Surgical paper X
Diagnosis and treatment of close duodenal retroperitoneal injury
ABSTRACT Closed duodenal injuries represent a unique and severe subtype of intra-abdominal trauma characterized by low incidence but high mortality rates. This study discusses six instances of retroperitoneal duodenal injuries, reporting a successful treatment outcome in four cases and fatalities in the remaining two. Such injuries are particularly elusive to early diagnosis due to their retroperitoneal location, which often results in the absence of overt symptoms and signs associated with hollow organ perforation. Therefore, clinicians must exercise heightened vigilance, carry out meticulous and ongoing dynamic monitoring, and seek robust diagnostic evidence to expedite surgical intervention. Given the specialized anatomical and physiological characteristics of the duodenum, the treatment approaches diverge significantly from those employed for other visceral injuries. This makes surgical choices pivotal to the prognosis. The study finds that comprehensive duodenal decompression and diverticularization techniques are dependable. The Berne procedure is particularly recommended for its efficacy in drainage and infection control, supplemented by requisite supportive care. Keywords: Retroperitoneal Duodenal Injury, Diverticularization, Berne Procedure
The duodenum, located deep within the posterior abdominal wall, is less frequently subjected to injury, making up only 3–5% of closed abdominal injuries and 10% of gastrointestinal injuries [1]. When a rupture occurs within the peritoneal cavity, it typically manifests quickly with signs of peritonitis, much like other hollow organ perforations. This draws immediate clinical attention, leading to timely surgical intervention. However, when the injury is confined to the retroperitoneal region, the leakage of intestinal fluids is concealed within the retroperitoneal space. This presents a diagnostic challenge as it lacks overt symptoms or positive physical signs, leading to delayed diagnosis and treatment. Consequently, the mortality rate for such injuries skyrockets to between 30–60% [2], posing a significant clinical conundrum.
Our hospital has treated 258 cases of closed abdominal injuries over the years, among which 8 involved duodenal injuries. Of these, 6 cases (2.3%) were retroperitoneal injuries. Each presented unique difficulties, resulting in delayed surgical interventions. Here, we dissect the complexities, experiences, and lessons gleaned from these cases.
Clinical Data
All patients in this study were male, ranging in age from 17 to 45 years. Of these, four sustained injuries to the descending part of the duodenum, while the remaining two had injuries in the transverse section. Two patients sought medical attention within four hours post-injury, and the other four within 24 hours. Associated injuries included one case each of liver trauma, inferior vena cava damage, mesenteric vascular injury, and splenic rupture. Additionally, two cases presented with isolated duodenal retroperitoneal injuries. The causes of injuries were varied: two resulted from falls, one from a blunt force injury by a wooden stick, and three from motor vehicle accidents.
As for the timing of surgical intervention, two patients underwent surgery within 24 hours post-injury due to concomitant severe intra-abdominal bleeding. The remaining patients were operated on between 24 and 48 hours post-injury, as positive abdominal signs progressively manifested.
Two patients received a straightforward repair followed by intraperitoneal drainage; however, both cases had unfortunate outcomes. One succumbed to hemorrhagic shock six hours post-surgery, and the other passed away on the 4th and 8th postoperative days due to complications from an intestinal fistula and subsequent infection and electrolyte imbalances, respectively.
The remaining four patients underwent a more complex surgical approach incorporating the Berne-like technique [3]. This involved duodenal and common bile duct fistulization, along with gastric-jejunal anastomosis following gastric antral resection. All four of these patients successfully recovered post-surgery.
Discussion
2.1 Mechanism of Injury
The injury mechanism is often a consequence of blunt trauma or inertial decompression, leading to a sudden shift in intra-abdominal pressure. This forces the duodenum against the spine and induces pyloric spasms, dramatically increasing intestinal pressure. Both internal and external bidirectional shearing forces act upon the frail and fixed duodenal wall, causing it to rupture.
2.2 Pathological Underpinnings of Duodenal Retroperitoneal Injury
In the early stages post-injury, leaked fluids accumulate locally in the ruptured area, manifesting few systemic symptoms and remaining largely undetectable. In our cohort, two cases featured isolated retroperitoneal injuries in the descending duodenum; surprisingly, these patients were ambulatory post-admission, experiencing only lower back discomfort. Symptoms generally worsened after 24 hours. A startling 80% of such cases are not definitively diagnosed preoperatively [4]. The leaking digestive fluids contain a myriad of components like hydrochloric acid, bile salts, cholesterol, and digestive enzymes, among others. These substances cause chemical irritation, autodigestion, and infection, leading to a cascade of complications, including severe inflammation, edema, necrosis, and multiple organ failure.
