Duodenal injury occurs less frequently than gastric injury, accounting for approximately 1.16% of abdominal injuries. It is more commonly observed in the horizontal and descending parts of the duodenum. Diagnosing and managing duodenal injuries is challenging, with high rates of complications and mortality. Studies indicate that the mortality rate for war-related duodenal injuries is approximately 40%, while peacetime injuries carry a mortality rate of 12–30%. Mortality rates are even higher when injuries involve nearby structures such as the pancreas or major blood vessels. Early mortality typically results from severe associated injuries, particularly major abdominal vascular trauma, while later deaths often occur due to delayed diagnosis or improper management, leading to duodenal fistulae, subsequent infection, hemorrhage, and multi-organ failure.
If the injury occurs within the peritoneal cavity, pancreatic fluid and bile leakage into the abdominal cavity can result in early signs of peritonitis. Preoperative diagnosis is often not precise regarding the specific injury site, although the symptoms are usually apparent enough to prompt timely surgical intervention. In cases of retroperitoneal duodenal rupture caused by blunt trauma, early symptoms and signs are often nonspecific, making recognition difficult. Certain clinical findings warrant a higher suspicion of duodenal injury, such as persistent and increasing localized tenderness in the right upper abdomen or right flank, which may radiate to the right shoulder or right testicle. Other suggestive findings include mild abdominal signs with progressively worsening systemic condition, hematemesis, elevated serum amylase, and radiographic evidence of retroperitoneal air or haziness in the psoas muscle region that expands over time. Leakage of contrast material from the duodenum may be observed following the administration of water-soluble iodinated contrast through a nasogastric tube. Imaging studies such as CT or MRI may reveal retroperitoneal gas or air in the perirenal space on the right side. Occasionally, rectal examination may detect crepitus in the presacral space, suggesting gas has spread to the retroperitoneal pelvic cavity.
Management
Treatment involves managing shock and performing timely and appropriate surgical intervention. During surgical exploration, the presence of retroperitoneal hematoma near the duodenum, tissue discoloration due to bile staining, or crepitus in the root of the transverse mesocolon should raise suspicion of retroperitoneal duodenal rupture. Exploration of the posterior peritoneum at the lateral edge of the duodenum or at the root of the transverse mesocolon may be performed to assess the descending and horizontal portions of the duodenum.
Surgical techniques commonly employed include:
- Primary Repair: Suitable for small, clean-edged tears with good blood supply and without tension.
- Pedicled Jejunal Patch Repair: For larger defects that cannot be directly sutured, a segment of jejunum with a vascular pedicle can be mobilized, opened, trimmed, and sewn into the defect.
- Duodenojejunostomy: Recommended for severe injuries to the horizontal or ascending portions of the duodenum, where primary repair is infeasible. Options include resection of the injured segment with end-to-side anastomosis of the proximal duodenum to the jejunum, or closure of both duodenal ends followed by side-to-side duodenojejunostomy.
- Duodenal Diverticulization: Involves repairing the duodenal injury, performing duodenostomy for decompression, partial gastrectomy with a Billroth II gastrojejunostomy, and, if necessary, pancreatic drainage. This method is typically reserved for severe injuries involving both the duodenum and pancreas. A modified approach involves temporary duodenal diverticulization by closing the pylorus using absorbable purse-string sutures via a gastrotomy, which can be reversed after three weeks.
- Seromuscular Incision and Hematoma Evacuation: For duodenal wall hematomas causing high-grade bowel obstruction unresponsive to conservative treatment within two weeks, hematoma evacuation and repair of the bowel wall are performed, or alternatively, gastrojejunostomy may be indicated.
- Pancreaticoduodenectomy: Considered for extensive duodenal and pancreatic injuries, although it carries high surgical morbidity and mortality.
- Resection with Anastomosis: For severe duodenal destruction sparing the area around the ampulla, the damaged duodenum can be resected, with the remaining duodenal wall around the papilla anastomosed to a jejunal loop and a separate gastrojejunostomy performed.
Any procedure for duodenal rupture should incorporate gastrointestinal decompression, such as nasogastric suction, gastrostomy, or jejunostomy to decompress proximal and distal duodenal segments. Placement of a T-tube in the common bile duct may also be necessary. Peritoneal drainage should be routinely performed using drainage tubes to ensure adequate drainage of the abdominal cavity. Nutritional support is essential to promote healing of duodenal injuries.