Management of Full-Thickness Duodenal Laceration in the Damage Control Era: Evolution to Primary Repair Without Diversion or Decompression

Abstract

The management of duodenal laceration (DL) is controversial. We sought to determine the influence of damage control (DC) on the use of decompression/diversion/exclusion (DDE) techniques and the risk of duodenal-related complications (DRC). We conducted a retrospective review of all patients with full-thickness DL surviving more than 72 hours in the years 1989 to 2009. Forty-one patients with a median duodenal organ injury scale of 3 and a mean abdominal trauma index (ATI) of 45 ± 24 underwent laparotomy. Twenty-five patients (61%) were treated with DC and 16 (39%) with fascial closure (FC). Although the ATI of the patients treated with DC was greater than the ATI of the patients treated with FC (56 ± 23 vs 28 ± 17, P < 0.001), DRCs were equivalent (two vs three, nonsignificant). Twenty-one patients were treated in the first decade and 20 in the second decade. Between the first and second decades, there were trends toward an increased use of DC (52 to 70%, nonsignificant) and a decreased use of DDE (52 to 35%, nonsignificant) with a significant reduction in DRC (5 vs 0, P = 0.04). Among the 18 patients (44%) who underwent DDE procedures there were 2 DRCs (11%) related to DDE. Among the 23 patients who did not have DDE, there were three DRCs (13%), including two obstructions, one partial and one complete. When DC is used after DL, DDE may be unnecessary. Diversion is recommended, however, when the duodenum is at risk for obstruction after primary repair.

Neglected, Traumatic Duodenal Rupture - Case Report

“…CT with contrast seems to be the most useful and effective method in diagnosis of nonpenetrating abdominal trauma including those addressing duodenum and pancreas. It allows visualization of majority of injuries of abdominal organs even stomach and intestines (4,5). We also performed CT in our case and its results were corresponding with intraoperational findings although it did not reveal laceration of posterior wall of duodenum.…”

“…Immediate diagnosis and repair of duodenal laceration seem to be the best and the most commonly performed procedures (2,4,5). Duodenal drainage by advancing of nasogastric tube or by jejunostomy can be added (8).…”

“…Duodenal drainage by advancing of nasogastric tube or by jejunostomy can be added (8). Safety duodenostomy, cholecystectomy and T-tube common bile duct drainage were described in previous papers (7,9) but their effectiveness has not been proved and they are not advised to be performed any more (1,4,5,10). Nutritional jejunostomy which is indicated allows intestinal feeding in case of dehiscence of the suture or other complications (1,2,5).…”

“…Safety duodenostomy, cholecystectomy and T-tube common bile duct drainage were described in previous papers (7,9) but their effectiveness has not been proved and they are not advised to be performed any more (1,4,5,10). Nutritional jejunostomy which is indicated allows intestinal feeding in case of dehiscence of the suture or other complications (1,2,5). Described repair of two-sites duodenal laceration was risky due to postponing of procedure, its size and inflammation phase of healing of perforation.…”

“…Literature reveals that posterior retroperitoneal duodenal wall is more vulnerable for rupture than anterior part and that duodenal laceration has higher incidence among children than adults (1,2,6). Isolated duodenal injuries are rare, they usually accompany more complex trauma including those extra-abdominal (2,3,5).…”