Keywords
duodenal trauma - AAST (American Association for the Surgery of Trauma) - rhabdomyolysis
- hyperkalemia - anastomosis
Duodenal injuries are uncommon and difficult to diagnose,[1] with an incidence between 1 and 5% in cases of abdominal trauma.[2]
[3] In a review by García Santos et al,[3] which included 23 case series of duodenal injury, it was found that the ratio of
penetrating to blunt abdominal trauma was 3.9:1. Among blunt abdominal trauma, the
most frequent mechanism of injury was due to motor vehicle crashes in 85%, due to
the crushing of the duodenum with the steering wheel and spine.[3]
[4] Among penetrating injuries, 81% were caused by gunshot wounds and 19% by stab wounds.[3]
The mortality associated with this type of injury ranges from 18 to 30%.[1]
[3] Early deaths are due to massive bleeding from major vascular injuries or associated
head trauma, while late deaths are associated with sepsis, duodenal fistulas, and
multiorgan failure. It is imperative to recognize these types of injuries in a timely
manner, since the most important risk factor associated with mortality is the delay
between diagnosis and treatment,[3] given that a diagnostic delay in the first 24 hours can increase mortality up to
four times. Other risk factors that increase the mortality rate include the presence
of an associated pancreatic injury and injury to the common bile duct.[3]
[5]
Since the duodenum is surrounded by other organs and vital structures, associated
intra-abdominal injuries are present in 68 to 100% of cases.[1]
[3]
[4] The trauma kinematics play an important role in the severity and the organ affected,
with the structures with the highest injury rate being the liver 17%, pancreas 12%,
small intestine 11%, colon 13%, stomach 9%, biliary tract 6%, kidney and urinary tract
6.5%, spleen 4.1%, and vascular injuries such as aorta, vena cava, and portal vein
in up to 15%. The vascular injuries pose the highest mortality rate due to the high
possibility of death from massive bleeding in the first minutes to hours after the
injury.[3]
Regarding the duodenum, an analysis was carried out on a total of 1,042 patients where
the most frequent site of injury was the second portion (D2) in 36%, followed by the
third portion (D3) in 18% and the fourth portion (D1) in 15%. The least frequently
injured duodenal portion was the first (D1), with 13%, and multiple portion injuries
were found in 18%.[3]
Clinical Case
A 30-year-old male with no comorbidities and a positive history of methamphetamine
(crystal meth) use was treated in a private institution for loss of consciousness
following a motorcycle collision. No relevant abdominal findings were noted at that
moment. Chest X-rays and a computed tomography (CT) scan of the head were performed,
and he was discharged with no neurological abnormalities. After 48 hours, he began
experiencing severe abdominal pain, signs of high intestinal obstruction, and syncope,
prompting transfer to our institution.
Upon arrival, the patient had a Glasgow Coma Scale score of 13, frank pallor, marbled
skin, tachycardia at 120 beats per minute, tachypnea at 40 revolutions per minute,
hypotension at 90/60 mm Hg, and a fever of 38.5°C. Abdominal examination revealed
absent bowel sounds, diffuse abdominal tenderness, and rigidity and tympanic percussion
over the liver.
An abdominal CT scan revealed free fluid in the perihepatic, perisplenic, and pelvic
spaces, and free air in the abdominal cavity, as seen in [Fig. 1]. There was also evidence of possible duodenal disruption, as seen in [Fig. 2].
Fig. 1 Abdominal computed tomography (CT) scan. Free intraperitoneal air, free fluid surrounding
the spleen and liver (the arrow signifies the free intraperitoneal air).
Fig. 2 Abdominal computed tomography (CT) scan showing duodenal disruption with intestinal
wall pneumatosis (the arrow signifies the duodenal disruption).
Prior to surgery, the patient received massive fluid resuscitation with 0.9% sodium
chloride, broad-spectrum antibiotics, analgesia, nasogastric tube catheter, and urinary
catheter with a urine output of 0.4 mL/kg/hour. Blood products, including packed red
blood cells, plasma, and platelet concentrates, were also administered.
