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KEY POINTS

KEY POINTS

  • The incidence of injuries to the duodenum at laparotomy is <2% with stab wounds, 5% to 6% with blunt trauma, and 10% to 11% with gunshot wounds.

  • A patient with a blunt rupture of the duodenum may have minimal symptoms initially due to its retroperitoneal location, low bacterial count, and neutral pH contents.

  • A computed tomography (CT) diagnosis of a ruptured duodenum is suggested by air outside the duodenum in the right upper quadrant on the “scout” film and leakage of contrast on the formal study.

  • A primary transverse or oblique suture repair of a blunt rupture or penetrating wound of the duodenum is appropriate if there is no loss of tissue and no injury to the major papilla.

  • Pyloric exclusion with gastrojejunostomy should be considered as an adjunct to a duodenal repair when the repair narrows the duodenum, the duodenal wall around the repair is severely contused, there has been a delay in diagnosis of the duodenal injury, or there are adjacent, but not destructive, injuries to the C-loop and head of the pancreas.

  • The incidence of injuries to the pancreas at laparotomy is approximately 6% with all forms of trauma.

  • When a contrast-enhanced multidetector CT study is unclear about whether an injury to the duct of Wirsung is present after blunt trauma, a magnetic resonance cholangiopancreatography and/or an endoscopic retrograde cholangiopancreatography is performed.

  • The Letton-Wilson Roux-en-Y distal pancreatojejunostomy is appropriate in a highly selected group of patients with Organ Injury Scale proximal grade III and grade IV injuries.

  • A damage control approach (sequential operations) is now used in the majority of patients who need a pancreatoduodenectomy after trauma.

  • Combined pancreatoduodenal injuries have significantly increased postoperative complications and mortality rates when compared to injury to either organ alone.

INTRODUCTION

The duodenum and pancreas are retroperitoneal structures that are protected somewhat from injury by the spine, retro-peritoneal muscles, and overlying intra-abdominal viscera. Injuries to these structures are uncommon, and many trauma surgeons have limited experience in treating them. In the United States, injuries to the duodenum and pancreas are noted at only 1.5% to 11% and 5% to 6% of all laparotomies for trauma, respectively.1 A recent review from the Trauma Audit and Research Network of the United Kingdom and Wales found that only 4.7% of patients with abdominal trauma had injuries to the duodenum or pancreas.2

Isolated injuries to the duodenum and pancreas are rare, and early deaths after injury are usually due to associated vascular injuries or multiple visceral and vascular injuries in the same patient. Other factors in management include delays in patient presentation after blunt trauma, the significant leak rate after pancreatic resections, and difficult decisions with combined injuries.

Outcomes for injuries to either organ have improved in recent years secondary to increased experience and to utilization of time-tested management algorithms.3-7

DUODENUM

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