Primary Closure without Diversion in Management of Operative Blunt Duodenal Trauma in Children

Background. Operative blunt duodenal trauma is rare in pediatric patients. Management is controversial with some recommending pyloric exclusion for complex cases. We hypothesized that primary closure without diversion may be safe even in complex (Grade II-III) injuries. Methods. A retrospective review of the American College of Surgeons’ Trauma Center database for the years 2003–2011 was performed to identify operative blunt duodenal trauma at our Level 1 Pediatric Trauma Center. Inclusion criteria included ages years and duodenal injury requiring operative intervention. Duodenal hematomas not requiring intervention and other small bowel injuries were excluded. Results. A total of 3,283 hospital records were reviewed. Forty patients with operative hollow viscous injuries and seven with operative duodenal injuries were identified. The mean Injury Severity Score was 10.4, with injuries ranging from Grades I–IV and involving all duodenal segments. All injuries were closed primarily with drain placement and assessed for leakage via fluoroscopy between postoperative days 4 and 6. The average length of stay was 11 days; average time to full feeds was 7 days. No complications were encountered. Conclusion. Blunt abdominal trauma is an uncommon mechanism of pediatric duodenal injuries. Primary repair with drain placement is safe even in more complex injuries. 1. Introduction Blunt duodenal trauma remains a relatively rare diagnosis among the pediatric population, accounting for 3 to 5% of all abdominal injuries [1]. Many cases are the result of lap belt or bicycle handlebar injuries, although higher mortality rates have been reported with blunt duodenal injury secondary to nonaccidental trauma [2]. In contrast to adult duodenal traumas, of which greater than 70% are penetrating, the majority of pediatric duodenal injuries are secondary to blunt trauma [3]. Cerise and Scully emphasized that trends in duodenal trauma have demonstrated a gradual increase in severity as a greater proportion are now secondary to motor vehicle accidents, with relatively fewer children experiencing low-velocity handlebar trauma [4]. Their collected cases allowed them to describe three general mechanisms of injury to the small bowel, which include crushing the bowel between the spine and a blunt object, tangential shearing against a relatively immobile segment of bowel, and increased intraluminal pressure causing rupture of a closed bowel loop [4]. Appropriate treatment of such injuries is hampered both by potential delay in diagnosis and by the controversial nature of optimal surgical