Surgical exploration via a midline laparotomy incision revealed 2,750 mL of hemobiliary
fluid and several organs injured. A duodenal injury was identified in the third portion
of the duodenum, with an American Association for Trauma Surgery (AAST) grade III
disruption (50–100% circumferential disruption), as seen in [Fig. 3]. A pancreatic injury AAST grade II, with superficial laceration and no involvement
of the main ducts. One jejunal injury AAST grade V, with a 5-cm segmental loss of
tissue 100 cm from the angle of Treitz. The patient also presented a vascular injury
to the middle colic artery in its lateral portion, which was repaired with 4-0 Vicryl
suture. The duodenal and jejunal injuries were repaired with two-layer end-to-end
anastomosis without tension, as seen in [Fig. 4]. The abdominal cavity was washed out with 4 L of warm solution. During the postoperative
period, the patient had low urine output, metabolic acidosis, and shock, necessitating
vasopressor support with norepinephrine and bicarbonate administration.
Fig. 3 Grade III duodenal laceration of D3.
Fig. 4 Duodenal end-to-end anastomosis (the arrow signifies the duodenal end-to-end anastomosis).
In the first 24 hours after surgery the patient developed rhabdomyolysis, worsening
of the kidney function, and hyperkalemia with a potassium level of 6.9 mmol/L. He
also demonstrated electrocardiographic changes consistent with supraventricular tachycardia,
probably associated to the vasopressor use and meth consumption. One session of hemodialysis
was sufficient to help restore kidney function. Early total parenteral nutrition was
initiated, and the nasogastric tube was removed on the second day, with enteral feeding
started on the fifth day without evidence of leakage via Penrose drain.
The patient was discharged without complications on the eighth day postoperatively.
Three outpatient follow-up visits showed only scant serous fluid around the wound,
which was drained without complications. The fluid was sent for analysis to rule out
pancreatic fistula, which tested negative for amylase and lipase.
Discussion
The diagnosis of duodenal injury can be difficult, especially in cases of blunt abdominal
trauma, as the symptoms may be unspecific; they may present with abdominal tenderness
and peritonitis on initial evaluation, highly suggestive of intra-abdominal injuries,
but not specific to a duodenal injury.[4]
[5]
Focused Assessment with Sonography in Trauma (FAST) is a widely accepted and useful
method in cases of blunt abdominal trauma; however, it has low sensitivity for duodenal
injuries, as up to 30% of patients with some type of retroperitoneal injury, including
the duodenum, may have a normal FAST exam.[4]
[5]
Abdominal radiography in the upright position may suggest duodenal injury if right
psoas muscle effacement or retroperitoneal air is found, however, it is unreliable.[3]
CT is one of the best methods for diagnosing duodenal injuries in hemodynamically
stable patients, even without the need for hydrosoluble contrast.[1] The sensitivity of CT for detecting biliopancreato-duodenal injuries approaches
83%, decreasing to 79% for biliopancreatic (BP) injuries and 50% for bilioduodenal
injuries.[5]
[6] The findings of a duodenal injury include thickening of the wall, periduodenal or
right pararenal fluid, decreased enhancement in the injured duodenal segment, and
accumulation of clots near the site of injury, which is visualized as a heterogeneous
fluid collection (the “sentinel clot sign”).[4] Findings suggestive of duodenal perforation include the presence of retroperitoneal
air, wall disruption, and contrast extravasation.[3]
[5]
Magnetic resonance imaging is more sensitive than CT for detecting low-grade injuries;
however, it is more expensive and lacks utility in the context of trauma; its use
is generally reserved for the evaluation of associated biliary or pancreatic ductal
injuries.[5]
Classification
There are different scales developed to classify the severity of injuries in the context
of trauma, such as the World Society of Emergency Surgery or the AAST, the latter
classifying duodenal injuries into five grades ranging from hematoma or laceration
to massive disruption of the pancreatoduodenal complex[7] ([Table 1]).
