Duodenal perforation following blunt abdominal trauma.

Duodenal perforation following blunt abdominal trauma is an extremely rare and often overlooked injury leading to increased mortality and morbidity. We report two cases of isolated duodenal injury following blunt abdominal trauma and highlight the challenges associated with their management. In both these patients, the diagnosis of the duodenal injuries was delayed, leading to prolonged hospital stay. The first patient had two perforations, one on the anterior and the other on the posterior wall of the duodenum, of which the posterior perforation was missed at initial laparotomy. In the other patient, the duodenal injury was missed during the initial assessment in the emergency department. He returned to the emergency department 24 hours after discharge with abdominal pain and vomiting. During trauma related laparotomy, complete kocherization (mobilization) of the duodenum must be mandatory, even in the presence of obvious injury on its anterior wall. We emphasize on keeping the management protocol simple by a "triple tube decompression", i.e. duodenorrhaphy (simple closure), tube gastrostomy, reverse tube duodenostomy and a feeding jejunostomy.

INTRODUCTION

The duodenum is injured due to crushing or shearing forces on the abdomen. It comprises 0.2–3.7% of all trauma related laparotomies. The incidence of duodenal injuries is 11.2–26% due to blunt trauma.[1-4] On an average, one to four other abdominal organ injuries are associated with duodenal trauma, which makes an isolated injury a rarity.[45]

The anatomical location of the duodenum makes diagnosis and treatment of isolated duodenal injury a difficult task. Due to its rarity and subtle clinical features, the diagnosis and management is often delayed. We describe two patients with isolated blunt duodenal injuries and highlight some problems and principles in the management of duodenal injury.

CASE REPORTS

Case 1

A 14-year-old boy had a fall from a bullock cart. He was initially managed in two private hospitals where he underwent a laparotomy and duodenorrhaphy for traumatic duodenal perforation 30 hours after injury. On the 6th postoperative day (POD), he was referred to our hospital with high-grade fever, altered mental status, abdominal distension and bilious discharge from the laparotomy wound. Hematological investigations revealed thrombocytopenia with features of disseminated intravascular coagulation (DIC).

After adequate resuscitation and stabilization, the patient was taken up for re-laparotomy. The peritoneal cavity was filled with bilious fluid and there was crepitus along the paraduodenal and paracolic area. The previous repair was seen intact on the anterior wall of the second part of the duodenum. On mobilization (Kocherization) of the duodenum, another perforation of size 1.5 cm was discovered on the posterior wall of the second part of the duodenum. The perforation was repaired in two layers and a triple tube decompression, i.e. tube gastrostomy, reverse tube duodenostomy and a feeding jejunostomy, was performed [Figure 1]. An abdominal drain was placed in the paraduodenal area and a polypropylene mesh laparostomy was done.

Figure 1

Graphical representation of the triple tube decompression technique (case 1) (A = tube gastrostomy, B = retrograde tube duodenostomy, C = feeding jejunostomy, P1 = site of the perforation on the anterior wall of the duodenum, P2 = site of the perforation on the posterior wall of the duodenum)

A contrast study on POD 15 showed normal passage of contrast into the jejunum, with no leak from the injury site. Though he had one episode of fever, he was finally discharged on POD 88 in a stable condition.

Case 2

A 21-year-old male had a fall from a scooter. He attended the emergency department in a stable condition, and after primary assessment, the attending physician discharged him. The patient returned to the emergency department with abdominal pain and vomiting 24 hours after discharge. On examination, he was conscious, afebrile, with pulse rate 110/min and a blood pressure of 90/60 mm Hg. There was tenderness in the upper abdomen. Serum amylase was 65 U/L (reference range 95 U/L); total leukocyte count was 11,000/mm3 (reference range 4000–11,000/mm3). Plain abdominal and chest radiographs were normal. Contrast-enhanced computed tomography scan of abdomen with intravenous and oral contrast media revealed free gas in the retroperitoneum, extravasation of contrast and free fluid in the abdomen.

The patient was taken up for emergency exploratory laparotomy. There was bile staining and crepitus in the paraduodenal area and nearly 200 mL of dirty fluid in the right paracolic gutter. Complete kocherization (mobilization) of the duodenum was done. There was a perforation in the second part of the duodenum involving more than 50% of the circumference [Figure 2]. Duodenorrhaphy was done in two layers with 3-0 vicryl and silk sutures. A tube gastrostomy, reverse tube duodenostomy through the proximal jejunum, and a feeding jejunostomy and polypropylene mesh laparostomy were performed. He was discharged home on POD 42.

