AAST 2018 PODIUM PAPER

Management of duodenal trauma: A retrospective review

from the Panamerican Trauma Society

Paula Ferrada, MD, Luke Wolfe, MS, Juan Duchesne, MD, Gustavo P. Fraga, MD,
Elizabeth Benjamin, MD, Augustin Alvarez, MD, Andre Campbell, MD, Christopher Wybourn, MD,
Alberto Garcia, MD, Carlos Morales, MD, Julieta Correa, MD, Bruno M. Pereira, MD, Marcelo Ribeiro, MD,
Martha Quiodettis, MD, Gregory Peck, DO, Juan C. Salamea, MD, Victor F. Kruger, MD,
Rao R. Ivatury, MD, and Thomas Scalea, MD, Richmond, Virginia

INTRODUCTION: The operative management of duodenal trauma remains controversial. Our hypothesis is that a simplified operative approach could
lead to better outcomes.
METHODS: We conducted an international multicenter study, involving 13 centers. We performed a retrospective review from January 2007 to
Downloaded from http://journals.lww.com/jtrauma by BhDMf5ePHKbH4TTImqenVIukvCljlO2s5/r/M6IR55kl/P0JxUFtnnHck3y00Fo8 on 09/01/2020

December of 2016. Data on demographics, mechanism of trauma, blood loss, operative time, and associated injured organs were
collected. Outcomes included postoperative intra-abdominal sepsis, leak, need for unplanned surgery, length of stay, renal failure,
and mortality. We used the Research Electronic Data Capture tool to store the data. Poisson regression using a backward selection
method was used to identify independent predictors of mortality.
RESULTS: We collected data of 372 patients with duodenal injuries. Although the duodenal trauma was complex (median Injury Severity
Score [ISS], 18 [interquartile range, 2–3]; Abbreviated Injury Scale, 3.5 [3–4]; American Association for the Surgery of Trauma
grade, 3 [2–3]), primary repair alone was the most common type of operative management (80%, n = 299). Overall mortality was
24%. On univariate analysis, mortality was associated with male gender, lower admission systolic blood pressure, need for transfusion
before operative repair, higher intraoperative blood loss, longer operative time, renal failure requiring renal replacement therapy,
higher ISS, and associated pancreatic injury. Poisson regression showed higher ISS, associated pancreatic injury, postoperative renal
failure requiring renal replacement therapy, the need for preoperative transfusion, and male gender remained significant predictors
of mortality. Duodenal suture line leak was statistically significantly lower, and patients had primary repair over every American
Association for the Surgery of Trauma grade of injury.
CONCLUSIONS: The need for transfusion prior to the operating room, associated pancreatic injuries, and postoperative renal failure are predictors of
mortality for patients with duodenal injuries. Primary repair alone is a common and safe operative repair even for complex injuries
when feasible. (J Trauma Acute Care Surg. 2019;86: 392–396. Copyright © 2018 American Association for the Surgery of Trauma.)
LEVEL OF EVIDENCE: Therapeutic study, level IV.
KEY WORDS: Blunt and penetrating duodenal trauma; duodenal trauma; surgical management of duodena trauma.

