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CHAPTER XVIII

Wounds of the Duodenum (118 Casualties)

W. Herschel Cave, M. D.

The figures from World War I indicate that wounds of the small intestine are among the most lethal encountered in warfare. Wallace, who reported 363 cases in 985 abdominal injuries in British soldiers, recorded a case fatality rate of 65.9 percent for uncomplicated (univisceral) injuries and of 74.1 percent for complicated (multivisceral) injuries.¹ The case fatality rate for American troops was between 70 and 80 percent.² That modern surgical measures and efficient adjunct therapy have greatly improved the chances of survival in this group of casualties is evident from the figures reported for World War II.

Wounds of the duodenum are infrequent. They accounted for only 6 percent of all injuries of the small bowel recorded among American soldiers in World War I,³ and there were only 16 (4.4 percent) in Wallace's⁴ series of 363 small-bowel injuries. The 118 wounds of the duodenum observed by the 2d Auxiliary Surgical Group in 1944-45 (table 45) represent only 3.7 percent of the 3,154 abdominal injuries treated by the group during that period.

TABLE 45.-Essential data in 118 wounds of duodenum

Wounds of the duodenum are almost never univisceral. In this series, other organs were injured in 116 of the 118 cases (table 45), while all 9 duodenal injuries observed in 1943 were multivisceral and were, like the 1944-45 cases, characterized by the variability of the organs involved.

¹Wallace, Cuthbert: War Surgery of the Abdomen. London: J. & A. Churchill, 1918.
²The Medical Department of the United States Army in the World War. Washington: U. S. Government Printing Office, 1927, vol. XI, pt. 1, pp. 65, 459-460.
³Ibid.
⁴See footnote 1.

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DIAGNOSTIC CONSIDERATIONS

The preoperative diagnosis of injuries of the duodenum was made principally on the basis of probability. As experience with the pattern of the injury increased, it could readily be deduced that a missile entering the right side of the abdomen or the right lumbar region was likely to injure not only the liver, the colon, and the right kidney, but also the duodenum. It therefore became routine, when the abdomen was opened for an injury in these regions, to reflect the right colon and examine the duodenum thoroughly. The results of increasing consciousness of the possibility of injury of the duodenum are seen in the fact that while 2 perforations of the duodenum were overlooked in the 9 duodenal injuries treated by the 2d Auxiliary Surgical Group in 1943, only 1 was overlooked in the 118 cases treated in 1944-45. Other visceral injuries in this series of duodenal injuries included 69 of the liver, 59 of the colon, and 37 of the right kidney.

NATURE OF THE INJURY

The site of the wound of entry was fairly constant in these injuries of the duodenum (fig. 27) and suggested the diagnostic pattern which has just been described. In 96 instances, 81.4 percent, the missile entered the right side of the trunk from the front or the back.

In the 112 wounds in which the details were stated (table 46), the second portion of the duodenum was injured in 49.1 percent, the first portion in 24.1 percent, and the third in 13.4 percent. In the remaining cases, more than one portion was injured. In many injuries of the first portion, the lesion was continuous with a wound of the pylorus, and several injuries of the third portion, similarly, were continuous with wounds of the jejunum. The predominance of injuries of the second portion of the duodenum suggests that many casualties with injuries of the first portion did not survive to reach the hospital because of simultaneous fatal injuries of such close-lying structures as the vena cava, the hepatic artery, and the portal vein. Similar reasoning can be applied to explain the small number of injuries of the third portion; there is a close anatomic relationship between the duodenum and the aorta, the vena cava, and the mesenteric vessels.

Although the majority of the duodenal wounds were perforating or lacerating (table 46), there were 20 instances of transection in the series. In one instance, the injury was attributed to indirect violence. The patient presented a large gutter wound across the epigastrium, through which omentum had herniated. No wound of exit was found, nor was a foreign body demonstrable by roentgenology. The stellate lacerations of the liver and the second portion of the duodenum discovered at laparotomy were assumed by the surgeon to have been caused by concussion.

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FIGURE 27.-Sites of wounds of entry in 118 injuries of duodenum.

