Indirect signs of blunt duodenal injury on computed tomography: Is non-operative management safe?

Surgical management of duodenal injury: experience from 92 cases

PURPOSE

Duodenal injury increases with traffic accidents, and delayed diagnosis or inappropriate operation increase mortality and complications. This study aimed to explore early recognition and timely surgical intervention.

METHODS

All patients with duodenal injuries treated operatively during the past 10 years were reviewed, and the data were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome.

RESULTS

A total of 92 patients with duodenal injuries accounted for 7.3% of 1258 patients with abdominal injury. Of the 92 patients, 71 (77.17%) experienced blunt trauma, with traffic accidents accounting for 59.2% (42/71). In 35 patients, a preoperative diagnosis was obtained by reviewing abdominal signs, peritoneocentesis, and imaging. The remaining 57 patients underwent urgent laparotomy, through which a definitive diagnosis of duodenal injury was confirmed during the operation. In all 92 patients, the surgical procedures involved simple sutures; pedicled jejunal piece coverings; and various anastomoses following resection of the injured duodenal portion, including the Whipple procedure and damage-control surgery principles. The overall mortality rate was 12.0% (11/92) with deaths mainly occurring due to associated injuries. When excluding 2 cases of intraoperative death, there were 47 cases in the double-tube gastrostomy group and 43 cases in the traditional triple-tube group, with mortality rates of 10.64% and 9.30% in the two groups, respectively (χ2 = 0.045, P > 0.05). Postoperative complications occurred in 15 patients (18.5%). There was a high incidence of duodenal (or pancreatic/biliary) leakage.

CONCLUSION

Early diagnosis and operation of duodenal injury are crucial to reducing complications and mortality. Surgical methods should be based on injury grade, associated injuries, and vital signs. Double-tube gastrostomy can reduce complications such as intestinal obstruction.

Imaging Spectrum of Duodenal Emergencies

The duodenum, the first portion of the small bowel, is divided into four segments and extends to both retro- and intraperitoneal spaces. Some conditions arise primarily from the duodenum, but it can be secondarily affected by processes that involve neighboring structures. When duodenal emergencies are not identified and treated promptly, they may result in high morbidity and mortality. Imaging plays an important role in the diagnosis of duodenal conditions in the acute setting. However, the radiologic findings can be subtle, and awareness of relevant patient history and clinical presentation is important as it may increase the index of suspicion and one's ability to diagnose these conditions. Duodenal peptic disease is common and can be complicated by bleeding and perforation. The duodenum can be secondarily involved by pancreatitis and gallbladder pathologic conditions and may be affected by iatrogenic complications following endoscopic procedures. Traumatic injuries to the duodenum are generally uncommon, with penetrating traumatic injury being the most frequent mechanism of injury. Duodenal vascular pathologic conditions such as aortoduodenal fistula are uncommon but can be life threatening. The knowledge of which pathologic condition can involve which duodenal segment can help the radiologist establish a differential diagnosis and achieve a more targeted imaging approach. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

Duodenal Rupture after Blunt Abdominal Trauma by Bicycle Handlebar: Case Report and Literature Review

Blunt abdominal trauma is most frequent in the pediatric population. Duodenal lesions after abdominal trauma in children are infrequent and tend to be secondary to traffic accidents. It is up to five times more frequent in males, with an average age between 16 and 30 years. Bicycle accidents continue to lead to morbidity and mortality in children, representing between 5% and 14% of total blunt abdominal injuries. The diagnosis of duodenal injuries after trauma is difficult and requires a high index of clinical suspicion. We present the case of a 17-year-old patient seen in the emergency room after falling off his bicycle and presented a blunt trauma in the epigastric region. On physical examination, there was a swelling in the upper right abdominal quadrant and epigastrium with tenderness on deep palpation. He presented with hematemesis without hemodynamic repercussion. A contrast abdominal computed tomography was performed and he was diagnosed with third-part duodenal rupture. A resection of the perforated third-part duodenal rupture was performed, and the transit was reconstructed using a Roux-Y duodenojejunostomy. The postoperative period was uneventful and the patient was discharged after 16 days of stay. Duodenal injury is very rare, produced by high-energy trauma. They rarely present as single lesions as other visceral lesions are usually associated. The early diagnosis is important to reduce the morbidity and mortality.

