Management of Duodenal T rauma

1. Management of Duodenal Trauma Dr. Chow Chi Woo Samuel Department of Surgery, Queen Elizabeth Hospital

2. Introduction • Duodenal trauma is uncommon • 3-5% • D2 most common (35%) • > D3 > D4 > D1 • Penetrating trauma (78%) • Gunshot wounds • Stab wounds • Blunt trauma (22%) • Motor vehicle collisions • Steering wheel • Seatbelt • Bicycle handle (paediatrics)

3. Introduction • Associated injuries are common • Liver • Pancreas • Bowel • Major vessels • High mortality (17%) • High morbidity (40%) • Duodenal fistula (7%)

4. Diagnosis • High index of suspicion • Symptoms/signs usually not helpful Penetrating trauma Intra-operative features 1. Bile staining at retroperitoneum 2. Periduodenal hematoma 3. Periduodenal crepitus Blunt trauma Radiological Imaging 1. X-ray 2. CT scan (IV + oral contrast) 3. Fluoroscopy

7. Management • Disease factors • 1. Severity of injury • 2. Associated injuries • Patient factors • 1. Hemodynamic stability

8. Grading of Severity Duodenum Organ Injury Scale (OIS) according to The American Association for the Surgery of Trauma (AAST)

9. Damage control Control hemorrhage Provisional repair Temporary abdominal closure ICU resuscitation Operative Unstable Delayed repair

10. Stable 1. Hemorrhage control 2. Decontamination 3. Repair * Associated injuries Penetrating Operative

11. Intramural hematoma Non-operative Blunt Equivocal CT scan Perforation Stable 1. Hemorrhage control 2. Decontamination 3. Repair * Associated injuries Operative

12. Repair • Aim • Close the defect • Restore continuity • Always ascertain location of ampulla (D2) • Options • Duodenorrhaphy • Duodenorrhaphy + diversion • Duodenal resection + anastomosis • Jejunal serosal patch • Pedicled graft • Whipple operation Simple Complex

13. Duodenorrhaphy • 75-85% of duodenal injuries • Debride non-viable tissue • Tension-free repair • Single/double layer closure • Transverse closure • < 50% of circumference

15. Duodenorrhaphy + Diversion • Indication • High risk of suture line dehiscence • Delayed injury • Large defect • Combined injury • Aim • Divert gastric secretions • Promote healing • Options • Tube decompression • Pyloric exclusion • Duodenal diverticulization Simple Complex

16. Tube decompression • External diversion

17. Pyloric exclusion • Internal diversion

18. Duodenal Resection + Anastomosis • Large duodenal defects (near-circumferential) • Duodenal transections • Segmental resection with end-to-end duodenostomy • Adequate mobilization, tension-free

19. Antrectomy + closure of duodenal stump + side-to-side gastrojejunostomy • Inadequate mobilization • Proximal to ampulla • Closure of duodenal stump + end-to-end duodenojejunostomy • Inadequate mobilization • Distal to ampulla

20. Which repair is the best?

21. Which repair is the best? Low grade injuries Duodenorrhaphy

22. Which repair is the best? High grade injuries 1. Involve CBD/pancreas 2. Devascularization Repairable Non-repairable 1. Damage Control Surgery + delayed reconstruction 2. Duodenorrhaphy + diversion + wide drainage Delayed reconstruction 1. Reimplantation of CBD 2. Hepaticojejunostomy 3. Whipple operation 1. Duodenorrhaphy + diversion 2. Duodenorrhaphy 1. Duodenal Resection + anastomosis 2. Jejunalserosal patch 3. Pedicled graft

23. High grade repairable injuries • Optimal repair remains debatable • Duodenorrhaphy + pyloric exclusion • Classically recommended (Vaughan, Degiannis, Cogbill) • Problems • Increased operative time and hospital stay, extra anastomosis, suture line ulcers • Role downplayed (Seamon) • Duodenorrhaphy + tube decompression • Controversial (Stone, Hasson, Ivatury, Girgin) • Problems • Increased hospital stay, dislodgement, obstruction • Duodenorrhaphy • Gaining popularity (DuBose, Velmahos, Siboni) • Concept of “less is better” Pyloric exclusion Duodenorrhaphy

24. Summary • Duodenal trauma is DEADLY and requires a HIGH INDEX OF SUSPICION for diagnosis • Management depends on HEMODYNAMICS, INJURY SEVERITY and ASSOCIATED INJURIES • DUODENORRHAPHY is good enough for most injuries – keep it simple, but consider DIVERSION when in doubt • Never forget DAMAGE CONTROL

25. References • Vaughan GD, Frazier OH, Graham DY, et al.. The use of pyloric exclusion in the management of severe duodenal injuries. Am J Surg. 1977;134(6):785-90. • Degiannis E, Krawczykowski D, Velmahos GC, et al. Pyloric exclusion in severe penetrating injuries of the duodenum. World J Surg. 1993;17(6):751-4 • Cogbill T H, Moore E E, Feliciano D V. et al. Conservative management of duodenal trauma: a multicenter perspective. J Trauma. (1990);30:1469–1475. • Seamon MJ, Pieri PG, Fisher CA, et al. A ten-year retrospective review: does pyloric exclusion improve clinical outcome after penetrating duodenal and combined pancreaticoduodenal injuries? J Trauma. 2007;62(4):829-33.Stone HH, Fabian TC. Management of duodenal wounds. J Trauma 1979;19:334-9 • Hasson JE, Stern D, Moss GS. Penetrating duodenal trauma. J Trauma. 1984 Jun;24(6):471–474. • Ivatury RR, Gaudino J, Ascer E, et al. Treatment of penetrating duodenal injuries: primary repair vs. repair with decompressive enter- ostomy/serosal patch. J Trauma 1985;25:337-41 • Girgin S, Gedik E, Yağmur Y, et al. Management of duodenal injury: our experience and the value of tube duodenostomy. Ulus Travma Acil Cerrahi Derg. 2009;15:467-72. • Siboni S, Benjamin E, Haltmeier T, et al. Isolated Blunt Duodenal Trauma: Simple Repair, Low Mortality. Am Surg. 2015 Oct;81(10)961-4 • Velmahos GC,Constantinou C,Kasotakis G. Safety of repair for severe duodenal injuries. World J Surg 2008;32:7-12. • DuBose JJ, Inaba K, Teixeira PG, et al. Pyloric exclusion in the treatment of severe duodenal injuries: results from the National Trauma Data Bank. Am Surg. 2008;74:925–9. • Ivatury RR, Malhotra AK, Aboutanos MB, et al. Duodenal Injuries: A Review. Eur J Trauma Emerg Surg 2007;33:231-7 • Ordoñez C, García A, Parra MW, et al. Complex penetrating duodenal injuries: less is better. J Trauma Acute Care Surg. 2014;76(5):1177-83.

26. Question Time