Table 1
AAST duodenum injury scale
|
Grade[a]
|
Type of injury
|
Injury description
|
|
I
|
Hematoma
|
Single portion fo duodenum
|
|
Laceration
|
Partial thickness
|
|
II
|
Hematoma
|
More than one portion
|
|
Laceration
|
< 50% of circumference
|
|
III
|
Laceration
|
50–75% of D2 circumference
|
|
50–100% of D1, D3, or D4 circumference
|
|
IV
|
Laceration
|
> 75% of D2 circumference
|
|
Involving ampulla or bile duct
|
|
V
|
Laceration
|
Massive disruption of duodenopancreatic complex
|
|
Vascular
|
Devascularization of duodenum
|
Abbreviations: AAST, American Association for the Surgery of Trauma; D1, duodenum
first portion; D2, duodenum second portion; D3, duodenum third portion; D4, duodenum
fourth portion.
Note: Adapted from Moore et al, 1990.[7]
a Advance one grade for multiple injuries up to grade III.
Medical Treatment
The initial management of all trauma is based on the ATLS (Advance Trauma Life Support);
if the patient is hemodynamically stable and demonstrates grade I or II duodenal injury
without other associated intra-abdominal injuries, conservative management can be
used, which consists of fasting, placement of a nasogastric tube, close monitoring,
and a CT scan in 12 to 24 hours in case of clinical deterioration. In case of grade,
I or II hematoma with clinical signs of intestinal obstruction, monitoring for 14
days is recommended, and if there is no resolution, surgical management should be
considered.[2]
Surgical Treatment
Up to 70% of duodenal injuries can be successfully resolved by primary repair, leaving
a remaining 30% that may require more complex procedures.[1]
[2]
[3] This includes pyloric exclusion, decompression, or duodenal diverticulization, among
others, especially for complex injuries.[1]
[8] Complex injuries are those that involve 75% of the duodenal wall, the first or second
portion of the duodenum, those with a repair delay greater than 24 hours, and those
associated with pancreatic or bile duct injuries.[3]
AAST grade I to II injuries: lacerations should be repaired in a transverse manner
with imbricating stitches, without tension, and nonviable edges should be debrided.
No superiority has been shown in performing closure in one or two layers. In case
of a hematoma that is obstructing > 50% of the lumen, it should be carefully drained.[2]
AAST grade III–V injuries that do not involve the duodenopancreatic complex can be
managed in the same way as minor injuries, by debriding necrotic edges and primary
closure or anastomosis.[4]
AAST grade IV and V injuries involving the ampulla increase the severity and complexity
of management.[4] For injuries limited to the ampulla, there is the possibility of placing stents
or performing sphincteroplasty. However, in case of total avulsion of the ampulla,
a choledocoduodenal anastomosis should be considered. Other extensive injuries in
this area, whether intramural or intrapancreatic of the common bile duct, may be candidates
for a pancreatoduodenectomy.[3]
[9]
Any method of duodenal exclusion has shown the same rates of complications and mortality,[8] but pyloric exclusion is the most commonly used procedure because it is technically
simpler.[4] Despite this, it offers little advantage over primary repair with adequate decompression
using a nasogastric tube, adding operative time and increasing the risk of an extra
anastomosis.[1] Another consideration for this procedure is the average time of spontaneous reopening
at 3 weeks regardless of the technique used. It is a frequent site of marginal ulcers
with an incidence up to 33%, so in addition to the surgical time and its few demonstrable
benefits, it is a procedure that is performed every time with less frequency.[10]
Duodenostomy
Duodenojejunostomy with creation of a Roux-en-Y anastomosis remains an accepted treatment,
especially in patients in whom primary repair could cause duodenal stenosis greater
than 50%, or in patients with associated pancreatic injuries.[1] With injuries involving the first or second proximal portion of the duodenum, an
antrectomy and Billroth II reconstruction may be an option.[2]
Pancreaticoduodenectomy
This complex procedure is reserved for injuries that damage the pancreatoduodenal
