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INTRODUCTION: Outcomes for patients with traumatic duodenal injury are determined by the location of the injury, injury severity, and associated injuries. We hypothesized that there is an association among the increased frequency of firearm injuries, the severity of duodenal injuries, trends in repair techniques, and mortality. METHODS: Duodenal injuries managed at an adult level 1 hospital from 2000 to 2022 were identified. Demographics, injury type, the American Association for the Surgery of Trauma (AAST) grade, type of surgical repair, and mortality data were obtained and aggregated into two periods (2000 to June 2011 and July 2011 to 2022) to evaluate trends over time. P values < 0.05 were considered significant. RESULTS: One hundred eighty eight cases were identified. Duodenal injuries due to firearms increased over time (30% versus 55%, P < 0.001). The distribution of AAST injury grade shifted over time with fewer grade 1 and more grade 2 to 4 injuries in the later period (P = 0.002). AAST grade 2 injuries or higher were more likely due to firearms (P < 0.001). Despite more high-grade injuries, there was no change in the use of primary repair with or without tube drainage (61% versus 70%, P = 0.35) and there was no change in mortality (15% versus 17%, P value 0.62) between the time periods. CONCLUSIONS: There was a proportional increase in the number of duodenal injuries caused by firearms. Higher grade duodenal injuries were more common with firearm injuries and were predominately repaired with simple techniques with no increase in mortality.

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INTRODUCTION: High-grade pancreaticoduodenal injuries are highly morbid and may require complex surgical management. Pancreaticoduodenectomy (Whipple procedure) is sometimes utilized in the management of these injuries, but guidelines on its use are lacking. This paper aims to present our 14-year experience in management of high-grade pancreaticoduodenal injuries at our busy, urban trauma center. METHODS: A retrospective review was performed on patients (ages >15 years) presenting with high-grade (AAST-OIS Grades IV and V) injuries to the pancreas or duodenum at our Southeastern Level 1 trauma center. Inclusion criteria included high-grade injury and requirement of Whipple procedure based on surgeon discretion. Patients were divided into two groups: (1) those who underwent Whipple procedures during the index operation and (2) Whipple candidates. Whipple candidates included patients who received Whipples in a staged fashion or who would have benefited from the procedure but either died or were salvaged to another procedure. Demographics, injury patterns, management, and outcomes were compared. Primary outcome was survival to discharge. RESULTS: Of 66,272 trauma patients in this study period, 666 had pancreatic or duodenal injuries, and 20 met inclusion criteria. Of these, 6 had Whipples on the index procedure and 14 were Whipple candidates (among whom 7 had staged Whipples, 6 died before completing a Whipple, and 1 was salvaged). Median (IQR) age was 28 (22.75-40) years. Patients were 85 % male, 70 % Black. GSWs comprised 95 % of injuries. All patients had at least one concomitant injury, most commonly major vascular injury (75 %), colonic injury (65 %), and hepatic injury (60 %). In-hospital mortality among Whipple patients was 15 %. CONCLUSIONS: Complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy are rare but life-threatening. In such patients, hemorrhage was the leading cause of death in the first 24 h. Approximately half underwent damage control surgery with staged Whipple Procedures. However, pancreaticoduodenectomy at the initial operation is feasible in highly selective patients, depending on the extent of injury, physiologic status, and resuscitation.

