Traumatic Duodenal Injury: Current Management Update

Management of Traumatic Duodenal Injury: Is There a Role for Early Parenteral Nutrition?

INTRODUCTION

Traumatic duodenal injuries are complex in nature and pose major challenges to trauma surgeons. These injuries are associated with high mortality rates ranging from 18% to 30% and require prompt, comprehensive care. Traumatic injury induces a hypercatabolic state that mobilizes body energy stores, leading to muscle wasting, delayed healing, and potential multi-organ failure. Nutritional support is vital in keeping up with the metabolic demands of traumatically injured patients. However, exactly when and how nutrition should be provided for traumatic duodenal injuries is unclear. We hypothesize that patients who sustain high-grade duodenal injuries (grades III-V) will be unable to tolerate enteral nutrition (EN) and may benefit from early initiation of total parenteral nutrition (TPN).

METHODS

In this retrospective chart review study, we queried the trauma registry for patients admitted between January 2018 and December 2022 with duodenal injury. Individuals under the age of 18 and individuals who were pregnant were excluded. Twenty-eight patients met the inclusion/exclusion criteria. The primary endpoint was median number of days from initial injury to supplemental nutrition. We also evaluated the route used to achieve adequate nutrition based on duodenal injury grade (I-V), mortality based on duodenal injury grade, morbidity based on route of nutrition supplementation (hospital length of stay [LOS], intensive care unit LOS, and ventilator days), and complications based on route of nutrition supplementation.

RESULTS

Of the 28 patients analyzed, 11 received EN, 10 received TPN (6 of which survived to transition to EN), and 7 died within 3 d of admission and did not receive any form of nutrition. The median number of days post-trauma to toleration of enteral feeding (defined as by mouth or tube feeding that meet total caloric needs based on nutritionist recommendations) was 4 d for those who did tolerate and maintained tolerance of enteral feeding, compared to 7.5 d post-trauma to initiate total parenteral feeding (P = 0.061). Injury grades I and II tolerated EN within a median of 6 d, whereas injury grades III and IV showed inability to tolerate EN until after a median of 22 d or longer (P = 0.02). Mortality increased as injury grade increased. Patients who received TPN were more likely to develop abscesses than those receiving EN (80% vs 27%, P = 0.03) but not more likely to develop a duodenal leak (P = 0.31). Patients who received TPN had longer hospital LOS (35.5 d vs 9 d, P = 0.008), longer intensive care unit LOS (17 d vs 4 d, P = 0.005), and increased ventilator days (9 d vs 1 d, P = 0.005) when compared to patients who received EN.

CONCLUSIONS

Individuals with higher grade duodenal injuries showed inability to tolerate EN until after a median of 22 d, and therefore, consideration should be given to initiating TPN early to mitigate the catabolic effects of malnutrition. Further studies need to be done with a larger number of patients to evaluate the effects of malnutrition in these patients.

Failed primary repair of blunt duodenal injury managed by tube duodenostomy, gastrojejunostomy and a feeding jejunostomy: a case report

BACKGROUND

The worldwide increase in road traffic crashes and use of firearms has increased the incidence of duodenal injuries. Upper gastrointestinal radiological studies and computed tomography (CT) in resource settings may lead to the diagnosis of blunt duodenal injury. Exploratory laparotomy remains the ultimate diagnostic test if a high suspicion of duodenal injury continues in the face of absent or equivocal radiographic signs. Although the majority of duodenal injuries may be managed by simple repair, high-risk duodenal injuries are followed by a high incidence of suture line dehiscence and should be treated by duodenal diversion.

CASE PRESENTATION

We report a case of a failed primary repair of a blunt injury to the second part of the duodenum (D2) in a 24-year-old African man. This was successfully managed by a tube duodenostomy, a bypass gastrojejunostomy and a feeding jejunostomy in a low resource setting.

CONCLUSIONS

Detailed knowledge of the available operative choices in duodenal injury and their correct application is important. When duodenal repair is needed, conservative repair techniques over complex reconstructions should be utilised. The technique of tube duodenostomy can be successfully applied to cases of large defects in the second part of the duodenum (D2), failed previous repair attempts and with defects caused by different aetiology. It may remain especially useful as a damage-control procedure in patients with multiple injuries, significant comorbidities and/or haemodynamic instability.

Delayed Primary Repair of Complex Duodenal Injury Associated to Multiorgan Failure Due to Blunt Abdominal Trauma

Duodenal injuries are rare and difficult to diagnose, with an incidence between 1 and 5% in cases of abdominal trauma. We present the case of a 30-year-old man who suffered a motorcycle collision presented with a 24-hour history of abdominal pain, peritoneal tenderness, and hemodynamic instability. Imaging studies show evidence of free fluid in the perihepatic, perisplenic, and pelvic space. An exploratory laparotomy was performed, finding a grade III duodenal, grade V jejunal, and grade II pancreatic injuries. The basis of surgical treatment being a primary anastomosis of duodenal and jejunal injuries, which allowed discharging him home 8 days after surgery and without any complications in his follow-up.

A delayed presentation of a traumatic isolated duodenal injury

Blunt injury to the abdomen resulting in isolated duodenal injury is rare in surgical practice. Due to the insidious onset of symptoms and the vague non-specific nature of the clinical presentation, these injuries can be easily missed even in experienced hands. Contrary to Europe or developed countries, assaults to the abdomen using hands, fists, and feet in home-based violence is common in third-world countries. These patients have the habit of hiding the assault part of the history to avoid litigations to 'known' people. A high level of suspicion, a continuous revisiting of the history, and timely damage control surgery can improve the outcomes of such patients.

Pancreas sparing duodenectomy in the treatment of primary duodenal neoplasms and other situations with duodenal involvement

BACKGROUND

There are no clearly defined indications for pancreas-preserving duodenectomy. The present study aimed to analyze postoperative morbidity and the outcomes of patients undergoing pancreas-preserving duodenectomy.

METHODS

Patients undergoing pancreas-preserving duodenectomy from April 2008 to May 2020 were included. We divided the series according to indication: scenario 1, primary duodenal tumors; scenario 2, tumors of another origin with duodenal involvement; and scenario 3, emergency duodenectomy.

RESULTS

We included 35 patients. Total duodenectomy was performed in 1 patient of adenomatous duodenal polyposis, limited duodenectomy in 7, and third + fourth duodenal portion resection in 27. The indications for scenario 1 were gastrointestinal stromal tumor (n = 13), adenocarcinoma (n = 4), neuroendocrine tumor (n = 3), duodenal adenoma (n = 1), and adenomatous duodenal polyposis (n = 1); scenario 2: retroperitoneal desmoid tumor (n = 2), recurrence of liposarcoma (n = 2), retroperitoneal paraganglioma (n = 1), neuroendocrine tumor in pancreatic uncinate process (n = 1), and duodenal infiltration due to metastatic adenopathies of a germinal tumor with digestive hemorrhage (n = 1); and scenario 3: aortoenteric fistula (n = 3), duodenal trauma (n = 1), erosive duodenitis (n = 1), and biliopancreatic limb ischemia (n = 1). Severe complications (Clavien-Dindo ≥ IIIb) developed in 14% (5/35), and postoperative mortality was 3% (1/35).

CONCLUSIONS

Pancreas-preserving duodenectomy is useful in the management of primary duodenal tumors, and is a technical option for some tumors with duodenal infiltration or in emergency interventions.