Introduction

Duodenal injury in blunt abdominal trauma is a rare, with an estimated incidence of 3—5% among patients with abdominal trauma [1]. These injuries are often severe and have high mortality rate (from 0 to 9.5%) [1, 2]. Previously, in our country, complex repair methods were prioritized for duodenal injuries such as: duodenal diverticulization, pyloric exclusion with gastrojejunostomy, pancreaticoduodenectomy, duodenojejunostomy [1, 3]. However, recent studies have shown that primary repair has been a new trend in the treatment of duodenal injuries, demonstrating reduction in surgical time, hospital stay, complication rates, and postoperative mortality [1, 4].

The duodenum is divided into four sections (D1—D4). Of these, the 4^th duodenum (D4) is the least damaged position in blunt abdominal trauma [5]. Due to its easily accessible location, in many cases patients can be treated with primary repair of injuries such as small bowel injury without the need for complex treatment options [3]. We present a case diagnosed with D4 duodenal injury combined with gastric injury that was successfully treated with primary repair combined with feeding jejunostomy. Through this clinical case, we hope to provide clinicians with additional less invasive option for repair of D4 duodenal injuries.

This case report has been reported in line with the SCARE 2023 guidelines [6].

Case presentation

Patient information: a 34-year-old male patient came to the emergency department with severe abdominal pain caused by a workplace accident. Approximately 1 hour before admission, the patient fell backwards while climbing a ladder, then was hit directly in epigastric area by a heavy object. After the accident, the patient woke up without memory loss, immediately appeared symptoms of severe abdominal pain, dizziness, without difficulty breathing or chest pain. The patient was taken to Thai Nguyen National Hospital in Vietnam by his family members. The patient’s condition on arrival was assessed according to the advanced trauma life support algorithm. The airway was patent, and bilateral breath sounds were clear. The heart rate was 91 beats per minute, blood pressure was 130/80 mmHg, and respiratory rate was 19 breaths per minute. He was conscious and lucid without any neurological deficits. The patient has a healthy medical history with no allergies. On abdominal examination, the patient experienced severe epigastric pain, bruising and skin scratches in epigastric area 3×5 cm, positive signs of abdominal rigidity, and inaudible peristaltic movement. Examination of lumbar region revealed mild pain without bruising, normal limb movement, and no suspicion of lumbar spine injury. Blood tests revealed white blood cell count 16.49×10⁹/liter, while lipase, amylase, and other tests were within normal limits. Focused abdominal ultrasound for trauma revealed small amount of thin fluid in the Morison’s pouch, around the spleen, and Douglas pouch, with no associated solid organ injury. Computed tomography (CT) of the abdomen showed free air in abdominal cavity and retroperitoneal space, combined with small amount of free fluid in abdominal cavity, infiltrates, and air bubbles adjacent to D4 (Fig. 1). Chest X-ray showed normal findings with no evidence of spinal injury.

Fig. 1. Free air in abdominal cavity and retroperitoneal space, D4 infiltration, air bubbles adjacent D4.

Preoperative diagnosis and prognosis

Based on clinical examination, it was found that the patient had surgical abdominal signs requiring surgical intervention, combined with images of free air in peritoneal cavity and retroperitoneal space without associated solid organ injury. Therefore, we preliminarily diagnose hollow viscus perforation secondary to blunt abdominal trauma. Due to retroperitoneal air and infiltration around D4, duodenal injury was suspected, that was considered a serious prognostic factor in this patient.

Surgical intervention

The patient underwent surgery 3 hours after admission. Skin incision was made along the midline between above and below the navel, approximately 20 cm long. Examination of abdominal cavity revealed significant amount of digestive fluid. The lesser curvature of the stomach was ruptured, measuring approximately 3×5 cm (Fig. 2). A Kocher maneuver was performed to mobilize the duodenum and head of the pancreas. Examination revealed that the pancreas and D1, D2, D3 of the duodenum were normal. The fourth part of the duodenum (D4) was found to be fractured along approximately 40% of its circumference, with clean edges and no sign of crushing (Fig. 3).

