Duodenal injuries: what you need to know

Duodenal injuries are uncommon, limiting most surgeon's experience in their management. The retroperitoneal location of the duodenum combined with associated major abdominal vascular and adjacent injuries further complicate the management decisions in treating duodenal trauma. Keys to successful management include wide exposure, achieved through a wide Kocher maneuver, dissection of the lesser sac, and mobilization of the ligament of Treitz to fully visualize the entire duodenum. Careful inspection of the medial wall is necessary to fully identify the extent of the injury. Primary repair, either in one or two layers, is the superior and preferred for almost all degrees of injuries except for destructive injuries and those associated with a significant pancreatic injury where a primary duodenojejunostomy or a pancreaticoduodenectomy may be required. Adjunctive maneuvers such as pyloric exclusion or tube duodenostomies have not been demonstrated to prevent or decrease the severity of a leak. External drainage in the absence of an associated pancreatic injury is not required. The appearance of a leak in the early postoperative period mandates reoperation. Providing enteral nutritional support is critical in improving outcomes, especially in the setting of a duodenal leak. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).