Surgical treatment and outcome after delayed diagnosis of blunt duodenal injury

Objective: To review our experience of 18 patients with duodenal injuries a fter blunt trauma, the diagnosis of which had been delayed for more than 24 hours. Design: Retrospective study. Setting: Teaching hospital, Taiwan, R.O.C. Subjects: 18 patients who presented with duodenal injuries between January 1986 and December 1995. Main outcome measures: Morbidity and mortality. Results: The reasons for the delay were: injuries not found during the firs t operation (n = 6), patients had not sought medical help (n = 6), and inju ries treated conservatively at local hospitals (n = 5). There was one delay in our department because the patient lost consciousness. 12 patients were treated by pyloric exclusion with no deaths and four complications (one du odenal fistula and 3 retroperitoneal abscesses). The other 6 had various op erations including pancreaticoduodenectomy, jejunostomy, and gastrostomy, w ith six complications and one death, giving an overall mortality of 6% and morbidity of 50%. Three patients developed delayed extensive retroperitonea l abscesses and all three were treated successfully by laparostomy. 16 of t he 18 patients required enteral feeding through a jejunostomy. Conclusions: Though the complication rate was high, the use of pyloric excl usion and a feeding jejunostomy kept the mortality low. Enteral nutrition s hould be started early. Laparostomy is a good way to manage retroperitoneal abscesses. To avoid delay, patients at risk of duodenal injuries should be evaluated early by experienced trauma surgeons and any central retroperito neal haematoma should be explored during the initial laparotomy.