Duodenal injuries

Determinants of outcome

Historical mortality from duodenal injury ranges from 6% to 29%. The determinants of outcome include the following: (1) timing to injury diagnosis; (2) ability to control of hemorrhage; (3) ability to identify and manage additional injuries; (4) ability to repair or reconstruct a duodenal injury without complications of duodenal leak and fistula.

The evidence is clear that delays in the diagnosis of duodenal injuries increase mortality. Roman and colleagues identified 10 patients in whom the diagnosis of duodenal injury was delayed over 24 hours. Their mortality rate was 40% with a 30% fistula rate. Lucas and Ledgerwood demonstrated that a delay in diagnosis of >12 hours occurred in 53% of their patients and a delay of >24 hours occurred in 28%. The mortality rate was 40% among the patients in whom the diagnosis was delayed greater than 24 hours versus 11% in those undergoing surgery within 24 hours. Cuddington noted that 100% of the deaths directly attributable to duodenal injury occurred in patients in whom there was a delay in diagnosing such injury.

Early deaths in patients sustaining duodenal injuries are due to exsanguinating hemorrhage from injuries to surrounding solid organs or major blood vessels. In Ivatury’s 1990 series of 100 consecutive penetrating duodenal injuries, the overall mortality rate was 25%, with 16% of patients dying within 48 hours of admission from “extensive trauma or coagulopathy.” In a 2006 series of 75 patients with gunshot wounds to the duodenum in Cape Town, an injury to the inferior vena cava was the most common associated major vascular injury, associated with a 25% mortality rate. Injury to the aorta or portal vein was universally fatal.

An isolated duodenal injury is rare. The rate of associated injuries differs from individual studies but most commonly include liver, pancreas, colon, small bowel, and named blood vessels. Injuries to these structures, in part, explain the persistent risk of morbidity and mortality following the index operation. In 2014, Ordonez demonstrated that patients who survived >24 hours with a penetrating duodenal injury had a 11.1% risk of mortality. In this series of 44 consecutive penetrating injuries, the median associated injuries per patient was 4. Those who survive face an overall morbidity rate as high as 63%, with one third suffering a complication specifically related to the duodenal injury or a complication from the duodenal repair.

Late deaths in patients admitted with a duodenal injury typically occur 1 to 2 weeks or more after the injury, with about one third of the late deaths attributable to the injury itself. Optimization of the patient’s physiology prior to creation of a duodenal anastomosis or suture repair is critical. A careful consideration of treatment options, the patient’s physiology (temperature, acidosis, shock, coagulopathy), and timing from injury all are part of the conscientious choice in the appropriate repair or reconstruction in an effort to prevent anastomotic breakdown, fistulas, or intra-abdominal abscess. These complications will be the major determinant of the other common intensive care complications, including pneumonia, septicemia, and organ failure.