Fig. 2. Lesser curvature of stomach ruptured.

Fig. 3. The fourth part of duodenum ruptured.

Examination of the entire abdomen did not reveal other associated lesions. The edges of the gastric incision were cleaned and sutured in two layers. At the site of the duodenal injury, the Treitz ligament was resected, and D3+D4 were mobilized to provide wide exposure of the injured area. The wound edges were then cleaned and sutured in two layers (Fig. 4). Approximately 40 cm from duodenal lesion, a feeding jejunostomy was performed. Finally, peritoneal cavity was irrigated with saline solution. Two F16 drainage tubes were placed beneath the duodenal injury site, while two F16 tubes were inserted to drain the Douglas pouch. Additionally, nasogastric decompression tube was inserted.

Fig. 4. D4 ruptured was sutured.

Result

Nutrition for the patient was provided via jejunostomy 10 days after surgery. The gastric decompression tube was removed, and oral feeding commenced on day 11. Clinical condition and postoperative blood test results were normal. The patient experienced no complications and was discharged after 13 days of treatment.

Discussion

Duodenal injuries, although rare, exhibit high rates of mortality and complications [2, 7]. Due to their infrequency, clinicians often overlook them following blunt abdominal trauma, resulting in delayed diagnosis and severe complications. Early detection of duodenal injuries is essential, necessitating the utilization of mechanisms such as multi-detector CT scans focused on the pancreas and duodenum to identify indicative signs. These signs may include free air in the retroperitoneal space, duodenal wall lacerations, duodenal wall thickening, and periduodenal hematoma [7, 8].

The patient under reported sustained a direct impact injury to the epigastric area, presenting typical surgical abdominal signs. CT imaging revealed free air in the peritoneal cavity, retroperitoneal free air, infiltrates with air bubbles adjacent to D4, and disruptions in the gastric curvature. Therefore, the patient received a preoperative diagnosis of hollow viscus perforation resulting from blunt abdominal trauma, leading to immediate surgical intervention. This exemplifies a case characterized by swift diagnosis and early intervention. Nevertheless, numerous patients with duodenal injuries experience ambiguous symptoms, posing challenges for early detection. EG Santos highlights the pivotal role of discerning the injury mechanism in guiding diagnostic endeavors. Instances involving high falls with subsequent back impact or direct trauma to the epigastric region represent notable risk factors warranting consideration for duodenal injury [9]. CT scan or MRI to evaluate the condition of the duodenal parts and detect signs of risk of injury is necessary for early diagnosis of duodenal injury [7, 9].

Management

The primary objective of blunt abdominal trauma surgery is to identify and manage bleeding promptly, followed by the assessment and repair of any injured abdominal organs [7, 10]. A thorough examination of the entire abdominal cavity during surgery is essential to detect damage to associated organs. To assess the duodenum, the Kocher maneuver is performed to inspect both its pre- and retroperitoneal surfaces. Examination of the fourth part of the duodenum (D4) occurs after resection of the Treitz ligament, with meticulous dissection to avoid injury to adjacent vessels [7]. Duodenal injuries are evaluated and categorized according to the guidelines of the American Association for the Surgery of Trauma (AAST) [11].

Treatment options for duodenal injuries vary depending on the location, grade of injury, and patient’s condition upon admission [7, 11]. These options range from complex procedures such as pancreaticoduodenectomy (Whipple procedure), duodenal diverticulization, Roux-en-Y duodenojejunostomy, and triple tube ostomy to simpler methods like primary repair. In recent years, primary repair has emerged as the preferred approach for managing grade I and II duodenal injuries [1, 2, 7, 12]. For grade III and IV injuries, primary repair may be feasible depending on factors such as timing of surgery, condition of the wound edges, and associated organ damage [1, 3, 7]. However, grade IV and V injuries often involve complex pancreatic injuries, making primary repair controversial. Current evidence suggests that grade III to V duodenal injuries require intricate reconstruction and are associated with elevated rates of complications and mortality [11, 13].

