Abdominal impalement resulting in an isolated duodenal injury

Robert G. Yavrouian, MD

Resident

Department of Surgery

Ahmed Mahmoud, MD, FRCS

Program Director

Surgery Residency Program

Graduate Medical Education Office

Department of Surgery

Nathaniel Matolo, MD

Attending

Department of Surgery

San Joaquin General Hospital

French Camp, CA

ABSTRACT

Introduction: Abdominal impalement is rare, and the resulting injuries can be challenging to diagnose and treat. Duodenal injuries arising from impalement or other traumatic incidents are unusual because of the duodenum?s protected location, deep in the retroperitoneal space.

Results and Discussion: This article reports what appears to be the first case of an isolated duodenal injury secondary to impalement. The authors review the literature and discuss transportation protocols and treatment modalities that must be followed when caring for impaled patients.

Conclusion: Any impaling object should be left in situ unless it must be trimmed to facilitate transport or patient positioning in the operating room. Removing an impaling object without operative guidance can cause life-threatening hazards, such as hemorrhage. Once in the operating room, exploratory laparotomy is performed to assess injuries and determine operative treatment.

The duodenum is usually well protected from abdominal injuries because of its location deep in the retroperitoneal space, where it lies in close proximity to the liver, pancreas, biliary tree, and vascular structures. Duodenal injuries occur in only 3% to 5% of patients who sustain abdominal trauma.¹ Approximately 75% to 85% of duodenal injuries result from firearms and stabbings. ^2,3We report a rare case of an isolated penetrating duodenal injury that occurred when the patient fell from a roof onto a tree branch. We also discuss the management principles of abdominal impalement and of penetrating duodenal injuries.

CASE REPORT

A 36-year-old woman fell from a one-story rooftop onto a tree and was impaled by a tree branch in her right flank at the level of the umbilicus (Figure 1). On arrival to the emergency department, she had a blood pressure of 124/100 mm Hg, pulse of 120 beats per minute, and a respiratory rate of 25 breaths per minute. Physical examination revealed equal breath sounds on auscultation and peritoneal signs on palpation.

The patient was resuscitated in the emergency department with crystalloids, which were administered through two large-bore venous catheters. She was transferred to the operating room conscious and supine. Extreme care was taken to avoid manipulating the branch, and rapid-sequence intubation was used to gain control of her airway.

The abdominal cavity was explored through a vertical midline incision. During the operation, bile-stained fluid was encountered in the right upper quadrant of the patient's abdomen, and a perforation of the lateral aspect of the second portion of the duodenum was noted (Figure 2). The gallbladder, pancreas, liver, and inferior vena cava were uninjured. The tree branch was removed carefully under direct vision once the extent of the patient's injuries was determined. Following mobilization of the patient's duodenum using the Kocher maneuver, the injury was repaired primarily by transverse closure in two layers, and a distal feeding jejunostomy tube was placed. The entrance wound was debrided of dirt and splinters, lavaged, and allowed to heal by secondary intention. The patient had a satisfactory recovery and was discharged to home on postoperative day 5. The jejunostomy was removed as an outpatient procedure on postoperative day 17.

DISCUSSION

Impalement injuries result when a solid object pierces a body cavity or extremity, usually with great force. The object often remains fixed firmly within the patient's body. Eachempati and colleagues classify impalement injuries as type I and type II.⁴ Type I injuries occur when a human body in motion strikes an immobile object, and type II injuries occur when a moving object collides with an immobile person.⁴ Although this classification scheme may be useful for documentation, it does not affect how impalement injuries are managed.

Management of impaling objects

Practice

Point

• When the impaling object causes a through-and-through injury, some surgeons recommend a fistulotomy-like incision between the entrance and exit sites.
• When only an entrance wound exists, a traditional midline laparotomy incision may be appropriate.

