|LETTER TO THE EDITOR
|Year : 2014 | Volume
| Issue : 2 | Page : 168-169
Isolated blunt duodenal injury: Role of triple tube decompression
Dharmendra L Pander, Dharmendra K Shah, Mihir K Shah, Aditya S Yadav
Department of Surgery, Government Medical College Baroda and SSG-Hospital, Vadodara, Gujarat, India
|Date of Web Publication||31-Jul-2014|
Dr. Dharmendra L Pander
Department of Surgery, Government Medical College Baroda and SSG-Hospital, Vadodara, Gujarat
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pander DL, Shah DK, Shah MK, Yadav AS. Isolated blunt duodenal injury: Role of triple tube decompression. Astrocyte 2014;1:168-9
Blunt duodenal injury is uncommon finding associated with significant morbidity (30-60%) and mortality (6-25%). ,, Blunt abdominal injuries account for 25% of all duodenum traumas, while the remaining 75% are due to penetrating trauma. ,, Isolated blunt duodenal injuries are rare, due to its retroperitoneal position and its proximity to other organs like pancreas, liver, and vessels. Duodenal injuries are usually involved with injury to these organs. We report a case of isolated blunt duodenal injury, which was managed with tripe tube decompression.
We report a case of a 25-year-old male patient laborer who was admitted to our hospital with history of blunt abdominal trauma 5 h back, due to fall on hard rock while running. He complained of acute severe abdominal pain associated with nausea and few episodes of vomiting. On admission, he was conscious, tachypneic and his pulse rate was 96/min and blood pressure was 120/70 mmHg. His hemoglobin was 15.8 g%, total white blood cell (WBC) count was 13,400/cmm with adequate platelet count. His abdominal examination revealed tenderness and generalized guarding. Focused abdominal sonogram for trauma (FAST) found moderate free fluid in peri hepatic and right paracolic gutter. X-ray abdomen does not show free gas. Patient was taken for surgery considering peritonitis (clinically) and FAST findings. Consent was taken and antibiotic prophylaxis was given. Abdomen was explored through midline incision, on opening there was about 150-200 ml of bilious fluid. Small intestine from duodenojejunal junction to ileocaecal junction, colon, liver, and spleen were explored and found normal. Duodenum was mobilized with Kocher's maneuver, hematoma was found in first and second part of duodenum; on opening hematoma, three perforations were found in first and second part of duodenum, all perforations were near to each other, involving >50% of circumference of first and proximal second part of duodenum creating grade III injury (according to American association for surgery for trauma), proximal to ampulla of vater, on anterolateral aspect of about 1 × 1 cm in size each. The injured segment of duodenum was resected and duodenal and gastric stumps were created (distal gastrectomy was done), followed by side to side retro colic iso peristaltic gastrojejunostomy, 30 cm distal to deuodenojejunal junction (DJ). Retrograde duodenostomy tube was inserted 5 cm distal to DJ in retrograde manner up to junction of 2 nd and 3 rd part of duodenum to decompress the duodenal stump (gravity drainage). Feeding jejunostomy was performed with no. 24 Foley's catheter, inserted in ante grade manner (40 cm distal to DJ). Nasogastric tube was properly placed to decompress the stomach. Abdomen was closed without tension; postoperative stay was uneventful. Feeding through jejunostomy was started on 3 rd postoperative day; sips of liquids started orally on 5 th day. He passed his first motions on 7 th day and nasogastric tube was removed on 7 th day. Drain was removed on 10 th day and orally soft diet started on 15 th day. Initially retrograde duodenostomy tube was draining about 1.6 L of bilious fluid than about 1 L, which was gradually decreased to 300 ml on 15 th postoperative day. Retrograde duodenostomy tube was removed on 28 th postoperative day after 5 days of intermittent clamping. Surgical wound was clean and stitch removed on 15 th day. Feeding jejunostomy tube was removed on 30 th day. Patient discharged on 31 st day.
| Discussion|| |
Protection of a duodenal repair is important to decrease the risk of duodenal suture dehiscence. Approximately 10 L of gastric, Biliary, pancreatic and duodenal secretions pass daily through the duodenum. ,, its proteolytic enzymes, great volume by itself may lead to breakdown of suture lines with subsequent fistula, which can lead to peritonitis and sepsis,  autodigestive effects of enzymes increase when all these secretions come together. Many methods of duodenal decompression and diversion of secretions from duodenal stump have been suggested, primary repair (duodenorraphy) followed by duodenal decompression with triple tube technique was originally described by Stone and Fabian.  In their study of 321 cases of duodenal injury over 30 years, they demonstrated 8% leak without decompression and less than 1% with duodenal decompression. Berne et al., in 1974, describe the technique in patients with severe duodenal injuries, which includes a distal gastrectomy, closure of duodenal wound, a gastrojejunostomy, and placement of a decompressive catheter into the duodenum.  Triple tube technique advocated for decompression of the duodenum and protection of the duodenum suture line was the earliest techniques used and had favorable results with a fistula rate of 2.3% with tube decompression and 11.8% without tube decompression.  The procedure gives importance to keeping the duodenum empty and tension free by decompressing all the fluids.  Bhattacharjee et al.  reported two cases of blunt duodenal injury treated with triple tube decompression and they favored this technique. Nobuaki et al.  concluded that simple principles of this technique resulted in good clinical outcome. They studied three cases of iatrogenic perforations after endoscopic mucosal resection, with the triple tube technique, with good outcome. They also inserted fourth tube in common bile duct through cystic duct after cholecystectomy, however they did give importance to duodenal decompression by retrograde jejunostomy tube. They concluded that duodenal decompression via triple tube technique (plus one more tube in common bile duct) decreases the risk of duodenal fistula. Similar result was shown in single patient of blunt duodenal injury by Crippa et al. 
| Conclusion|| |
- A high degree of suspicion is necessary for early diagnosis of blunt duodenal injury.
- Triple tube decompression technique is effective and require in management of duodenal injuries to decrease the risk of duodenal fistula by adequate decompression.
Early feeding improves nutrition and gives better healing of tissues.
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