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Management of the complex duodenal injury

Published:December 26, 2022DOI:https://doi.org/10.1016/j.amjsurg.2022.12.016

      Highlights

      • Complex duodenal trauma occurs in 1–4.7% of all abdominal trauma.
      • The AAST grading system utilizes the presence of duodenal hematomas and lacerations. Grade III to V are considered complex injury patterns.
      • The tenets of surgical duodenal management include resection, restoring continuity, diversion, and providing feeding access.

      Abstract

      Introduction

      Complex duodenal trauma is a rare injury with an incidence of 1–4.7% of all abdominal trauma. Historically, varied approaches have been used in the management of these complex injuries and the prevention of complications. This is a review of the current management methodology of complex duodenal injury.

      Methods

      A review of the medical literature to include the past and current management of duodenal trauma was performed. Google scholar (1970–2022) and PubMed (1970–2022) were searched using the keywords: complex duodenal trauma, surgical management, and duodenal complications.

      Discussion

      Complex duodenal trauma can be classified using the AAST grading scale as those encompassing grades III-V. Multiple studies and review articles characterize the difficulty in managing complex duodenal injuries. The tenets of operative management of duodenal trauma include the decision for damage control, resection of non-viable tissue, restoring gastrointestinal continuity, diversion of gastrointestinal contents, bile and pancreatic enzymes, allowing the repair to heal, and providing feeding access. The variety of both historic and current approaches attempt to address these tenets. The incidence of complications are as high as 65% with the most common complications including abscess formation, suture line dehiscence and fistula formation. The overall mortality ranges from 5 to 30%.

      Conclusions

      Many different approaches and strategies have been proposed to repair complex duodenal injuries, all of which address important tenets of its management. The risk of complications remains high, therefore, it is vital to have a thoughtful and multidisciplinary approach when treating these injuries.

      Keywords

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