bubble_chart Overview

Duodenal injury is a severe form of abdominal internal damage, accounting for approximately 3-5% of all abdominal visceral injuries. The duodenum is adjacent to the liver, gallbladder, pancreas, and major blood vessels, so duodenal injury is often accompanied by damage to one or more organs.

bubble_chart Pathogenesis

Duodenal injuries are classified into three types: penetrating, blunt, and iatrogenic. Penetrating injuries are more common abroad, while blunt injuries predominate domestically. The mechanism of duodenal rupture caused by blunt injury involves either direct violence compressing the duodenum against the spine or sudden closure of the pylorus and the duodenojejunal flexure due to trauma, forming a closed-loop segment in the duodenum. This leads to a sharp increase in intraluminal pressure, resulting in rupture and severe retroperitoneal infection. The second and third parts of the duodenum are the most common sites of injury, accounting for 83% of cases observed at Zhongshan Hospital. One notable case involved a crush injury to the upper abdomen, causing complete transection of the duodenum distal to the pylorus and at the junction of the second and third parts, along with necrosis of the horizontal part of the duodenum, highlighting the severity of such injuries. If the injury is limited to the submucosal vascular rupture, it may lead to an intramural hematoma of the duodenal wall, though this is relatively rare.

bubble_chart Diagnosis

Penetrating injury to the upper abdomen should raise suspicion of duodenal injury. Preoperative diagnosis of blunt duodenal injury is extremely difficult due to the following reasons: ① The incidence of duodenal injury is low, and surgeons often lack vigilance. At Zhongshan Hospital, although 6 cases were preoperatively diagnosed with traumatic gastrointestinal perforation, none were considered duodenal injuries. ② Except for the first part, the duodenum is located retroperitoneally, so symptoms and signs after injury are often subtle. Some patients experience no significant discomfort initially, only to develop delayed rupture days later with obvious symptoms and signs. Zhongshan Hospital treated 3 cases of duodenal injury where patients initially presented only with grade I right upper abdominal pain, remaining ambulatory and able to eat. These cases subsequently developed aggravated abdominal pain and diffuse peritonitis at 12 hours, 29 hours, and 4 days post-injury, respectively. While severe abdominal pain and peritoneal irritation signs often appear immediately after duodenal rupture, these are common manifestations of intra-abdominal organ injuries rather than specific to duodenal injury. Concurrent multi-organ injuries further complicate diagnosis. Therefore, the key to preoperative diagnosis lies in considering the possibility of duodenal injury, especially in cases of blunt trauma to the lower chest or upper abdomen followed by severe abdominal pain and peritonitis, or when patients experience relief of upper abdominal pain for several hours before developing right upper abdominal or back pain radiating to the right shoulder or inner thigh. Due to stimulation of the retroperitoneal testicular nerves and sympathetic nerves accompanying the spermatic cord by intestinal fluid leakage, symptoms such as testicular pain and penile erection may occur. Hypotension, vomiting of bloody gastric contents, or crepitus palpable in the rectal pouch should raise suspicion of duodenal injury.

Peritoneal puncture and lavage: This is a reliable auxiliary diagnostic method. Aspiration of intestinal fluid, bile-like fluid, or blood indicates organ injury but is not specific to duodenal injury. Negative peritoneal puncture does not rule out duodenal injury—we encountered one case with five consecutive negative punctures.

X-ray examination: Abdominal plain films showing air masses below the right diaphragm or around the right kidney, disappearance or blurring of the psoas shadow, or scoliosis can aid diagnosis. Oral administration of water-soluble contrast medium followed by imaging revealing contrast extravasation confirms the diagnosis.

bubble_chart Treatment Measures

Abdominal injury: As long as there are indications for exploratory laparotomy, surgery should be performed immediately. It is crucial to conduct a thorough exploration during the operation to avoid a diagnosis of fistula disease.