D uodenal injuries requiring surgical repair are rare. Higher-

grade injuries are even more unusual. Hence, the best sur-
gical treatment for complex duodenal injuries is controversial.1,2
Over the years, there have been many techniques described in
the treatment of these injuries, especially when involving other
organs.2–10 Primary repair is technically possible most of the
time. More advanced procedures exist, largely to protect the suture
line form dehiscence as leak from the duodenal repair, and can
From the Virginia Commonwealth University (P.F., L.W., R.I.), Richmond, Virginia; Tulane
University (J.D.), New Orleans, Louisiana; University of Campinas (G.P.F., B.M.P.),
Campinas, Brazil; Keck School of Medicine (E.B., A.A.), University of Southern
California, Los Angeles, California; University of San Francisco (A.C., C.W.),
San Francisco, California; Clinical Research Center (A.G.), Fundación Valle del
Lili, Cali, Colombia; Universidad de Antioquia-Hospital Universitario San Vicente
Fundación (C.M.J.C.), Medellin, Colombia; Hospital Geral Grajaú–Universidade
Santo Amaro (M.R.), São Paulo, Brazil; Hospital Santo Tomas (M.Q.), Cuidada
de Panamá, Panamá; Robert Wood Johnson Medical School (G.P.); Hospital
Vicente Corral Moscoso–Universidad del Azuay (J.C.S.), Cuenca, Ecuador; and
Shock Trauma Centre (T.S.), University of Maryland, College Park, Maryland.
Address for reprints: Paula Ferrada, MD, VCU Surgery Trauma, Critical Care and Emergency
Surgery, PO Box 980454, Richmond, VA 23298; email: pferrada@mcvh-vcu.edu.
Presented as an oral presentation at the 77th American Association for the Surgery of
Trauma annual meeting in San Diego, California, September 2018.
DOI: 10.1097/TA.0000000000002157
392
result in life-threatening complications such as septic shock and,
in some cases, an increased mortality.2–10
Some of the techniques used to protect the suture line of the
duodenum include duodenal diverticulization, pyloric exclusion
with or without gastrojejunostomy, and primary repair with a
retrograde duodenostomy tube and distal feeding tube.7,11–13
For more complex injuries with devascularization of the duode-
num, other options such as resection with enteric anastomosis
and the Whipple procedure have been described.7,16–21
We hypothesized that a primary repair alone can be used
for duodenal injuries without increased complications such as
intra-abdominal sepsis or increased mortality even in cases of
high-grade duodenal injuries.
METHODS
A retrospective multicenter trial was conducted including
11 Panamerican Trauma Society centers. An international chat
created by the society, including surgeons from international
centers, was used as a recruitment tool.
Each center obtained its own approval of its institutional
review board (IRB). Virginia Commonwealth Center was the site
J Trauma Acute Care Surg
Volume 86, Number 3

