Triple Diversion Technique in Complete Duodenal Transaction Following Blunt Trauma Abdomen: A Time-Tested Method in a Very Rare Injury

Abstract

Duodenal injury following blunt abdominal trauma is extremely rare in children and many times, it has delayed presentation, leading to increased morbidity and mortality. A patient with complete duodenal transaction is a surgical challenge and management involves the time of presentation and extent of visceral damage. A 10-year-old boy was brought with features of bowel perforation after road traffic accident and underwent emergency laparotomy which revealed complete transaction of duodenum at D1 and D2 and pyloroduodenal junction extending toward lesser curvature. Primary closure of pyloroduodenal junction and D1–D2 was done with omental patch along with triple tube decompression (cholecystostomy, gastrostomy, and jejunostomy). The patient had an uneventful recovery. Primary closure of disturbed ends with triple diversion is a safe approach in young children with complete duodenal transaction in absence of gross peritoneal contamination and early presentation.

INTRODUCTION

Duodenal injury in children secondary to a blunt abdominal trauma or road traffic accident is a rare event with a reported incidence of 11%–26%.[1] Usually, duodenal injury is associated with other visceral injuries. Isolated duodenal injuries are a rare event.[2] Treatment is aimed at maintaining anatomical continuity. The surgical technique chosen, out of several ones described in available literature, should take into account of time since injury, extent of tissue lost, and peritoneal contamination. We describe a case report of a boy who had pyloroduodenal tear along with complete transaction at D1 and D2 and extending toward lesser curvature due to blunt trauma abdomen.

CASE REPORT

A 10-year-old boy was brought to us after being run over by a bullock cart, 6 h after injury. Preliminary examination revealed signs of peritonitis. The patient was stabilized in the pediatric surgery emergency department. E FAST was positive for free fluid abdomen, with normal-appearing solid organs. X-ray of the chest and abdomen erect was done showing free air under the diaphragm. He was taken up for exploratory laparotomy within 2 h of presentation. Exploration revealed hemoperitoneum and pyloroduodenal tear along with complete transection of D1 and D2 [Figure 1]. Rest of the viscera did not have any signs of injury. Gastroduodenal and duodenoduodenal anastomosis were done after freshening the transected margins with PDS 5-0 supported by an omental patch. Triple tube decompression was done, namely decompressive gastrostomy (DG), feeding jejunostomy (FJ), and cholecystostomy. The patient could be ambulated by postoperative day (POD) 3. FJ feeds were started by POD 5 with due replacements of cholecystostomy and gastrostomy losses. Cholecystostomy was clamped and subsequently removed on POD 15. A dye study was done after POD 15 which revealed normal distal passage of contrast following which DG and FJ were clamped and oral feeds were initiated. The patient could tolerate full oral feeds by the 3^rd postoperative week following which DG and then FJ were removed. The patient has been doing well during 1-year postoperative follow-up.

Figure 1.

Intraoperative photograph showing complete transaction of D1 and D2 loop of duodenum (black asterisk: transacted D2, white arrow: transacted D1, black arrow: tear extending toward lesser curvature, white arrowhead: bile flowing from transacted distal duodenum)

DISCUSSION

The mobile portions of the duodenum are D1 and D4. The anatomical relations of duodenum make it highly difficult to resect and anastomose. The mechanisms of duodenal injury can be due to a direct blow to abdomen (crushed against a rigid vertebral column), or seat belt injury.[3] The mechanism of injury in our case could be the effect of crushing and shearing forces.

Eventual outcome of a patient is determined by time interval from trauma to definitive management. Surgery in <24 h of injury carries a mortality rate of 11%, which increases to 40% if surgery gets delayed for >24 h.[4] Anatomical factors influencing the outcome are relation of injured part to bile duct, type of injury, ranging from hematoma of duodenal wall to partial and complete transaction of duodenal segment, and associated pancreatic and vascular injuries. In our case, surgery was undertaken within 6 h of presentation and there were no associated pancreatic/bile duct injuries. Interposition of vascular ileal pedicle has been described to restore intestinal continuity.[5] In our case, a primary repair could be done without tension. Primary abdominal closure in such cases may prove to be difficult and lead to abdominal compartment syndrome in postoperative period, thus necessitating laparostomy.

The American Association for the Surgery of Trauma has described a grading system of duodenal injury,[6] but preoperative assessment and intraoperative exploratory findings better serve in deciding the definite surgical repair, from a practical point of view. Surgical options in duodenal trauma include repair of the duodenum, diversion of the gastrointestinal tract (pyloric exclusion or duodenal diverticulization), gastric decompression (gastric tube insertion or gastrojejunostomy), gastrointestinal tract access for feeding (jejunostomy tube or gastrojejunal anastomosis), decompression of the duodenum (duodenostomy tube), biliary tube drainage, and wide drainage of the repaired area (lateral duodenal drains).[7] Lateral duodenal injury is usually treated by primary duodenal repair and pyloric exclusion consisting of closing the pylorus with an absorbable suture and gastrojejunostomy and closed suction drainage of the repair. For combined proximal duodenal and pancreatic injury, duodenal diverticulization with resection and closure of the duodenal stump, tube duodenostomy, tube cholecystostomy, gastrojejunostomy, multiple closed suction drains, and an FJ should be strongly considered.[7]

Young age, prompt early intervention, and simple definite intervention with triple diversion without disturbing the adjacent anatomy were the keys for successful outcomes in our case.

CONCLUSION

In our case of pyloroduodenal tear with complete duodenum transection, we had limited reconstruction options. Performing a pyloric exclusion or duodenal diverticulization could have proved too morbid a procedure in a young age boy. Doing primary closure and restoring the anatomical continuity of duodenum and pylorus with triple diversion prove to be a simple and effective method with l ittle morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.