The treatment of duodenal injury primarily depends on the timing of diagnosis, the location of the injury, and its severity. Lucas (1977) classified duodenal injuries into four grades: Grade I: Duodenal contusion with hematoma of the duodenal wall but no perforation or pancreatic injury; Grade II: Duodenal rupture without pancreatic injury; Grade III: Duodenal injury with grade I pancreatic contusion or laceration; Grade IV: Duodenal injury combined with severe pancreatic injury. Duodenal lacerations can be further categorized by size into: ① Perforation wounds; ② Transmural injury involving less than 20% of the circumference; ③ Transmural injury involving 20–70% of the circumference; ④ Transmural injury involving more than 70% of the circumference. Local management methods for duodenal injury include:

1. For intramural hematoma of the duodenum without rupture, non-surgical treatment may be considered, including gastrointestinal decompression, intravenous fluids and nutrition, and antibiotic administration to prevent infection. Most hematomas can be absorbed and heal spontaneously through organization. If the hematoma persists for more than two weeks and causes obstruction, the intestinal wall may be incised to remove the hematoma, followed by suturing or gastrojejunostomy.

2. For small duodenal lacerations with clean edges, simple suturing and repair may suffice. To avoid stenosis, transverse suturing is preferred. Approximately 80% of duodenal lacerations can be treated this way. If the injury is too severe for suturing, the injured segment may be resected, and an end-to-end anastomosis performed. If tension is too high for anastomosis, the distal end may be closed, and the proximal end anastomosed side-to-side with the jejunum.

3. For large duodenal defects with severe contusion and edema at the edges, diversion procedures may be employed. The goal is to divert duodenal fluid and decompress the lumen to promote healing. There are two diversion methods: - One is jejunoduodenostomy, where the duodenal defect is anastomosed side-to-side or end-to-side with the jejunum using a Roux-en-Y technique, which is the simplest and most reliable method. - The other is duodenal diverticulization, which involves repairing the duodenal defect, resecting the gastric antrum, severing the vagus nerve, performing gastrojejunostomy, and creating a duodenostomy for decompression to exclude the duodenum and facilitate healing. This method is suitable for severe duodenal injuries or those combined with pancreatic injuries. Three cases at Zhongshan Hospital achieved satisfactory results with this approach, but the procedure is complex and time-consuming, limiting its application. Some authors propose a temporary duodenal diverticulization without gastric antral resection, where the greater curvature of the antrum is incised and closed with absorbable sutures, temporarily preventing food from entering the duodenum until the sutures dissolve and pyloric function resumes. For large duodenal defects, a pedicled jejunal patch may also be used to repair the defect, known as the "patch tonifying method."

4. For cases diagnosed late, with severe infection or abscess formation around the injury, suturing and repair are not advisable. Instead, the defect may be used to create a duodenal fistula, which can heal spontaneously with treatment. If it does not heal, fistulectomy may be performed after inflammation subsides.

5. Combined severe injuries of the duodenum and pancreas are the most challenging to manage. Generally, duodenal diverticulization or pancreaticoduodenectomy is performed. The latter has a mortality rate as high as 30–60% and is reserved for cases with extensive injury to the duodenum and pancreatic head where repair is impossible.

Regardless of the surgical method chosen, effective duodenal decompression is critical for wound healing. Stone reported that among 237 cases of duodenal injury, only one case developed a duodenal fistula when decompression was routinely applied after repair, whereas 7 out of 23 cases without decompression developed fistulas, highlighting its importance. Methods of duodenal decompression include nasogastric tube decompression, gastrostomy, duodenostomy at the repair site, or retrograde intubation via jejunostomy. In recent years, triple-tube decompression has been advocated: one tube inserted via gastrostomy and two via proximal jejunostomy—one for retrograde duodenal decompression and the other for distal enteral nutrition support.

Adequate peritoneal drainage and early nutritional support are of great significance for duodenal injury.

The most common complications after surgery are duodenal fistula, intra-abdominal and subphrenic abscesses, duodenal stenosis, etc.