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J Trauma Acute Care Surg
Volume 86, Number 3
for principal investigator and as such had an IRB approved for
this purpose.
We included patients with duodenal injuries that required
surgical management from January 2007 to December 2016.
Data were collected using the REDCap (Research Electronic
Data Capture) tool. We also included demographics, mechanism
of injury, blood loss, operative time in minutes, and associated
injuries. Outcomes included postoperative intra-abdominal sep-
sis, leak, need for unplanned surgery, length of stay, incidence of
renal failure requiring dialysis, and mortality.
All analyses were performed using SAS 9.4 (Statistical
Analysis System, North Carolina State University). All tests
were two-tailed and assumed a significance level of 0.05. Con-
tinuous variables are reported as median with interquartile range
and were compared using the Wilcoxon rank test or the Kruskal-
Wallis test. Categorical variables were compared using the Fisher
exact test. Poisson regression using a backward selection
method was used to identify independent predictors of mortality.
The center was used to model for intrafacility cluster effects.
Inclusion criteria included patients with duodenal trauma
older than 18 years who needed surgical intervention. Exclusion
criteria included pregnant patients, incarcerated patients, and pa-
tients who died in the first 24 hours.
We hypothesized that there would be far more primary re-
pairs than other types of repairs and that a 20% difference in the
rate of complications between primary repairs and other repairs
would be significant. We therefore used a Fisher exact test of
equal proportions assuming a significance level of 0.05, at
two-tailed test, a 3:1 ratio of patients with a 20% difference in
complication rates to calculate a power analysis of 73% with
Group 1 as other repairs with a sample size of 60 and primary
repairs alone with a sample size of 180.
RESULTS
During the study, 372 patients had duodenal injuries re-
quiring surgical repair. Penetrating trauma was the most com-
mon mechanism (79%). The majority of these patients had
associated intra-abdominal injuries (n = 253 [68%]). There were
128 colon injuries, 107 pancreas injuries, 90 gastric injuries, 44
kidney injuries, 34 inferior vena cava injuries, 24 liver injuries,
23 splenic injuries, 20 injuries to the common bile duct, 14 inju-
ries to the diaphragm, and three aortic injuries. The overall in-
jury burden and severity of duodenal trauma were high, with a
median Injury Severity Score (ISS) of 18 (interquartile range,
2–3), median abdominal Abbreviated Injury Scale of 3.5
(3–4), and a median American Association for the Surgery of
Trauma (AAST) duodenal injury grade of 3 (2–3). There were
181 Grade 3 injuries. However, of the 283 patients where the
AAST grade was available, 217 (77%) were high grade (AAST
grade >2).
Primary repair alone was the most common type of oper-
ative management (299 [80%]). In addition, 16 patients had pylo-
ric exclusion with a gastrojejunostomy, 13 had pyloric exclusion
without gastrojejunostomy, 37 had primary repair with retrograde
decompressive duodenostomy with or without distal feeding
tube, five had resection with primary anastomosis, and two had
a Whipple procedure (Table 1).
© 2018 American Association for the Surgery of Trauma.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Ferrada et al.
TABLE 1. Patient Counts by Type of Repair and AAST Grade
AAST PADT PE With PE Without Other Primary Total
Grade n = 37 GJ n = 16 GJ n = 13 n = 7 n = 299 N
1 0 0 0 0 14 14
2 16 3 1 0 52 72
3 16 10 10 1 181 218
4 2 3 1 1 33 40
5 1 0 0 4 3 8
Missing AAST 2 0 1 1 16 20
grade
GJ, gastro jejunostomy; PADT, primary repair with retrograde decompressive
duodenostomy with or without distal feeding tube; PE, pyloric exclusion.
Overall mortality was 24%. On univariate analysis, mor-
tality was associated with male gender, lower admission systolic
blood pressure, need for transfusion before operative repair, higher
intraoperative blood loss, longer operative time, renal failure re-
quiring renal replacement therapy, higher ISS, and associated
pancreatic injury (Table 2). Poisson regression showed higher
ISS, associated pancreatic injury, renal failure requiring renal re-
placement therapy, the need for preoperative transfusion, and male
gender remained significant predictors of mortality (Table 3).
Duodenal suture line leak was statistically significantly lower,
and patients had primary repair over every American Associa-
tion for the Surgery of Trauma grade of injury (Table 4).
DISCUSSION
Injuries to the duodenum requiring surgical repair are rel-
atively rare. However, the morbidity and mortality of these re-
main high. The location of the duodenum adjacent to important
vascular and biliary structures, as well as the pancreas, makes
isolated duodenal injuries relatively rare. This was certainly true
in our data, as nearly 70% of patients had an associated intra-
abdominal injury. Immediate mortality is usually not due to
the duodenal injury, but instead due to hemorrhagic shock from
associated injuries. As we wished to examine success of primary
duodenal repair, we excluded early deaths.
Morbidity and late mortality in duodenal injuries are usu-
ally related to sepsis and/or other intra-abdominal complications,
particularly duodenal suture line dehiscence. However, deter-
mining the safest way to repair the injured duodenum to prevent
duodenal suture line leak has been difficult. For years, trauma
surgeons assumed that more complex duodenal injuries were
better served by more complicated methods of repair. A number
of rules were generated with a paucity of data to support any of
these. For instance, common dogma was that any duodenal in-
jury greater than 50% of the circumference required some man-
ner of duodenal diversion.
A number of procedures became popular. Stone and Fabian14
described a method of triple-tube diversion. Patients with duo-
denal injury had a primary repair and then were diverted with
a gastrostomy, a retrograde duodenostomy, and a feeding
jejunostomy. In their series of 237 patients, only one patient devel-
oped suture line leak when using this technique. However, eight
of the 44 patients not treated with decompression developed
duodenal leak.
393
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Ferrada et al. Volume 86, Number 3

