Suture Selection for Duodenum Repair
For duodenal repair, use monofilament absorbable sutures such as polydioxanone (PDS) 3/0 or polyglactin, which provide optimal tissue handling with reduced bacterial seeding and appropriate delayed resorption rates for this high-risk anatomical location. 1, 2, 3
Primary Suture Material Recommendations
Monofilament absorbable sutures are the gold standard for duodenal repair based on their superior properties in contaminated fields and reduced infection risk compared to multifilament options. 1, 3
Specific Suture Types:
Polydioxanone (PDS) 3/0 is the most commonly reported suture for duodenal trauma repair, offering delayed resorption appropriate for duodenal healing timelines. 2, 3
Polyglactin represents an acceptable alternative monofilament option with similar handling characteristics and delayed resorption. 3
Avoid catgut sutures as they are associated with increased pain and higher resuturing rates. 1
Avoid multifilament sutures due to increased bacterial seeding potential in the duodenum, which is at high risk for contamination from biliary and pancreatic secretions. 1, 3
Technical Considerations by Defect Size
Small Perforations (<1-3 cm):
Primary repair with simple suture closure using 3/0 PDS in a tension-free transverse fashion after complete debridement of devitalized tissue. 4, 2
Reinforce with omental patch sutured to healthy tissue (not directly through the perforation) using the same monofilament absorbable material. 4, 1, 2
The omental patch is particularly valuable when edges are friable to prevent sutures from cutting through tissue. 1
Large Perforations (>3 cm) or Complex Injuries:
Jejunal serosal patch technique can be employed using 3/0 PDS to suture the antimesenteric jejunal serosa to duodenal serosa (serosa-to-serosa only, not full thickness) over the primary repair. 2
Consider pyloric exclusion with absorbable sutures if there is concern about duodenal healing, though this remains controversial and is no longer routinely advocated. 4, 2, 5
Critical Technical Principles
The suture technique matters more than the number of layers. 3
Place sutures in healthy tissue only, maintaining adequate distance (0.8-1.5 cm) from the defect edge. 3, 6
Tissue inversion is more important than mucosal inversion - focus on incorporating the seromuscular layer adequately. 3
Use tension-free technique in a transverse orientation to avoid luminal narrowing. 4
Avoid overly tight sutures that can strangulate tissue and impair healing, particularly critical in the well-vascularized duodenal wall. 1
Endoscopic Repair Considerations
For iatrogenic perforations during ERCP or ESD:
Small perforations (<13 mm) can be managed endoscopically with through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs) with 88-100% success rates. 4
Vicryl mesh can be used to cover ESD defects, affixed with endoscopic clips to prevent delayed perforation. 4
Novel endoscopic suturing devices may close larger defects endoscopically in selected cases. 4
Common Pitfalls to Avoid
Never use non-absorbable sutures for duodenal repair as they increase long-term complications including fistula formation and marginal ulcers. 3, 5
Delayed recognition beyond 6 hours dramatically increases mortality and morbidity, necessitating more aggressive surgical intervention. 4
Inadequate debridement of devitalized tissue before suturing leads to higher leak rates. 4
Placing sutures through friable ulcer edges rather than healthy tissue proximally increases dehiscence risk. 3, 6
Adjunctive Measures
Nasogastric tube decompression should be placed routinely to reduce intraluminal pressure during healing. 4
External drain placement near the repair site is recommended for high-grade injuries to control potential leaks. 4
Consider feeding jejunostomy for severe injuries requiring complex reconstruction, though jejunostomy-related complications occur in up to 7% of cases. 4