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PURPOSE: Duodenal/pancreatic injuries occur in less than 10% of intra-abdominal injuries in pediatric blunt trauma. Isolated duodenal/pancreatic injuries occur in two-thirds of cases, while combined injuries occur in the remaining. This study aimed to investigate pediatric patients with pancreatic and duodenal trauma. METHODS: Data from 31 patients admitted to Atatürk University, Medical Faculty, Department of Pediatric Surgery for pancreatic/duodenal trauma between 2010 and 2019 were retrospectively analyzed. Age/gender, province of origin, duration before hospital admission, trauma type, injured organs, injury severity, diagnostic and therapeutic modalities, complications, hospitalization duration, blood transfusion requirement, and mortality rate were recorded. RESULTS: Twenty-four patients were male, and 7 were female. The mean age was 9 years. The leading cause was bicycle accidents, with 12 cases, followed by traffic accidents/bumps, with 7 cases each. Comorbid organ injuries accompanied 18 cases. Duodenal trauma was most commonly accompanied by liver injuries (4/8), whereas pancreatic injury by pulmonary injuries (7/23). Serum amylase at initial hospital presentation was elevated in 83.9% of the patients. Thirty patients underwent abdominal CT, and FAST was performed in 20. While 54.8% of the patients were conservatively managed, 45.2% underwent surgery. CONCLUSION: Because of the anatomical proximity of the pancreas and the duodenum, both organs should be considered being co-affected by a localized trauma. Radiologic confirmation of perforation in duodenal trauma and an intra-abdominal pancreatic pseudocyst in pancreatic trauma are the most critical surgical indications of pancreaticoduodenal trauma. Conservative management's success is increased in the absence of duodenal perforation and cases of non-symptomatic pancreatic pseudocyst.

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BACKGROUND: Duodenal injuries are relatively rare but remain a management challenge with a high incidence of postoperative complications. Guidelines from the World Society of Emergency Surgery and American Association for the Surgery of Trauma favour a primary repair for less-complex injuries, but the management of more complex duodenal trauma remains controversial with varying techniques supported, including pyloric exclusion, omental or jejunal patch closure, gastrojejunostomy and pancreatoduodenectomy. We describe the techniques used in one case of complex duodenal trauma. TECHNIQUE: The duodenum is approached via a standard laparotomy with Kocherisation. Primary repair of the duodenal perforations is performed using a 3/0 polydioxanone suture (PDS), followed by mobilisation of a loop of mid-jejunum against the area of duodenal trauma over the primary repair as a jejunal serosal patch. The antimesenteric jejunal serosal border is sutured to the serosa of the duodenum (serosa only) using a 3/0 PDS. Pyloric exclusion is then performed through an anterior gastrostomy, to control the volume of gastric juice entering the duodenum. The pylorus is sutured closed using an absorbable suture followed by closure of the anterior gastrostomy using a GIA stapling device.

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Penetrating injuries to the duodenum can present a complex case for trauma or acute care surgeons. The associated injuries and complications can have devastating results. This report presents the case of a 41-year-old male who presented with a gunshot wound to his abdomen and suffered a gastric injury, transverse colon injury, duodenal injury, renal injury, and pancreatic tail injury. In this case, the patient underwent a complex Roux-en-Y reconstruction. The patient had a good outcome and continues to recover at home.

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Introduction: Duodenal trauma is rare but can be associated with significant morbidity and mortality (Pandey et al., 2011). Adjunct procedures, such as pyloric exclusion, can be performed to assist in surgical repair of these injuries. However, pyloric exclusion can lead to severe long-term complications associated with significant morbidity that can be difficult to repair. Case: A 35-year-old man with a history of duodenal trauma from a gunshot wound (GSW) status post pyloric exclusion and Roux-en-Y gastrojejunostomy presented to the Emergency Department (ED) with complaints of abdominal pain and leakage of food particles and fluid from an open wound around his surgical scar. Computed tomography (CT) scan on admission showed a tract extending from the gastrojejunostomy anastomosis to the skin representing a fistula. Esophago-gastro-duodenoscopy (EGD) reconfirmed a large marginal ulcer that had fistulized to the skin. After nutritional repletion, the patient was taken to the operating room (OR) for takedown of the enterocutaneous fistula and Roux-en-Y gastrojejunostomy, closure of gastrostomy and enterotomy, pyloroplasty and feeding jejunostomy tube placement. The patient was re-admitted after discharge with abdominal pain, vomiting and early satiety. EGD showed gastric outlet obstruction and severe pyloric stenosis which was managed with endoscopic balloon dilation. Conclusion: This case represents the severe and potentially life-threatening complications that may occur after pyloric exclusion with Roux-en-Y gastrojejunostomy. Gastrojejunostomies are prone to marginal ulceration which can perforate if not adequately treated. Free perforations cause peritonitis, but if the perforation is contained it can erode through the abdominal wall creating the rare complication of a gastrocutaneous fistula. Even after restoration of normal anatomy with a pyloroplasty, patients may suffer additional complications such as pyloric stenosis requiring continued intervention.