TABLE 2. Univariate Comparisons by Mortality

Mortality No (n = 283) Yes (n = 89) p Test
Gender (male) 13.30% 30% 0.0462 Fisher exact test
Blunt trauma 25.30% 19% 0.2987
Penetrating trauma 19.20% 25.20% 0.2997
Transfusion before operating room 13.70% 36.40% <0.0001
Massive transfusion 10.50% 49.70% <0.0001
Associated intra-abdominal injury 9.70% 25.20% 0.0756
Colon 21.90% 25.40% 0.4409
Pancreas 18.20% 36.40% 0.0003
Liver 21.70% 26.40% 0.3261
Common bile duct 22.70% 10.20% 0.0311
Stomach 20.90% 33% 0.0232
Other injury 22% 26.50% 0.4813
Associated extra-abdominal injuries 19.60% 31% 0.0168
Intensive care unit admission 33.10% 18.60% 0.0022
Unplanned surgery 22.40% 27.10% 0.3611
Renal failure on dialysis 20.70% 70.80% <0.0001
Ventilator >3 d 21.80% 31% 0.0854
Leak 23.10% 28.30% 0.4096
Sepsis 19.70% 40.30% 0.0003
Age median (interquartile range), y 20–39) 29 (22–40) 0.1249 Wilcoxon rank test
ISS 18 (16–25) 29 (25–35) <0.0001
AAST grade 3 (2–3) 3 (3–3) 0.0368
Initial systolic blood pressure, mm Hg 115 (93–130) 100 (70–130) 0.0032
Admission systolic blood pressure, mm Hg 112 (98–130) 94 (73–114) 0.0033
Estimated blood loss, CC 500 (300–1,000) 1,000 (500–4,000) <0.0001
Operative time, min 152 (110–195) 120 (70–185) 0.0379

Duodenal diverticularization was first described by Berne true, for the most part, on both univariate analysis and logistic re-
et al.15 to treat a severe duodenal injury. The duodenal injury gression. The choice of the method used for duodenal repair did
was repaired. An antrectomy with end-to-side gastrojejunostomy not predict morbidity or mortality. In fact, complications such as
was then performed with a tube duodenostomy for duodenal de- duodenal leak, sepsis, and need for unplanned reoperation were
compression. The magnitude of this operative procedure re- statistically significantly lower when primary repair was used.
quired some degree of hemodynamic stability. It also altered This was true over every AAST grade of injury.
normal anatomy, interfered with normal eating, and could be ul- Death is a consequence of blood loss. This seems to be the
cerogenic. Finally, pyloric exclusion was described in the late case, even when early deaths (within 24 hours) are excluded.
1970s. This consists of opening the stomach and suturing the There are major adjacent vascular and structures such as the in-
pylorus closed with an absorbable suture. This was originally ferior vena cava in the aorta. Approximately 12% of our pa-
done with a gastrojejunostomy to drain the stomach. Later, sur- tients had injury to these structures. In addition, an additional
geons began eliminating the gastrojejunostomy and drained the 70 patients had solid organ injury, to the kidney, liver, or spleen.
stomach with either a nasogastric tube or a gastrostomy. This Any of these injuries could have produced a substantial blood
protected the duodenal repair, at least temporarily. Over some
weeks, the pyloric closure reopened, restoring normal anatomy.
In our series, primary repair alone was the most common TABLE 3. Predictors of Mortality
method used to repair duodenal injuries. Primary repair alone
Risk 95% Confidence Poisson
was used in 80% of patients. This was true even in high-grade Ratio Limit p Regression
duodenal injuries. In the 20% treated with other techniques, a va-
riety of operative procedures were used. The most common pro- ISS 1.0554 1.0455–1.0653 <0.0001 Backward
selection
cedure used was primary repair supplemented with retrograde
Transfusion 1.9925 1.4682–2.7039 <0.0001
decompression. Only seven patients, approximately 2.5%, had before operating room
injuries where primary repair was not possible. Five had resec- Pancreas 1.5116 1.2588–1.8151 <0.0001
tion with anastomosis, and two had a Whipple procedure. Renal failure on 1.7753 1.2292–2.5641 0.0022
Overall mortality was approximately 25%. Perhaps not dialysis
surprisingly, mortality was related to physiology at the time of Gender (male) 1.8492 1.1783–2.9020 0.0075
presentation, intraoperative factors such as blood loss, injury se-
Goodness of fit: deviance p = 0.5106, Pearson χ p = 0.6499.
2
verity, renal failure, and associated pancreatic injury. This was

394 © 2018 American Association for the Surgery of Trauma.

