Evolution in the management of duodenal injuries

The use of the duodenal Organ Injury Scale,17 will facilitate the surgical management of these injuries, and the development of protocols. Our current treatment philosophy includes the following tenets: (1) less treatment is probably best treatment, (2) most duodenal injuries can be treated with primary repair, (3) resection and diversion should be done in Grade IV and Grade V injuries (15 to 25% of patients), (4) tube duodenostomy should be used in only a few selected high-risk cases, (5) pyloric exclusion with gastrojejunostomy is probably a better option than duodenal "diverticulization" in most duodenal injuries, and (6) pancreatoduodenal resections should be used only in those patients when there is destruction of the duodenopancreatic complex associated with involvement of the biliary system. In these patients, the techniques and principles of staged surgery with abbreviated laparotomy and planned reoperation50-53 should be used, and we strongly support this as a viable option in critically ill patients with multiple injuries.