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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.

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BACKGROUND: Traumatic duodenal injury is a rare, potentially devastating condition with challenging management decisions. Contemporary literature on operative management of duodenal injury is lacking. The purpose of this study is to assess optimal management strategies based on outcomes of patients with traumatic duodenal injury at a single trauma center. METHODS: A retrospective study of patients with traumatic duodenal injury from 2013-2020 at a level 1 trauma center was performed. Patient demographics, grade of injury as noted on CT scan or intraoperatively, surgical procedure(s) performed, and resultant outcomes were extracted. RESULTS: After excluding one patient due to death on arrival, 23 patients met inclusion criteria. Injuries consisted of grade 1 (n = 7), grade 2 (n = 2), grade 3 (n = 12), and grade 5 (n = 2); there were no grade 4 injuries. Patients were predominantly male (83%) with a median age of 30 years old. Nineteen patients (82%) underwent surgery. Four of nine patients (44%) with grade 1/2 injuries had hematomas and were managed non-operatively. The remaining five patients (56%) with grade 1/2 injuries underwent operation, which included primary repair (n = 3), duodenal exclusion (n = 1), and periduodenal drainage (n = 1). Of 12 patients with grade 3 injury, 6 underwent primary repair and 6 underwent resection. Three patients who underwent primary repair and one who underwent resection developed a duodenal leak. All patients with grade 5 injury (n = 2) underwent pancreaticoduodenectomy. CONCLUSION: Grade 1 and 2 duodenal hematomas can be managed non-operatively, while lacerations require operative repair. Outcomes may be better following resection in patients with grade 3 injury.

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Duodenal injury following blunt abdominal trauma is extremely rare in children and many times, it has delayed presentation, leading to increased morbidity and mortality. A patient with complete duodenal transaction is a surgical challenge and management involves the time of presentation and extent of visceral damage. A 10-year-old boy was brought with features of bowel perforation after road traffic accident and underwent emergency laparotomy which revealed complete transaction of duodenum at D1 and D2 and pyloroduodenal junction extending toward lesser curvature. Primary closure of pyloroduodenal junction and D1-D2 was done with omental patch along with triple tube decompression (cholecystostomy, gastrostomy, and jejunostomy). The patient had an uneventful recovery. Primary closure of disturbed ends with triple diversion is a safe approach in young children with complete duodenal transaction in absence of gross peritoneal contamination and early presentation.

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INTRODUCTION AND IMPORTANCE: The rare presentation of duodenal injuries has led to a lack of guidelines for managing and diagnosing such cases. In most duodenal injuries, intramural hematoma and perforation are seen; however, complete resection of the duodenum is rare, which is seen in our case. CASE PRESENTATION: We report a rare case of a 6-year-old boy who suffered from a complete isolated duodenal transection at the pylorus and a 90% transection at D3 and D4 following a seat-belt injury. The surgeon performed a primary anastomosis for the first part of the duodenum with pyloric exclusion. Then, primary repair with controlled fistula for the second transection at D3 and D4 and a gastrojejunostomy were performed. After further management, the patient was discharged with no further complaints. CLINICAL DISCUSSION: Due to the retroperitoneal location of the duodenum, it is challenging to diagnose a duodenal injury. CT scan with contrast is considered the best diagnostic tool in the case of a duodenal injury. Treatment of duodenal injuries depends on the type of injury and the present level of damage. It is imperative to differentiate between a duodenal hematoma, a duodenal perforation, or a duodenal transection as the management for each complication differs. CONCLUSION: No official guidelines have been set in the case of management or diagnosis of duodenal transection. Based on our experience with this patient and similar literature, guidelines for managing and diagnosing duodenal transection should be set, and further studies on the matter are warranted.