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J Trauma Acute Care Surg
Volume 86, Number 3
TABLE 4. Number of Patients With a Leak by AAST Grade and Repair Type
AAST Grade PADT (n = 37) PE With GJ (n = 16)
1 0 0 0
2 1/16 (6.3%) 0/3
3 6/16 (37.5%) 5/10 (50%)
4 1/2 (50%) 2/3 (66.7%)
5 1/1 (100%) 0 0
Missing AAST grade 2 0
loss. Admission blood pressure, need for preoperative transfu-
sion, and intraoperative blood loss all predicted mortality on uni-
variate analysis.
Common complications included sepsis, duodenal leak,
and the need for unplanned reoperation. Associated pancreatic
injury is a known risk factor for these complications. Even with
good external and/or internal drainage, pancreatic enzyme leak
can weaken gastrointestinal suture lines producing leak. It is not
a surprise that associated pancreatic injury was associated with
mortality on both univariate analysis and logistic regression.
We retrospectively reviewed data from 11 Panamerican
Trauma Society centers over 10 years. Despite the fact that most
of these are high-volume centers, seeing a large amount of pen-
etrating injury, in fact each center saw a mean of 3.5 duodenal
injuries per year. Given the number of surgeons taking call, each
individual surgeon performed a relatively small number of duo-
denal repairs. This may have affected results. Additionally, the
number of procedures performed other than primary repair is
fairly small. This also could potentially have affected the data.
The resources between the various hospitals may have varied.
It is not possible to know whether this affected the choice of du-
odenal repair and/or the outcomes.
Primary repair is a safe and efficacious manner of treating
duodenal injury. The vast majority, 98% of patients in this series,
had duodenal injuries amenable to primary repair. While more
complex options do exist, it is unclear that they are any better
than primary repair alone. Primary repair is the treatment of
choice. Adding pyloric exclusion and/or additional decompres-
sion should be reserved for special cases.
AUTHORSHIP
P.F. developed the hypothesis, recruited centers, and collected the data.
L.W. analyzed the data. All other authors contributed with data as well as re-
visions of the manuscript. T.S. performed a critical revision of the manuscript.
ACKNOWLEDGMENTS
Jinfeng Han was the main site study coordinator in charge of managing
the data and IRB procedures and site coordination. Salem Rustom assisted
with the statistical analyses.
DISCLOSURE
The authors declare no conflicts of interest.
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Ferrada et al.
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Ferrada et al.
DISCUSSION
Gregory J. “Jerry” Jurkovich, M.D. (Sacramento,
California): Good afternoon, members and guests, President-Elect
Croce, Dr. Winchell. Thank you for the honor of discussing this
important paper.
The presentation was based, as you heard, on a multi-center
review from North, Central and South American trauma hospi-
tals. It represents an effort from the Panamerican Trauma Society,
and this collaboration is representative of this landmark meeting
of the AAST and the World Trauma Congress, so well done.
Dr. Ferrada and her colleagues have emphasized the great
variability that exists in the management of duodenal injuries.
Over the decade of this retrospective review, the 13 trauma
centers who compiled the data managed a large number – 372
patients – with duodenal injuries. It is not a common entity,
but also not so rare that every surgeon will eventually have to
face this management dilemma.
I have a few observations about this cohort of duodenal
trauma patients that are worth noting, and along with that will
be my questions.
Number one, 80 percent of this population suffered pene-
trating trauma. Are the factors that influence the outcome any
different between penetrating and blunt trauma mechanisms?
Secondly, associated injuries are highly common, and I
presume that hemorrhage control and control of contamination
remain the highest priorities of initial trauma care.
To that end, mortality was high, at 24 percent, and while
many of these deaths are likely due to acute blood loss, the au-
thors did not provide us with data on the timeline nor the cause
of mortality, so what was the time of death and the cause of death
in these 24 percent of patients?
And fourth, four of the study centers were from North
America, but the remainder were from Central or South Amer-
ica. Are there any differences in management style and outcome
noted based on the geography of the trauma centers?