Nonsurgical management of traumatic pneumoperitoneum in a cat

OBJECTIVE

To describe the nonsurgical management of a cat with traumatic pneumoperitoneum.

CASE SERIES SUMMARY

A 4-year-old cat was presented following vehicular polytrauma. Thoracic radiographs revealed 4 rib fractures, a scapular fracture, and pneumothorax. Abdominal ultrasound revealed a small volume of free abdominal fluid. Computed tomography showed a mild pneumoretroperitoneum and a pneumoperitoneum in the region of the porta hepatis. The cat was managed conservatively with close monitoring. Exploratory laparotomy was not pursued given patient stability and static serial imaging studies revealing no indications for surgical intervention. After 6 days, the pneumoperitoneum was no longer detectable.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first report of successful nonsurgical management of traumatic pneumoperitoneum in a cat.

Effectiveness of computed tomography scanning to detect blunt bowel and mesenteric injuries requiring surgical intervention: A systematic literature review

BACKGROUND

Computed tomography (CT) diagnostic accuracy for blunt bowel and mesenteric injuries (BBMI) is controversial.

DATA SOURCES

A literature review to compute aggregate CT performance and individual CT sign sensitivity, specificity, and positive predictive value (PPV) for operative BBMI.

CONCLUSIONS

Sensitivity, specificity, and PPV were: overall CT performance 85.3%, 96.1%, 51.4%; abnormal wall enhancement 30.1%, 95.7%, 64.0%; bowel wall discontinuity 22.3%, 99.0%, 87.9%; bowel wall hematoma 22.5%, 100%, 19.5%; bowel wall thickening 35.2%, 96.5%, 32.1%; free air 32.0%, 98.7%, 57.1%; free fluid 65.6%, 85.0%, 25.5%; mesenteric air 27.6%, 99.1%, 85.3%; mesenteric extravasation 22.9%, 99.6%, 73.9%; mesenteric hematoma/fluid 33.9%, 98.7%, 52.8%; mesenteric stranding/streaking 34.3%, 91.8%, 31.6%; mesenteric vessel beading 32.1%, 97.2%, 60.4%; mesenteric vessel termination 31.6%, 97.2%, 63.5%; oral contrast extravasation 10.0%, 100%, 100%; retroperitoneal air 9.4%, 94.9%, 55.6%; and retroperitoneal fluid 44.2%, 49.4%, 38.5%. Sensitivity, specificity, and PPV vary substantially among known signs. Other clinical factors are necessary for comprehensive BBMI identification.

Duodenal trauma

Duodenal trauma represents a unique challenge to the surgeon due to its relative rarity, anatomic location, and often the difficulty in diagnosing and managing these injuries. Despite these challenges, significant advances have been made over the previous century, and mortality has fallen to as low as 17%. The CT scan is the primary modality for diagnosis in the blunt trauma patient, and thorough surgical exploration at laparotomy is the mainstay for penetrating injuries. Management is guided by the grade of injury, with low-grade hematomas managed by observation, intermediate grade injuries by primary repair, and high-grade injuries with a damage control surgery approach. While pyloric exclusion remains the most common technique to augment primary repair in intermediate and higher grade injuries, the utility of this procedure has come into question in current literature, and an overall ‘less-is-more’ surgical approach has been advocated in recent publications. Complications following duodenal trauma are common and include fistulae, duodenal obstruction, and infectious complications. However, the overall morbidity and mortality have improved with these injuries. Future investigation is needed to determine the optimal management approach for these challenging patients.