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BACKGROUND: In the present study we performed a systematic review and meta-analysis regarding the initial management of perforations following endoscopic retrograde cholangiopancreatography (ERCP). METHOD: A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. RESULT: In total, 10 comparative studies and 223 patients with post-ERCP perforations were included in the present study. In type I and II perforations, the success rate of initial surgical management was higher compared to the non-operative management (NOM) group (P=0.09 and P=0.02, respectively). There was no statistically significant difference in mortality rates or length of hospital stay between initial surgical and NOM management for any type of perforation. CONCLUSIONS: The current meta-analysis demonstrated the significance of the initial management of patients with post-ERCP perforations. Whether a surgical or an endoscopic approach is chosen, the patient should immediately be evaluated by an experienced surgeon or endoscopist.

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Isolated duodenal injury is rare as they are usually associated with other visceral injuries. Diagnosis of a duodenal injury is difficult, and its management is challenging. Hence, it is important to timely recognize such injuries for better outcome.

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Postcholecystectomy duodenal injuries are very rare complications. Early surgical intervention is a common practice due to its fatal consequences. Most of the patients with post laparoscopic cholecystectomy duodenal injury reported in literature have been successfully managed by early surgical repair. We present here a case of a 32-year-old female who underwent open cholecystectomy and had an injury in the second part of the duodenum. She was subsequently managed conservatively.

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INTRODUCTION: The conventional techniques for management of complex duodenal injuries are duodenal diverticularisation, pyloric exclusion or triple tube decompression. We here present a salvage technique of primary reinforcement with pedicled rectus abdominis muscle flap (RAMF) for a tenuous post traumatic duodenal perforation (PTDP). The majority of the studies in the literature are on the use RAMF for the secondary repair of peptic duodenal perforations. PRESENTATION OF CASE: A 38 year old male presented with an acute abdomen, three days after sustaining a blunt abdominal trauma. The clinical and radiological findings in the abdomen were subtle and not contributory. An emergency laparotomy with a high index of suspicion revealed a large perforation in the anterolateral wall of the second portion of the duodenum with a friable unhealthy wall and shearing of the serosa around the perforation site. The entire omentum was unhealthy, contused with areas of gangrene and omentectomy done. The perforation site was closed using 3.0 vicryl and reinforced with a pedicled right RAMF based on the superior epigastric artery. The patient recovered uneventfully and was discharged. DISCUSSION: The addition of conventional diversion techniques to primary duodenorrhaphy is sophisticated, time consuming and adds morbidity. CONCLUSION: RAMF is a good tissue substitute to buttress tenuous duodenal injuries presenting late with inflamed, friable perforation sites and associated tissue loss, where duodenorrhaphy alone may not be successful. RAMF is a valuable salvage technique when the omentum is not available and the local tissue condition negates the effectiveness of other simpler techniques.

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INTRODUCTION: Isolated duodenal injuries are particularly rare in blunt abdominal trauma as the duodenum is at a deep and relatively well-protected anatomical site. CASE PRESENTATION: We present a case report of a 22-year-old male patient who presented to an accident and emergency department at a tertiary training hospital within four hours of sustaining blunt abdominal trauma. His vital signs were stable at this point and was found to have slight abdominal tenderness in the epigastric area with no abdominal rigidity and normal bowel sounds on auscultation. A CT Scan of the abdomen done was normal. He was admitted to the surgical ward for serial abdominal monitoring. Eight hours into his admission, his physical condition deteriorated necessitating an emergency laparotomy where a perforation of D4 on the anterior wall was found. This was repaired primarily and he had a relatively calm post-operative stay in the surgical ward and was discharged home. DISCUSSION: Diagnosis of blunt duodenal injury is often delayed because of its retroperitoneal nature. Initial clinical changes in isolated duodenal injury may be extremely subtle before peritonitis sets in. It is therefore important to consider both mechanism of injury and other clinical signs such as tachycardia and raised white cell count as delays in diagnosis and subsequent management adversely affect morbidity and mortality. CONCLUSION: Timely management of this rare and life threatening injury is hinged on a high index of suspicion in spite of what previous imaging may show to the surgeon.