complex, with ampullary destruction and BP ducts involvement. Other indications include
massive or difficult to control bleeding.[1]
In a retrospective review from the Panamerican Trauma Society which included 11 centers
and 372 patients over a 10-year period, primary repair was the most common type of
surgical management (80%). Sixteen patients underwent pyloric exclusion with gastrojejunostomy,
13 had pyloric exclusion without gastrojejunostomy, 37 had primary repair with retrograde
decompressive duodenostomy with or without distal feeding tube, 5 had resection with
primary anastomosis, and 2 had a Whipple procedure. Primary repair was used in 80%
of patients, even in high-grade duodenal injuries, and 2.5% of patients had injuries
where primary repair was not possible. Primary repair was a safe and effective way
to treat duodenal injuries. Although there are more complex options available, it
is not clear that they are better, thus, primary closure is still the treatment of
choice.[8]
A review by Siboni et al[11] with a total of 743 patients with duodenal trauma showed 280 (37.7%) underwent primary
repair, 68 (9.2%) gastrojejunostomy, and 5 (0.7%) pancreatoduodenectomy. For most
injuries, primary repair was performed regardless of the severity of the duodenal
injury. Although there was no statistical difference in the choice of procedure according
to the severity of the injury, in a small number of complex duodenal injuries, surgeons
tended to be less likely to perform primary repair. Hospital mortality and postoperative
sepsis were similar in patients undergoing primary repair versus gastrojejunostomy,
even in high-grade injuries (mortality 6.6% vs. 4.5%, p = 0.777, sepsis: 10.4% vs. 6.7%, p = 0.578). The mean time of hospital stay, however, was significantly shorter in patients
treated with primary repair (11 vs. 18 days), with no significant difference in sepsis
or mortality rate.[11]
Complications
Duodenal injuries are associated with a complication rate up to 65%, such as fistulas
(6–33%), intra-abdominal abscesses and sepsis (17.8%), or posttraumatic pancreatitis
(3–15%).[2]
[4]
[8]
The most important risk factor for the development of complications is the presence
of preoperative and intraoperative hypotension.[10] Other risk factors include blunt abdominal trauma, high-speed projectiles, the degree
of duodenal injury, delay of more than 24 hours to treatment, and the presence of
bile duct injury.[4]
A retrospective cohort study analyzing primary repair in duodenal injuries, compared
physiological variables between patients who had leaks and those who did not; pH and
lactate were the two physiological parameters most associated with this adverse outcome.[9] In addition, the percentage of leaks was classified according to the anatomical
site of the affected duodenum. A total of 91 duodenal injuries were analyzed, D1 (31),
D2 (12), D3 (37), and D4 (16), the chi-square test revealed a significant difference
in the leak rate between AAST-I (0%), AAST-II (1.6%), and AAST-III (66.7%) injuries
(p < 0.01). Six out of seven (86%) patients who developed a leak had an AAST grade III
injury and one had grade II injury. AAST grade III injuries also had significantly
higher mortality rates (33.3%) than grade II (9.3%) and grade I (11.1%) injuries (p = 0.04).[9]
It is essential for the comprehensive management of patients with severe abdominal
trauma to identify rhabdomyolysis as the main cause of acute renal failure. Timely
management is based on rapid and effective restoration of volume status, improvement
of renal blood perfusion, use of renal protectants, administration of diuretics with
normal volume status, and especially in rhabdomyolysis and oliguria, control of acidosis;
as well as monitoring and correction of hyperkalemia, even considering hemodialysis.[12]
Conclusion
There are several surgical techniques described for treating high-grade duodenal injuries,
some more complex than others. However, primary closure has been shown to be superior
in terms of postoperative results, showing to be the least complex procedure and the
fastest to perform. Therefore, it can be applied in patients with this type of duodenal
injury who are also hemodynamically unstable.