2.3 Diagnostic Key Points
A hallmark symptom is the dispersion of caustic fluids into the retroperitoneal space, resulting in lower back and right testicular pain. Escaping intestinal gas accumulates in the retroperitoneal space and can be visualized via plain abdominal X-rays; this gas often outlines the right kidney, making it more discernible. Retroperitoneal inflammatory edema may blur the right psoas muscle shadow and abdominal fat lines. A digital rectal examination may reveal presacral crepitus. Elevated levels of pancreatic amylase serve as an additional diagnostic marker. A positive abdominal puncture is favorable for diagnosis, but a negative result does not rule it out. Oral administration of iodine water can confirm and locate the spillage outside the intestine. During laparotomy, methylene blue can be administered via a nasogastric tube to directly visualize the spillage, aiding even in the identification of multiple injuries and avoiding missed diagnoses.
2.4 Surgical Procedure Selection
2.4.1 Minimized Duodenal Injury
For cases with limited duodenal injury and minor local inflammation that undergo early surgical intervention, cautious use of simple repair is possible. However, it's critical to inspect the orifice of the hepatopancreatic ampulla to ensure its patency. In one such case in our cohort, we used a technique akin to ERCP catheter placement and left a side hole for drainage and decompression. No postoperative complications like jaundice or pancreatitis were observed.
2.4.2 Implementing "Three Fistulas"
For effective duodenal decompression and early nutritional perfusion, one approach includes raising the jejunal wall for repair and adding three fistulas: gastrostomy, proximal jejunostomy into the duodenum, and distal nutritional fistulization.
2.4.3 Berne-Like Procedure
Delayed diagnosis often results in late surgical intervention and aggravated local inflammation. We advocate for the Berne-like surgical approach, which comprises multiple elements like intestinal repair, duodenal fistulization, and abdominal drainage. This method has shown to be effective in the complete and permanent diverticularization of the duodenum. This procedure is generally safe and can be completed within three hours.
2.4.4 Pancreatoduodenectomy
This radical surgery is suitable for severe injuries involving the head of the pancreas and the duodenum but should be reserved for extreme cases due to its high mortality rate and the stress it puts on critically ill patients.
2.4.5 Complete Debridement
Intraoperative debridement of the abdominal and retroperitoneal spaces is vital. Removal of necrotic or devitalized tissue, along with extensive irrigation, helps reduce toxin absorption. Effective drainage measures, such as double-tube negative pressure suction, are also crucial and can be used for irrigation and medication postoperatively if necessary.
2.5 Postoperative Management
Maintaining gastrointestinal decompression and ensuring unobstructed suction through the created fistulas are pivotal for sustaining low pressure within the duodenum. Effective abdominal and retroperitoneal drainage systems should be kept in place, and if necessary, they can be removed 5-7 days postoperatively to account for potential intestinal leakage.
Eliminating the stimulating effects of extra-intestinal fluid accumulation at the site of duodenal injury is crucial for successful wound healing. Systemic balance of water and electrolytes, along with nutritional supplementation—particularly albumin and calorie intake—bolsters the body's reparative abilities.
The choice of effective antibiotics, particularly intravenous infusion of anti-anaerobic drugs such as metronidazole, is vital for infection control. Adopting a semi-recumbent position post-surgery helps avoid subdiaphragmatic fluid accumulation and enhances effective drainage, all of which are integral components of a holistic postoperative care strategy.
References
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Hu Zhenxiong, et al. "Selection of Surgical Procedures for Duodenal Injury," Journal of Practical Surgery, 1989, 9(8): 441.
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He Liangjia, et al. "Diagnosis and Treatment of Closed Duodenal Injury," Journal of Practical Surgery, 1985, 5(11): 571.
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Berne CT, et al. "Duodenal Diverticularization for Clodenal and Pancreatic Injury," American Journal of Surgery, 1974, 127: 503.
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Chen Rufa, et al. "Principles of Surgical Treatment of Duodenal Injury," Journal of Practical Surgery, 1993, 3: 134.
This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30 Changhang Hospital, Li Mingjie
from 闭合性十二指肠腹膜后损伤诊治分析