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We are reporting a rare case of an isolated duodenal injury (IDI) involving the second and third parts of the duodenum in a 22-year-old male patient following a blunt abdominal trauma. The purpose of this paper is to report the clinical findings, cross-sectional imaging findings, and management of IDI. As IDI can be vague clinically, the presence of periduodenal free fluid on computed tomography scan should raise the suspicion of the diagnosis. Early recognition and management are essential to prevent associated morbidity and mortality.

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BACKGROUND: The risk factors of duodenal injury from distal migrated biliary plastic stents remain uncertain. The aim of this study was to determine the risk factors of distal migration and its related duodenal injury in patients who underwent placement of a single biliary plastic stent for biliary strictures. METHODS: We retrospectively reviewed all patients with biliary strictures who underwent endoscopic placement of a single biliary plastic stent from January 2006 to October 2017. RESULTS: Two hundred forty-eight patients with 402 endoscopic retrograde cholangiopancreatography procedures were included. The incidence of distal migration was 6.2%. The frequency of duodenal injury was 2.2% in all cases and 36% in cases with distal migration. Benign biliary strictures (BBS), length of the stent above the proximal end of the stricture (> 2 cm), and duration of stent retention (< 3 months) were independently associated with distal migration (p = 0.018, p = 0.009, and p = 0.016, respectively). Duodenal injury occurred more commonly in cases with larger angle (≥ 30°) between the distal end of the stent and the centerline of the patient's body (p = 0.018) or in cases with stent retention < 3 months (p = 0.031). CONCLUSIONS: The risk factors of distal migration are BBS and the length of the stent above the proximal end of the stricture. The risk factor of duodenal injury due to distal migration is large angle (≥ 30°) between the distal end of the stent and the centerline of the patient's body. Distal migration and related duodenal injury are more likely to present during the early period after biliary stenting.

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BACKGROUND: A penetrating injury of a hollow viscus is an obvious indication for an exploratory laparotomy, but is not typically an indication for endoscopic treatment. CASE SUMMARY: A 27-year-old man visited the emergency department with a self-inflicted abdominal stab wound. Injuries to the colon and ileum were detected, but an injury to the second portion of the duodenum was missed. On the day following admission to our institution, the patient became hemodynamically unstable with massive hematochezia, although there was no evidence of bleeding in the Levin tube or Jackson-Pratt drain. We thus performed an upper gastrointestinal endoscopy and discovered a missed duodenal injury that was actively bleeding. An endoscopic band ligation was performed for hemostasis and closure of the perforation. The patient was subsequently discharged without any complications. CONCLUSION: A penetrating injury of the duodenum can be overlooked, so careful abdominal exploration is very important. If a missed duodenal injury is suspected, a cautious endoscopic approach may be helpful.

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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.

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Background/Purpose: During laparoscopic excision of choledochal cysts (CDCs), if duodenum injury is encountered, conversion to open repair of duodenal injury is often the standard approach. This study evaluates if it is safe to repair the duodenal injury laparoscopically in CDC children. Materials and Methods: CDC children who underwent single-incision laparoscopic repair for iatrogenic duodenal injury between October 2013 and September 2018 were reviewed. According to the pathophysiology, duodenal injuries were categorized into two subtypes: Type 1: injury caused by severe adhesions between perforation site at distal CDC and the duodenum; Type 2: anatomical variation, that is, distal CDC shared the common wall with the duodenum. A transabdominal wall suture was placed through distal end of CDC. Relying on the adhesion between distal CDC and duodenum, the injured duodenum can be clearly exposed when the assistant pulled on the retraction suture. The duodenal injury was repaired by a two-layer 5-0 polydioxanone running suture. The distal CDC was transected after repair was accomplished. Results: Five children were reviewed (Type 1: n = 4, Type 2: n = 1). Median age at surgery was 1.2 years. Median operative time was 4.0 hours. Median postoperative hospital stay was 7 days. Median duration of full diet resumption and drainage were 5 days, respectively. Median follow-up period was 31 months. Liver function tests and serum amylase levels were normalized within 1 year. None of patients had intestinal leak, anastomotic stenosis, bile leak, cholangitis, pancreatic leak, pancreatitis, or adhesive intestinal obstruction. Conclusions: Single-incision laparoscopic repair for iatrogenic duodenal injury in CDC children is safe and effective.

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