Almost 150 years ago, Dr. JH Bill first published his findings that supported the practice of leaving impaling arrow shafts undisturbed, which he based on postmortem examinations that revealed their tamponade effect on the surrounding injured vasculature.^5-7 His recommendation to leave impaling objects in situ during patient transport is still followed today because the tamponade effect on injured vasculature and the potential for life-threatening hemorrhage and contamination are well-recognized. The object can be carefully shortened by severing it above the level of the skin if needed to facilitate patient transport, prevent unintentional dislodgement, or position the patient on the operating room table.^4,5,8,9

When the impaling object causes a through-andthrough injury, some surgeons recommend a fistulotomy- like incision between the entrance and exit sites.^4,8 This allows the surgeon to remove the object without pulling it through the abdominal wall along its entire length and avoids the risk of fragmenting the object. In some instances, this incision also allows better visualization of the extent of the patient's injuries and the trajectory of the object. When only an entrance wound exists, as in the case presented here, a traditional midline laparotomy incision may be appropriate.

Repair of duodenal injuries

Most penetrating duodenal injuries are amenable to simple primary repair in one or two layers. Repair in a transverse fashion is recommended to avoid luminal narrowing. Some authors have reported success with this technique in 60% to 85% of cases involving penetrating injury.^1,10,11 Decompressive tube duodenostomy through a healthy portion of the duodenum, retrograde jejunostomy tube placement, or reinforcement with a serosal or omental patch are techniques that can be used to bolster a tenuous duodenorrhaphy. ^2,3,12 However, there is no consensus in the literature on the use of decompression techniques, and reported incidences of fistulas and overall mortality associated with decompressed versus nondecompressed duodenal repairs vary.^11,13,14

More extensive injuries require more complex repairs. Injuries that result in duodenal transection may be managed using segmental resection with reanastomosis if the first, third, or fourth portions of the duodenum are involved and the affected segment can be adequately mobilized. If the injury occurs in the first portion of the duodenum and the two ends cannot be mobilized adequately, antrectomy with Billroth II gastrojejunostomy and closure of the duodenal stump should be performed.¹² For a similar injury distal to the ampulla of Vater, oversewing the distal duodenum with Roux-en-Y duodenojejunostomy is the repair of choice.¹² Resection is not feasible for injuries involving the second portion of the duodenum because of its shared blood supply with the pancreas and its proximity to the ampulla of Vater. In such cases, or when adequate mobilization is impossible and the defect is large, repair can be accomplished using a Roux-en-Y jejunal limb anastomosed directly to the duodenal defect.^3,12

Practice

Point

Resection is not feasible for injuries involving the second portion of the duodenum because of its shared blood supply with the pancreas and its proximity to the ampulla of Vater.

Pyloric exclusion and duodenal diverticulization are two techniques used to repair major duodenal injuries. These procedures divert the flow of gastric contents, thereby allowing the duodenum to heal. Pyloric exclusion involves closing the pylorus and gastrojejunostomy; duodenal diverticulization uses gastric antrectomy with Billroth II gastrojejunostomy, tube duodenostomy, and external drainage with or without truncal vagotomy and biliary drainage.^15,16 Pancreaticoduodenectomy is reserved for select cases in which there is combined injury to the pancreas and duodenum, devascularization of the duodenum, massive uncontrollable hemorrhage, or irreparable injury to the second portion of the duodenum.^3,10,12

CONCLUSION

Duodenal and impalement injuries are rare, and treating them presents surgeons with challenging dilemmas. Strict adherence to the transportation and management principles outlined in this paper are necessary to prevent morbidity and mortality. Although the surgical literature contains other reports of duodenal injuries resulting from impalement, the patients described in those reports sustained injuries that differed from our patient's situation.^9,11,17 Our report appears to relay the first case of impalement causing an isolated injury to the duodenum.

Disclosure

The authors have no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attest that the data meet the requirements for informed consent and for the Institutional Review Boards.