TABLE 46.-Site and type of injury in 112 wounds of duodenum

TECHNICAL CONSIDERATIONS

Lacerations and perforations of the duodenum were usually repaired by a standard, fairly uniform technique. Transections were repaired by end-to-end anastomosis with running sutures of atraumatic chromic catgut, usually reenforced with silk or cotton sutures. The peritoneum, as a rule, was closed over the wound. The site of repair was drained in almost every case, and drainage was mandatory if the pancreas or the liver was also wounded. In the four cases in which gastrojejunostomy was necessary (all of which were promptly fatal), the damage to the duodenum was extensive and beyond repair.

POSTOPERATIVE COMPLICATIONS

Two fistulas of the duodenum are known to have developed in the field hospitals in which these 118 duodenal injuries were treated. Both occurred on the sixth postoperative day, and both in cases in which transactions of the

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duodenum had been repaired by end-to-end anastomosis with chromic catgut reenforced by silk. The figures are too small to be significant, but it may be that there is a tendency for fistulas to develop after transection of the duodenum. Drainage following repair, therefore, seems indicated in all injuries of this type.

In another instance, it was assumed that fistula developed. The injury was a simple laceration of the second portion of the duodenum, which had been repaired by a single running suture of atraumatic chromic catgut reenforced with interrupted silk sutures. The clear, irritating discharge which began to issue from the wound on the sixth day was regarded as duodenal in origin.

TIME AND CAUSES OF DEATH

Sixty-seven of the one hundred and eighteen patients with duodenal injuries (56.8 percent) are known to have died in forward hospitals within the first 10 days after operation. In two additional cases, it is believed that death also occurred within this period, though the records are too incomplete to permit a positive statement. These figures are to be compared with the World War I American Army figures, which show 8 fatalities in the 10 recorded instances of duodenal injury.⁵ In 47 of the 67 fatalities (table 47), death occurred within the first 3 days after operation.

TABLE 47. -Primary cause of death and time of death in 67 injuries of duodenum

Shock and hemorrhage were recorded as the cause of 39 of the fatalities, 58.2 percent (table 47). The patients who did not survive were, on the whole, in a more severe state of shock when they were hospitalized than were those who survived (table 48). Two of the three deaths attributed to peritonitis occurred in cases in which visceral injuries had been overlooked at operation;

⁵ See footnote 2, p. 235.

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one was a laceration of the common bile duct and the other a perforation of the third portion of the duodenum.

Of the 20 patients who sustained transections of the duodenum, 14 died within the first 6 days after operation. The other six are known to have survived beyond this period. In one instance, in which autopsy was not performed, it was thought that the duodenal suture had given way. The patient had sustained a through-and-through perforation of the upper pole of the right kidney, which had been drained, and a through-and-through perforation of the second portion of the duodenum, which had been closed with two layers of running sutures of atraumatic chromic catgut. He became greatly distended on the seventh postoperative day and complained of severe epigastric pain; death occurred 8 hours later.

TABLE 48.-Influence of degree of shock on case fatality rates in 114 wounds of duodenum

Multivisceral wounds, as already noted, were the rule in duodenal injuries (table 49), being present in all but two instances in this series. Both patients with univisceral injuries survived. The factor of multiplicity greatly increased the lethality of wounds of the duodenum. The major surgery required in multivisceral wounds played an important part in the increase in the case fatality rates. The rate was 57.0 percent in the 21 cases in which nephrectomy was done, 75.0 percent in the 8 cases of cholecystectomy, 70.0 percent in the 13 small-bowel resections, 77.7 percent in the 9 cases of colectomy, and 80.0 percent in the 5 cases of splenectomy.

Wounds of the large blood vessels played a particularly important part in the high case fatality rate of duodenal injuries. Of the 9 patients who had lacerations of the vena cava, 8 died; the only survivor was not in shock when he was first seen. Death also occurred in the 2 injuries of the portal vein, the 2 injuries to the pancreaticoduodenal artery, and the injuries of the hepatic and the right spermatic artery (1 each).

Pancreatic injuries were also highly fatal; death occurred in 8 of the 9 cases, though in only 1 instance was the head of the pancreas so badly damaged that the duct was severed.

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TABLE 49.-Influence of multiplicity factor on case fatality rates in 118 wounds of duodenum

¹One fatality in this category was a univisceral wound, complicated by a wound of the portal vein, which was primarily responsible for the fatal outcome.

In 15 of the 118 duodenal injuries, an associated chest injury was present, varying in severity from a simple perforation of the diaphragm to severe lacerations or contusions of the lung. Eleven of these fifteen patients died.

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