Management of Duodenal Wounds

A 30-year experience with 321 wounds of the duodenum was reviewed. Of the total, 302 had some form of perforation; 19 had intramural hematomas. All patients underwent laparotomy shortly after admission except six cases of radiographically diagnosed submucosal hematoma. Occasional dehiscence of the duodenal suture line and its life-threatening complications (six of 52 cases, or 12%) led to a policy of routine duodenal decompression by gastrostomy plus twin jejunostomies in 1962. Following use of the latter technique in 237 patients, only one leak occurred. By contrast, failure to decompress had an 8% leak rate; direct drainage of the suture line gave an even greater incidence of dehiscence or fistula, 23%. Associated pancreatic injuries were treated as separate wounds by sump drainage of distal pancreatectomy. None of three patients subjected to pancraticoduodenectomy for massive combined pancreatic and duodenal trauma survived. A long-armed T-tube was always inserted for recognized as well as suspected common duct wounds. Although most of the 41 deaths were due to major vascular trauma and sequelae of hemorrhagic shock, duodenal complications did contribute to significant morbidity and five mortalities during the earlier years of review.