Surgical procedure

In our case, the patient presented with a grade II duodenal injury, characterized by a lesion involving less than 50% of the circumference at D4. According to author E. Degiannis, D3 and D4 are considered the lower portion of the duodenum and the treatment direction when injury is similar to the small intestine [3]. Therefore, we opted to mobilize the lower portion of the duodenum. Subsequently, a tension-free transversely oriented repair was performed using two layers at the site of the lesion. Furthermore, the patient exhibited a gastric lesion measuring 3×5 cm, indicative of a grade II injury [14]. Accordingly, the lesion was sutured in two layers.

In reviewing the literature, there remains considerable debate regarding the management of duodenal injuries. Decisions often hinge on surgeon’s experience, leading to a range of treatment options. Recent studies have explored the safety of primary repair methods for duodenal injuries. For instance, R.D. Weale’s study applied primary repair techniques across grades I to III injuries, encompassing all part of the duodenum. The study suggests: “The trend toward simple primary repair of duodenal injuries away from more complex strategies appears to be justified”. However, the study also identifies a subgroup at high risk of duodenal leaks following primary repair, such as grade III injuries, delayed diagnosis, or contaminated abdominal conditions … [4]. Similarly, J.M. Aceves-Ayala discusses in his article that primary repair may be applicable to all grade I and II duodenal injuries. Delayed or contaminated grade II injuries may be managed as grade III injuries. This often requires to perform a roux-en Y duodeno-jejunostomy in cases of extensive defects. For grade III injuries involving D1, D3, or D4 primary repair may be considered [15]. Thus, through the studies we referenced, it has been shown that primary repair for D3, D4 injuries to level III is appropriate [3, 4, 15].

Early feeding via jejunostomy was our choice for this patient because we lacked sufficient experience to predict the risk of duodenal leaks. Therefore, we opted to perform jejunostomy for feeding and placed an extensive drainage tube. Perhaps due to early nutritional provision through jejunostomy, the patient recovered very well after surgery with no complications. In R.N. Dickerson’s study, the author also emphasized the importance of early postoperative nutrition in reducing complication rates and mortality among patients with severe duodenal injuries [16]. The studies also indicate that, feeding jejunostomy is recommended for patients with duodenal injury, particularly in cases of severe duodenal injury [7, 17]. External drainage of the anastomosis is vital for any future anastomotic leaks and establishes the ability to create a controlled fistula [7]. Recognizing the significance of early nutritional support via jejunostomy is paramount in reducing the likelihood of post-operative electrolyte and nutritional imbalances. Moreover, in instances where complications such as duodenal fistulas impede oral and gastric nutrition intake, the role of jejunostomy for feeding and external drainage is extremely important. Efficient drainage of digestive fluids from the abdominal cavity and provision of supplemental nutrition are crucial while awaiting fistula closure.

Conclusions

Due to the anatomical characteristics of D4, primary repair can be effectively employed for duodenal injuries up to grade III. Extensive abdominal drainage alongside jejunostomy are crucial elements in facilitating swift patient recovery post-surgery and addressing complications related to duodenal leaks.

Ethical approval

Not applicable.

Sources of funding

None.

Author contribution

S.T.D. and T.P.T.N: Concept and design, data interpretation and analysis, drafting, revision, and approval of final manuscript. S.H.T., T.T.H. and H.D.H: Design, data collection, data interpretation and analysis, drafting, revision and approval of final manuscript.

Consent

Written informed consent was obtained from the patient.

Conflicts of interest disclosure

The authors have no financial, consultative, institutional or any other relationships that might lead to bias or conflict of interest.

Guarantor

Son Hong Trinh

Data statement

The data in this guideline are derived from individual responses to the survey and are therefore confidential and not in the public domain.

Provenance and peer review

Not commissioned, internally reviewed.