References

1. Levinson MA, Petersen SR, Sheldon GF, et al. Duodenal trauma: experience of a trauma center. J Trauma. 1984;24(6):475-480.
2. Jurkovich GJ, Bulger EM. Duodenum and pancreas. In: Moore EE, Feliciano DV, Mattox KL, eds. Trauma. New York, NY: McGraw-Hill; 2004:709-734.
3. Weigelt JA. Duodenal injuries. Surg Clin North Am. 1990;70(3):529-539.
4. Eachempati SR, Barie PS, Reed RL 2nd. Survival after transabdominal impalement from a construction injury: a review of the management of impalement injuries. J Trauma. 1999;47(5):864-866.
5. Horowitz MD, Dove DB, Eismont FJ, et al. Impalement injuries. J Trauma. 1985;25(9):914-916.
6. Thomson BN, Knight SR. Bilateral thoracoabdominal impalement: avoiding pitfalls in the management of impalement injuries. J Trauma. 2000;49(6):1135-1137.
7. Bill JH. Note on arrow wounds. Am J Med Sci. 1862;44:365-387.
8. Ketterhagen JP, Wassermann DH. Impalement injuries: the preferred approach. J Trauma. 1983;23(3):258-259.
9. Golder SK, Friess H, Shafighi M, et al. A chair leg as the rare cause of a transabdominal impalement with duodenal and pancreatic involvement. J Trauma. 2001;51(1):164-167.
10. Shorr RM, Greaney GC, Donovan AJ. Injuries of the duodenum. Am J Surg. 1987;154(1):93-98.
11. Hasson JE, Stern D, Moss GS. Penetrating duodenal trauma. J Trauma. 1984;24(6):471-474.
12. Degiannis E, Boffard K. Duodenal injuries. Br J Surg. 2000;87(11): 1473-1479.
13. Ivatury RR, Nallathambi M, Gaudino J, et al. Penetrating duodenal injuries. Ann Surg. 1985;202(2):153-158.
14. Stone H, Fabian TC. Management of duodenal wounds. J Trauma. 1979;19(5):334-339.
15. Berne CJ, Donovan AJ, White EJ, et al. Duodenal "diverticulization" for duodenal and pancreatic injury. Am J Surg. 1974;127(5): 503-507.
16. Vaughan GD 3rd, Frazier OH, Graham DY, et al. The use of pyloric exclusion in the management of severe duodenal injuries. Am J Surg. 1977;134(6):785-790.
17. Grindlinger GA, Vester SR. Transvaginal injury of the duodenum, diaphragm, and lung. J Trauma. 1987;27(5):575-576.

Self-assessment questions

1. Resection and anastomosis can be appropriate treatment for injury to all portions of the duodenum, except: First Second Third Fourth
2. You are informed that a 30-year-old man who has a knife impaled in his mid-abdomen will be arriving at the hospital via ambulance. The patient?s vital signs are stable and his only complaint is pain at the entrance wound. What is the correct course of action? Instruct the emergency medical technicians to remove the knife en route and apply a firm dressing to the wound. Remove the knife yourself after the patient arrives at the emergency department. Remove the knife in the operating room before performing laparotomy. Alert the operating room staff to prepare for laparotomy and remove the knife intraoperatively after adequate exposure of the injury tract.
3. Which of the following is true regarding the surgical repair of duodenal injuries? Simple repair is successful in 20% to 30% of injuries. Pyloric exclusion is used to avoid stricture of the repaired duodenum. Second-portion injuries can be repaired by resection and anastomosis. Simple repair is carried out in a transverse fashion to avoid stricture.
4. During laparotomy in a hemodynamically stable patient with a gunshot wound to the abdomen, you note a large 3-cm defect in the second portion of the duodenum and moderate bruising of the head of the pancreas. The aorta and inferior vena cava are uninjured. What is the most appropriate action? Whipple procedure (pancreaticoduodenectomy) Primary repair of the duodenum and drain the pancreas and lesser sac Duodenal repair using a jejunal patch, pyloric exclusion, and pancreatic drainage Decompression tube duodenostomy and drainage of the pancreas

Answers

1. b—Because the second portion of the duodenum shares its blood supply with the pancreas, management with resection and anastomosis is typically not appropriate for injuries to this segment.
2. d—Patients suffering from impalement injuries should be transferred to the operating room, and the impaled object should be removed only after adequate exposure of the injury tract. Excessive bleeding or massive contamination can occur if the impaling object is removed before surgery.
3. b—Simple repair should be performed in a transverse fashion to avoid luminal compromise and is successful in 60% to 85% of cases. Pyloric exclusion is used in cases of tenuous repair to divert gastric flow for 2 weeks and allow healing to occur. Resection and anastomosis is not appropriate for injuries to the second portion of the duodenum.
4. c—Using a jejunal patch decreases the chance of stricture and applying pyloric exclusion allows time for healing. Draining the pancreas is the most common treatment for pancreatic head trauma. Pancreaticoduodenectomy is indicated only when the combined injuries of the duodenum and pancreas cannot be repaired by any other means or in cases of uncontrolled hemorrhage. Primary repair in this case would lead to stricture because of the large defect.