Difficult duodenum

Peptic perferation

• Lavage, lavage, lavage
• Leave NGT
• Main repair strategy is patch
  • Omental (Graham patch)
  • Small bowel serosa
  • Falciform
• If > 50% of lumen
  • May require pyloric exclusion or distal gastrectomy
    • Options for management of duodenal stump
      • Options that require duodenal transection
        • Nissen closure- Management of the Difficult Duodenal Stump , page 2
        • Bancroft closure - Management of the Difficult Duodenal Stump , page 3
        • Duodenostomy - Management of the Difficult Duodenal Stump , page 3
      • T-tube (controlled fistula) - placed through the hole
    • Options for management of stomach
      • Distal gastrectomy with Roux-en-Y or Billroth II reconstruction
      • Pyloric exclusion
        • Absorbable suture or non-cutting linear stapler across pylorus
        • Over period of weeks the sutures/staples will give way and normal anatomy restored
        • Gastric continuity
          • Loop gastrojejenostomy
          • Gastrostomy/NG for venting and Feeding jejunostomy or TPN for feeding
    • Place many drains

Duodenum Trauma

• General
  • Relatively well-protected like the pancreas
  • If it’s injured then very likely for other things to be injured too
  • Doesn’t present with peritonitis making dx hard
• Mechanism of Injury
  • Penetrating (more common and seldom isolated)
  • Blunt (associated pancreatic injury, steering wheel/handle bar/chance # of L1/L2)
• Presentation
  • Dependent on location of injury and where it drains
  • Retro | Lesser Sac | Greater Sac
• Signs of duodenal injury at surgery
  • Retroperitoneal haematoma
  • Peri-duodenal air bubbles
  • Peri-duodenal haematoma
  • Bile staining of tissues
• Investigation
  • CT
  • Laparotomy Duodenal Injury Scale

Operative management

• Operative Possibilities
  • Simple suture repair
  • Duodenal diversion
  • Suction drainage peri-duodenal
  • Damage control preceded Whipple’s
• Surgical Approach
  • Key factors
    • Proximity to ampulla
    • Injury characteristics - Simple vs complex
    • Circumference of involved duodenum
    • Associated injuries - Biliary tree, pancreas, vascular
  • Can’t really dissect D2 away from pancreas - closely apposed and inter-reliant on blood supply
  • D3 exposure via Right medial visceral rotation - Cattell Brasch and SB mesentery mobilisation
  • D4 exposure by mobilising ligament of Treitz
  • Intramural haematoma
    • Leave alone if possible
    • Can cause duodenal obstruction but should settle with time
    • If doesn’t - warrants exploration
  • Options
    • Laceration and perofation
      • Simple suture closure of simple wounds
        • Closure of longitudinal duodenotomy transversely if length <50% is of circumference
    • Complete transection
      • Primary anastomosis often possible if mobility permits (D1,D3,D4)
      • May need reconstruction
        • Proximal to ampulla - antrectomy and Bilroth II
        • Distal to ampulla - R&Y duodenojejunal anastamosis and closure of distal duodenum
        • D2 - R&Y end-to-side duodenojejunal anastamosis
    • Duodenal diversion with gastrojejunostomy
      • Consider this in high risk repairs to divert gastric content and improve chance of healing + make a leak easier to manage
    • Other options
      • Duodenal Diverticulation - this is dated
        • This is Bilroth II gastrectomy + closure of duodenal injury + placemnet of a decompressive catheter into the duodenum (also described is performing a truncal vagotomy and biliary drainage at the same time to decrease the fluid in the repair)
      • Diversion
      • Triple tube decompression
      • Pyloric excl
      • Whipple
  • Consider cholangiogram if close to ampulla/bile duct