And finally, I would like to emphasize the operative tech-
niques utilized. Primary repair alone was performed in 80 per-
cent of the patients, as we heard.
Are any of the adjuncts to simple primary repair or resec-
tion in primary anastomosis really necessary or beneficial in the
management of duodenal trauma?
I believe that's the crux of the dilemma of judgment that
faces the trauma surgeon in the middle of the night in trying to
decide how to manage these patients.
Perhaps for the very rare circumstance of significant loss
of duodenal tissue, a resection and primary anastomosis will be
required – that was five patients in this series –, or if tension ex-
ists, a roux-en-Y limb of intestine will need to be sutured to the
proximal duodenum to establish continuity – none in this series
– or even rarer, a pancreatic-duodenectomy and Whipple recon-
struction will be needed for a complete destruction of the duode-
num and pancreatic head – and there were two in this series.
But the role of pyloric exclusion, duodenostomy tube, pro-
grade or retrograde duodenal lumen decompression, buttressing
of the duodenal repairs, et cetera, their role remains unanswered.
And I wonder what the authors could suggest as a way to help re-
solve some of these uncommon intra-operative questions about
management.
396
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J Trauma Acute Care Surg
Volume 86, Number 3
Finally, my sincere congratulations on this accomplishment,
as this is the first multi-center trial study from the PanAmerican
Trauma Society.
Sheldon H. Tepperman (Bronx, New York): Dr. Ferrada,
I, too, offer my congratulations. Awesome.
So, Dr. Ron Gross is sitting here in the audience on his
computer, and he is about to update the definitive textbook on this
question, which would be the Advanced Trauma Operative Man-
agement course. And so there is a chapter on duodenal injury.
And as we are teaching this course, it's confusing for our
young surgeons. So is it time to turn to Dr. Gross and offer
the advice of, let's down-regulate all of these tubes and things
and just tell people to do a primary repair?
Omar Bekdache, M.D., F.R.C.S., F.A.C.S. (Montreal,
Canada): My question is, how was the assessment of the asso-
ciated pancreatic injury done intra-operatively, and how did this
impact your management protocol intra-operatively for the pri-
mary type of repair? Thank you.
Marc A. de Moya, (Milwaukee, Wisconsin): Thank you,
Dr. Ferrada, always great presentations, and my question actually
has to do with the leaks.
You had a significant number of patients in this cohort,
and so it would be nice to kind of drill down into the type of
leak, and whether or not, if you separated those that had a leak
versus those who didn't have a leak, rather than look at the
mortality.
Was there any difference at all among the groups, in terms
of the technique of closure, and then also the management, be-
cause not all leaks are the same, right? So, if you could just shed
some light on that, perhaps.
Ari K. Leppaniemi, M.D., Ph.D. (Helsinki, Finland):
Nice work, Paula. Congratulations. As Marc was saying, the
key to duodenal injuries is really the leak. And I saw you showed
some data on that, but I would be interested if you could elaborate
a little bit more how you managed the leaks, and how much the
leaks actually contributed to the outcomes in terms of not just
mortality, but complications, length of stay, and so on.
Paula Ferrada, M.D.(Glen Allen, Virginia): Thank you
everybody for the wonderful comments and support.
We excluded the deaths within the first 24 hours, be-
cause we wanted to hone in on the deaths secondary to intra-
abdominal sepsis.
Regarding how many patients had a leak, those that
underwent primary repair leaked less however no repair showed
a decreased mortality.
To answer the question about if there was a difference be-
tween North America and Latin America, the large majority of
the patients underwent primary repair, and surgeons in Latin
America almost exclusively used primary repair.
I agree with the statement that perhaps it's time to at the
very least attempt primary repair, if there is adequate blood
supply, and no other injuries that can prevent this repair. It is
more likely the patients would heal one anastomosis than several
other enterotomies that can cause further morbidity for our
patients.
Thank you so much for the opportunity to present this pa-
per. It is an honor for the Panamerican Trauma Society to present
our fist multicenter trial in this forum.
© 2018 American Association for the Surgery of Trauma.