Evolution in the Management of Duodenal Injuries

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Because of its retroperitoneal location, injuries to the duodenum are uncommon, although not rare. Duodenal injuries represent approximately 3 to 5% of all abdominal injuries. [1-3] Mortality and morbidity from duodenal injuries are related to the causative agent, location, presence of associated injuries, and type of surgical repair. However, the interval from injury to operation plays the most significant role in determining the incidence of morbidity and mortality. Lucas and Ledgerwood reported a mortality rate of 40% in patients who were not operated on within the first 24 hours after injury, in contrast to a mortality rate of 11% among those patients operated on less than 24 hours after the injury. [4] Over the last two decades, there has been a decline in the overall mortality in these injuries with an overall current mortality between 10.5% and 14%. [5] Penetrating trauma accounts for 78% of all duodenal injuries, whereas blunt trauma accounts for 22%. [1]Our objectives in this article are (1) to review the anatomy of the pancreas and duodenum and its implications in diagnosis and treatment of duodenal injuries, (2) to unify concepts of surgical management based on the Organ Injury Scaling, (3) analyze complications and their relationship to morbidity and mortality, and (4) to present current trends and alternatives in the surgical management of these injuries. The general philosophy of surgical treatment has been to simplify the operative management when possible.AnatomyThe small bowel begins with the duodenum, which is its shortest segment measuring approximately 30 cm in adults. The duodenum is relatively fixed in comparison with the other portions of the small bowel. It is divided into four portions. The first superior portion originates from the pylorus to the common bile duct superiorly and the gastroduodenal artery inferiorly. This portion is fairly mobile. The second or descending portion of the duodenum extends from the gastroduodenal artery and common bile duct to the ampulla of Vater. The third or transverse portion extends from the ampulla of Vater to the superior mesenteric vessels, which divides the third and fourth portions of the duodenum. The first three duodenal segments from the "C" loop, which surrounds the head of the pancreas. The fourth or ascending portion of the duodenum extends from the mesenteric vessels to the point where the duodenum joins the jejunum to the left of the second lumbar vertebra. This is also a mobile segment of the duodenum and is fixed only by the ligament of Treitz which extends from the right crus of the diaphragm to the duodenal wall. The first portion of the duodenum is partially covered by peritoneum; the other portions are retroperitoneal. [6]Posteriorly, the duodenum is in proximity to the vertebral column, right kidney with its vascular pedicle, vena cava, and aorta. Anteriorly, the liver, right colon, gallbladder, and stomach are the adjacent structures. In penetrating trauma, associated injuries are the rule.The head of the pancreas is attached to the medical surface of the second and third portions of the duodenum, and blood vessels from the pancreas continue onto the duodenum. This relationship makes isolated resection of the head of the pancreas difficult. The vascular supply of the duodenum is provided by the anastomosis of the superior and inferior pancreatoduodenal arteries and branches of the gastroduodenal and superior mesenteric artery. The origin of the gastroduodenal artery can be anomalous in 20 to 25% of patients. [7] and occasionally leads to inadvertent injury during duodenal mobilization.

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