Evaluation of minor penetrating duodenal injuries

Penetrating duodenal injuries can present a confusing picture for the surgeon. A variety of treatment modalities exist including primary repair alone, primary repair with pyloric exclusion, duodenal resection, duodenal diverticulization, and the Whipple procedure. We reviewed 40 consecutive penetrating duodenal injuries in order to determine factors that led to complications of duodenal injuries, and to determine the most appropriate way to treat these injuries. Fourteen patients had combined pancreaticoduodenal injuries, five of whom developed pancreatitis. None of the patients without a combined pancreaticoduodenal injury developed pancreatitis (P < 0.05). Sixteen patients with minor duodenal injuries were treated by primary repair alone. In this group, five had combined pancreaticoduodenal injuries. Two of these five patients developed a suture line dehiscence and leak (P < 0.05). None of the 11 patients without a combined pancreaticoduodenal injury that were treated by primary repair alone developed a leak. Three patients with combined intermediate pancreaticoduodenal injuries were treated by primary repair with pyloric exclusion. None of these three patients developed a suture line dehiscence or leak. We conclude that combined pancreaticoduodenal injuries are more likely to develop pancreatitis, and that minor or intermediate combined pancreaticoduodenal injuries are more likely to develop a suture line dehiscence and leak. We recommend that the treatment of duodenal injuries be based on severity, location, and the presence of associated injuries. Minor injuries can be treated by primary repair alone, adding pyloric exclusion if there is a concomitant pancreatic injury.