What is the management for duodenal blowout?

Management of Duodenal Blowout

For duodenal blowout (perforation/leak), proceed immediately to operative management if the patient is hemodynamically unstable or has peritonitis; perform primary repair with nasogastric decompression and external drainage for most injuries, reserving damage control surgery for unstable patients with associated vascular injuries. 1

Initial Assessment and Indications for Immediate Surgery

All patients with hemodynamic instability or peritonitis require immediate operative management. 1 Hemodynamic instability occurs in 10-44% of duodenal injury patients, and associated injuries are present in 68-86.5% of cases. 1

Hemodynamically stable patients should also proceed to immediate surgery if CT demonstrates: 1

• Free air
• Extravasation of enteral contrast from the duodenum
• Full thickness laceration (WSES class III, AAST-OIS grade III-V)

Operative Strategy Based on Patient Stability

Damage Control Surgery (DCS)

Consider DCS in hemodynamically unstable patients, particularly those with associated vascular injuries or higher grade duodeno-pancreatic lesions. 1 DCS is reported in 20-63% of cases and has been associated with improved survival and equivalent or improved complication rates. 1 However, DCS is rarely needed for isolated duodenal injuries. 1

Once hemostasis is achieved, address the duodenal injury at the initial surgery only if the patient's physiology allows. 1

Definitive Repair for Stable Patients

The surgical approach depends on injury severity:

WSES Class I-II Lacerations (AAST-OIS Grade I-II)

Perform primary repair in a tension-free transverse fashion after complete exposure and removal of all devitalized tissue. 1

• Place a nasogastric tube for proximal decompression 1
• Routine periduodenal drain placement is not supported by evidence 1

WSES Class III Lacerations (AAST-OIS Grade III-V) Without Massive Duodeno-Pancreatic Disruption

Modern evidence advocates primary repair, NGT decompression, and external drain placement even for large, high-grade injuries. 1 These conservative techniques demonstrate better mortality and duodenal-related morbidity compared to complex drainage and reconstructive procedures. 1

If primary repair is not possible, perform segmental resection with primary duodeno-duodenostomy. 1

Important caveat: Duodenal diverticulization and triple tube decompression are no longer advocated for duodenal injury treatment. 1

Pyloric Exclusion - Controversial and Generally Not Recommended

Pyloric exclusion (PE) shows no improvement in morbidity or mortality compared to primary repair with NGT decompression alone, and may increase complications. 1 Multiple studies report prolonged length of stay with PE, and concerns exist regarding increased procedure time, gastric suture line complications, and marginal ulcers. 1

PE may still be considered in select cases, but definite indications remain controversial. 1

WSES Class III with Massive Duodeno-Pancreatic Complex Disruption

For complex injuries involving extensive tissue loss: 1

• Proximal duodenum/D1 lesions: Consider antrectomy with gastrojejunostomy and duodenal stump closure 1
• Distal to ampulla: Perform Roux-en-Y duodeno-jejunostomy 1
• Ampulla/distal CBD involvement: Re-implantation into healthy duodenum or Roux-en-Y reconstruction if tissue loss is minimal 1
• Severe devitalization of duodenum/pancreatic head: Pancreaticoduodenectomy (Whipple) may be required, but strongly consider staged approach with DCS first 1

Size-Based Algorithm for Duodenal Perforations

For small perforations (<2 cm), perform primary repair whenever technically possible. 1

For large perforations (>2 cm), surgical technique selection depends on: 1

• Hemodynamic stability
• Extent of duodenal tissue loss
• Presence of experienced surgeon
• Associated injuries

For D1/D2 ulcers with significant tissue loss, consider pancreas-sparing duodenectomy. 1

Critical warning: In perforations involving the ampulla, do not perform definitive resectional approaches in the emergency setting due to reconstruction complexity. 1 Instead, use damage control options including pyloric exclusion, gastric decompression, and external biliary drainage alongside primary repair. 1

Post-Bariatric Surgery Context

If duodenal blowout occurs after bariatric surgery (particularly RYGB), assess the jejuno-jejunostomy for stricture, kinking, or twisting, as gastric remnant perforation may be secondary to back pressure from distal obstruction. 1 Resect any anomalies at the jejuno-jejunostomy to prevent vascular compromise. 1

Adjunctive Measures

• Always place NGT for proximal decompression 1
• External drainage is recommended for high-grade injuries 1
• Consider tube duodenostomy for insecure closures or established leaks - this technique has shown effectiveness in preventing and managing duodenal stump leakage 2
• Enteral nutrition via jejunostomy should be started early 3

Key Pitfall to Avoid

Delayed diagnosis significantly increases morbidity and mortality. 1 Any central retroperitoneal hematoma should be explored during initial laparotomy, and patients at risk require early evaluation by experienced trauma surgeons. 3