Figure 2

Photograph showing the traumatic perforation on second part of duodenum (a), gall bladder (b). Please note the extensive bilious staining and pus flakes all around in the retroperitoneum

Technique of mesh laparostomy

We performed a polypropylene mesh laparostomy in both the patients, since a safe definitive closure of the abdominal wall was not feasible due to tension and a primary closure could have resulted in the development of an abdominal compartment syndrome. Instead, a transparent low-cost plastic sheath (unprinted side of a sterile urine collection bag) was placed between the abdominal wall and the exposed viscera. An appropriate size of a plain polypropylene mesh was then sutured to the linea alba to cover the abdominal contents without tension. After 48 hours, the plastic sheath was gradually removed through the caudal end of the laparostomy. As the abdominal distension decreased, the polypropylene mesh was divided in the midline and gradually trimmed over several days. Each time the mesh was trimmed, the cut edges of the mesh were re-sutured with 1-0 polypropylene suture to maintain the continuity of the mesh.

DISCUSSION

Here, we have described two patients with duodenal perforation following blunt abdominal trauma. In both the patients, the diagnosis was delayed. In the first patient, a second perforation was found during re-laparotomy. In the second patient, the diagnosis was made 24 hours after the first discharge.

Diagnosis of blunt duodenal injury is often delayed unless a very high index of suspicion is kept during initial assessment and tertiary survey after resuscitation and stabilization of patients. The mechanism of injury (acceleration and deceleration impact), upper abdominal tenderness with tachycardia, raised temperature and vomiting should warrant further evaluation. Contrast-enhanced computed tomographic scan of the abdomen with oral and intravenous contrast media is highly sensitive to detect small amounts of retroperitoneal air, paraduodenal hematoma or extravasated contrast from the duodenum. Occasionally, contrast-enhanced computed tomographic scan may also be negative when performed early or may suggest subtle findings like small amount of unexplained fluid or unusual bowel morphology due to paraduodenal hematoma.[5-7]

There are several options to deal with duodenal injury, which range from simple repair like primary closure (duodenorrhaphy) to more complex procedures like resection and anastomosis, duodenal diverticulation, pyloric exclusion, pancreaticoduodenectomy. However, no single method of repair completely eliminates the possibility of a duodenal fistula.[8] Most of the duodenal injuries are adequately managed with primary closure (duodenorrhaphy) in one or two layers or by resection and anastomosis.[268]

Options are limited for a patient presenting late with sepsis. This was evident in both of our cases. In both the patients, “damage control surgery” in the form of polypropylene mesh laparostomy after duodenorrhaphy, tube gastrostomy, reverse tube duodenostomy and a feeding jejunostomy was performed. Salvage procedures like quick “damage control” with delayed definitive surgery, Foley catheter duodenostomy, duodenal decompression by quadruple tube technique are sparingly reported.[6910]

Both of our patients were effectively managed by simple repair and duodenal decompression by triple tube technique. Simple repair followed by duodenal decompression with triple tube technique was originally described by Stone and Fabian.[11] This triple tube technique comprises a tube gastrostomy for decompressing the stomach, a reverse tube duodenostomy for duodenal decompression and an antegrade tube jejunostomy for enteral feeding [Figure 1]. For reverse tube duodenostomy, the tube is passed through the proximal jejunum and guided into the second part of duodenum. This triple tube technique is rapid, needs only basic surgical experience, and provides a portal for early enteral feeding obviating the need for intravenous hyperalimentation. Thus, it is a cost-effective option with least morbidity for managing these severely injured sick patients.

In our first case, the injury on the posterior wall of the duodenum was missed at the time of the first laparotomy. The obvious perforation on the anterior wall probably prevented the operating surgeon from proper mobilization (Kocherization) of the duodenum. In the second patient, the index of suspicion for severe internal injury was low in view of absence of clinical signs, hence the patient was discharged.

Mobilization of the duodenum is known to reveal significant injury even in the absence of apparent signs of trauma on it.[12] Recently, Zelić et al.[13] reported a case of complete transection of the duodenum at two places, one just beyond the pylorus and the other between the second and third part of duodenum.[13] This report, as well as our first case, highlights the possibility of duodenal injury occurring at multiple sites. We strongly suggest that in all major blunt trauma cases, even in the presence of obvious perforation on the duodenum, the duodenum should always be mobilized and evaluated for additional injury.

Another option to manage such patients could have been a controlled duodenal fistula following peritoneal lavage. However, we preferred triple tube decompression as the feeding jejunostomy associated with the procedure helps in early enteral feeding, thereby avoiding the need for more expensive total parenteral nutrition (TPN) with its attendant complications.

The mesh laparostomy prevents evisceration of gut and the abdominal compartment syndrome. It also facilitates drainage of infectious material, permits visual control of the underlying viscera, facilitates wound care, simplifies repeated exploration if required, and hastens healing by secondary intention.

Isolated duodenal injury following blunt abdominal trauma is rare; therefore, most general surgeons have a low index of suspicion and may not be experienced in handling such problems. These two cases highlight the difficulties that can be encountered during diagnosis and management of blunt abdominal trauma with isolated duodenal injury. The diagnosis depends on a high index of suspicion not only during the initial clinical evaluation but also during trauma related laparotomies. When diagnosed late, especially when the patient's general condition is severely compromised, simple duodenorrhaphy with duodenal decompression by triple tube technique may be a good selection because the procedure is simple, rapid, and provides a portal for early enteral feeding.