, and two incurred duodenal leaks. Three of the pa-
tients with combined injuries had pyloric exclusion as a treatment
adjunct, and none had duodenal leaks.39
An alternative or addition to gastric diversion is duodenal
decompression via retrograde jejunostomy. Stone and Fabian10
reported a fistula rate of less than 0.5% (1 in 237 patients) in a
variety of duodenal injuries all treated by retrograde jejunostomy
tube drainage, in contrast to a 19.3% incidence of duodenal com-
plications when decompression was not used. Retrograde duode-
nodenal drainage is preferred to lateral duodenostomy. Direct
drainage with a tube through the suture line results in a high de-
hiscence or fistula rate of 23%. Hasson and colleagues40 reviewed A
the literature up to 1984 on penetrating duodenal trauma and
tube duodenostomy, evaluating eight retrospective series and over
550 patients. They reported overall mortality of 19.4% and a fis-
tula rate of 11.8% without decompression, compared with 9%
mortality and 2.3% fistula rate with decompression. They too con-
cluded that tube drainage should be performed either via stomach
or retrograde jejunostomy, as these methods had a lower fistula
rate and less overall mortality than lateral tube duodenostomy.
Nonetheless, as is the case of pyloric exclusion for gastric diver-
sion, there has been no prospective, randomized analysis of the
efficacy of tube duodenal drainage techniques, and not all sur-
geons support use of decompression techniques.
In very massive injuries of the proximal duodenum and head of
the pancreas, destruction of the ampulla and proximal pancreatic
duct or distal common bile duct may preclude reconstruction. In
addition, because the duodenum and the head of the pancreas have
a common arterial supply, it is essentially impossible to entirely
resect one without making the other ischemic. In this situation, a
pancreatoduodenectomy is required. Between 1961 and 1994, 184
Whipple procedures were reported for trauma, with 26 operative
deaths (14%) and 39 delayed deaths, for a 64% overall survival rate.41
With appropriate selection criteria, pancreatoduodenectomy for in-
jury can be performed with similar morbidity and mortality as de-
scribed in resections done for cancer.42–44
DUODENAL HEMATOMA
Duodenal hematoma is generally considered an injury of childhood
play or child abuse, but can occur in adults as well. In one report,
50% of the cases of duodenal hematoma in children resulted from
child abuse.45 Remarkably, the duodenum is the fourth most com-
monly injured intra-abdominal organ after blunt abdominal trauma, B
occurring in 2%–10% of children.46 Nearly one-third of the patients Figure 7 Duodenal hematoma. The two images are sequential.
present with obstruction of insidious onset at least 48 hours after (A) Initial showing near total duodenal obstruction. (B) Portrays
injury, presumably the result of fluid shift into the hyperosmotic contrast passage into the jejunum. The hematoma has infiltrated the
duodenal hematoma. Duodenal hematoma in general represents a wall, producing fold thickening, loop narrowing, and displacement.
nonsurgical injury, in that the best results are obtained with conser- The mesentery is also involved, and there is a pronounced
vative or nonsurgical management.47 It can be diagnosed either by hematoma component nearly occluding the first jejunal loop. This
contrast-enhanced CT scan or upper gastrointestinal (UGI) study case shows the characteristic involvement of the duodenum as it
(Figure 7). The initial water-soluble contrast (meglumine diatri- traverses the spine, sparing, but obstructing, the proximal duodenal
zoate) exam should be followed by barium to provide the greater (1 and 2) segments.
detail needed to detect the so-called “coiled spring” or “stacked coin”
sign. Although characteristic of intramural duodenal hematoma, this
finding is present in only approximately one-quarter of patients with
hematoma.

7. 378 DUODENAL INJURIES
Although the initial treatment is nonoperative, associated injuries 12. Shorr R, Greaney G, Donovan A: Injuries of the duodenum. Am J Surg
should be excluded, particularly pancreatic injury. Desai et al.46 re- 154(7):93–98, 1987.
ported that 42% of pediatric patients with a duodenal injury (perfora- 13. Jurkovich GJ, Bulger E: Duodenum and pancreas. In Moore EE,
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obstruction do not spontaneously abate. Ultrasound has also been treatment of pancreatic trauma. Surgery 80(4):523–529, 1976.
used to follow a resolving duodenal hematoma.48 Percutaneous drain- 16. Sukul K, Lont H, Johannes E: Management of pancreatic injuries. Hepa-
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24 hours and never attempted nonoperative management.46 Nasogas- 24. Timaran CH, Daley BJ, Enderson BL: Role of duodenography in
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PANCREATIC INJURIES spleen. The splenic artery and vein can be found along the superior
border of the pancreas. The superior mesenteric artery and vein re-
Louis J. Magnotti and Martin A. Croce side just behind the neck of the pancreas and are enclosed posteriorly
by the uncinate process. This process can be absent or can almost
completely encircle the superior mesenteric artery and vein.
The head of the pancreas is suspended from the liver by the hepa-
toduodenal ligament and is firmly fixed to the medial aspect of the
t he pancreas is relatively protected deep within the confines of
the retroperitoneum. As such, injuries to the pancreas are
uncommon, but not rare, and can present a diagnostic dilemma. In
second and third portions of the duodenum. A line extending from
the portal vein superiorly to the superior mesenteric vein inferiorly
marks the division between the head and the neck of the gland. The
neck of the pancreas measures approximately 1.5–2 cm in length and
fact, despite advances in modern trauma care, there remains signifi-
lies at the level of the first lumbar vertebra. It overlies the superior
cant morbidity and mortality, with mortality rates ranging from
mesenteric vessels and is fixed between them and the celiac trunk
9%–34%.1 Frequent complications are also common following pan-
superiorly. The body of the pancreas is technically defined as that
creatic injuries, occurring in 30%–60% of patients. The high compli-
portion of the pancreas that lies to the left of the superior mesenteric
cation rate associated with these injuries is primarily secondary to
vessels. There is no true anatomic division between the body and the
diagnostic delays and missed injuries. When identified early, the
tail, nor is there any imaginary dividing line as in the case of the head
treatment of most pancreatic injuries is straightforward. It is the
and neck.
delayed recognition and/or treatment of these injuries that can result
The main pancreatic duct of Wirsung originates in the tail of the
in devastating outcomes.
pancreas and typically traverses the entire length of the gland and
There are few well-documented historical accounts about the
joins the common bile duct before emptying into the duodenum.
management of pancreatic injuries. The first documented case of
Throughout its course in the tail and body, the duct lies midway be-
pancreatic trauma was an autopsy report from St. Thomas Hospital
tween the superior and inferior margins and slightly more posterior.
in London in 1827 in which a patient struck by the wheel of a stage-
The accessory duct of Santorini usually branches out from the pan-
coach suffered a complete pancreatic body transection.2 Over the
creatic duct in the neck of the pancreas and empties separately into
next several decades, reports of pancreatic injuries were scattered. In
the duodenum. A significant number of anatomic variants exist and
1903, after extensive review of the literature, only 45 cases of pancre-
must be recognized: (1) in 60% of individuals, the ducts open sepa-
atic trauma, 21 resulting from penetrating injuries and 24 from blunt
rately into the duodenum; (2) in 30%, the duct of Wirsung carries
trauma could be identified.3 The occurrence of complications fol-
the entire glandular secretion and the duct of Santorini ends blindly;
lowing pancreatic injury was also noted early. In 1905, Korte4 re-
and (3) in 10%, the duct of Santorini carries the entire secretion of
ported a case of an isolated pancreatic transection with resultant
the gland and the duct of Wirsung is either small or absent. In all
pancreatic fistula. The fistula closed spontaneously and the patient
cases, the ducts lie anterior to the major pancreatic vessels.
survived.
The arterial and venous blood supply of the pancreas is relatively
The following chapter attempts to clarify the anatomic and
constant. The arterial blood supply of the pancreas originates from
physiologic basis for the concerns over injuries to the pancreas as well
both the celiac trunk and the superior mesenteric artery. The blood
as elucidate specific diagnostic and therapeutic interventions after
supply to the head of the pancreas appears to be the greatest, with less
traumatic injuries to the pancreas.
flow to the body and tail and the least to the neck. The veins, like the
arteries, are found posterior to the ducts, lie superficial to the arter-
ies, and parallel the arteries for the most part throughout their
ANATOMY course. The venous drainage of the pancreas is to the portal, splenic,
and superior mesenteric vein.
A complete understanding of pancreatic relational anatomy is es-
sential for providing appropriate treatment and understanding the
potential for associated injuries. The pancreas is about 15–20 cm in PHYSIOLOGY
length, 3.1 cm wide, and 1–1.5 cm thick. The average mass is 90 g
(ranging from 40 to 180 g).5 The inferior vena cava, aorta, left kidney, The pancreas is a compound tubuloalveolar gland with both endo-
both renal veins, and right renal artery lie posterior to the pancreas. crine (insulin, glucagon, somatostatin) and exocrine (digestive en-
The head of the pancreas is nestled in the duodenal sweep, with the zyme precursors, bicarbonate) function. The endocrine cells are
body crossing the spine and the tail resting within the hilum of the separated histologically into nests of cells known as the islets of