Retroperitoneal duodenal rupture

Retroperitoneal

Duodenal

Proposed

Review of Literature

Mechanism, Report

Rupture and

of a Case

WILLIAM M. COCKE, JR., M.D.* AND KENNETH K. MEYER, M.D., New Orleans, Louisiana

From

the Department

Orleans, Louisiana.

of Surgery,

Ochsner

Clinic,

is a difficult one to handle and a dangerous one to mishandle. A recent experience with this injury stimulated a review of the literature and report of our case in an attempt to resolve some of the difficulties associated with this surgical problem.

New

HE MORTALITY and morbidity rates assoT ciated with retroperitoneal duodenal rup-

ture secondary to blunt abdominal trauma remain high. In 1944 Johnson [1] reported a mortality rate of 50 per cent in fifty-two cases of retroperitoneal duodenal rupture! and complications in 54 per cent of the twenty-six patients who lived. The perforation was not found at initial laparotomy in 19 per cent of these patients with an associated mortality rate of 77 per cent. Cohn [2], who reviewed the twenty-five cases recorded in the literature from 1943 to 1952, reported a mortality rate of 20 per cent and postoperative complications in 20 per cent of the survivors. Since 1952 we have been able to find forty-eight additional cases of retroperitoneal duodenal rupture secondary to blunt trauma reported in the medical literature. (Table I.) Nineteen per cent of these patients died and 69 per cent of the survivors had complications. Duodenal fistula and retroperitoneal abscess accounted for two thirds of the complications. In 15 per cent of the patients the duodenal rupture was either not operated on or not found at laparotomy; 71 per cent of these patients died. The frequent history of a trivial injury, lack of initial symptoms, unsuspecting surgeon, diagnostic delay and the failure to locate the perforation at initial laparotomy in a high percentage of cases are reasons why this lesion

MECHANISM

* Present address: Department of Plastic Surgery, New York Hospital-Cornell Medical Center, New York, N. Y. American

Journal

of Surgery,

Vol.

108,

December

1964

834

Automobile accidents account for many of these injuries, although the majority result from blows to the body received in athletics, fights, falls or, as in the case to be reported, a relatively minor blow to a relaxed abdominal wall [3-71. The mechanism of injury has been considered to be crushing of the duodenum against the vertebral column, a tangential or shearing force applied to the duodenum or a closed-loop type of injury with a gas-filled duodenum due to a closed pylorus and an acutely flexed duodenojejunal angle secondary to the contracted fibromuscular ligament of Treitz [8-101. It is unlikely that any one of these mechanisms is responsible for every retroperitoneal duodenal rupture. For example, the force that would occur if an individual were caught between a mobile or immobile object would be crushing in type. This kind of injury would be expected to be associated with considerable trauma to the pancreas, superior mesenteric vessels and other viscera in the area. In many of the reported cases the force causing the injury was described as crushing, but there was striking absence of associated major injuries. A shearing or tangential blow would entail a different type of force and supposedly would tear a rent in the duodenum. Among the cases collected from the literature

Retroperitoneal

Duodenal

Rupture

TABLE I C:\SESOF RETROPERITONEALDUODENALRUPTUREAPPEARINGIN THE LITERATURESINCE 1951 -Time from Injury to Surgery

Type of Trauma

Author

(hr.)

!

~ Complications

Results

i :

_

-i

Estes Pirtle Crone [43] Stransky Keith Keith Cottrell Wilder Schlosser Schlosser Strode Strode

Crushing Crushing Fall Auto accident Auto accident Auto accident Crushing Crushing Blow to abdomen Struck in abdomen Fall Crushing

Lawrie Murphy

Blow to abdomen Blow to abdomen

Murphy Capobianco Rothchild

Auto accident Fall Struck in abdomen by horse Auto accident Fall

Kelly Kelly Duncan Duncan

.

I ~

4 6 3 10 18 30

8 . ~ 20 3

~ 1

9.5

. 27 18 12 18 19 18

...

Patton Patton Patton Hansen Eklund

Struck in abdomen Crushing Fall Horse fell on patient Motorcycle accident

Hanley Kane Boggs deNiord deNiord

Crushing Struck in abdomen Auto accident Auto accident Auto accident

Field Field Mabry Brabrand Brabrand Thorlakson

Auto accident Auto accident Struck in abdomen Kicked in abdomen Struck in abdomen Struck in abdomen

Thorlakson Adnopoz Burrus [42]

Auto accident Fall Blunt trauma (8 cases)

12 36

Cocke & Meyer

Bicycle accident

14

26 3 12 21 2 2j 16

. 18 9 4 12 32 Few

Recovered Recovered Recovered Recovered Recovered Not operated; recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Not operated 27 hr. Recovered Recovered Recovered

on;

Duodenal fistula Abscess Fistula Wound disruption Pancreatitis Abscess; intestinal obstruction Duodenal fistula Retroperitoneal

abscess

Pyloric obstruction; fistula

pancreatic

died

Duodenal fistula

Recovered Recovered Recovered Perforation missed at laparotomy; died Died Recovered Recovered Recovered Recovered ; missed at laparotomy Recovered Recovered Recovered Recovered Missed at laparotomy; died Died Died Recovered Recovered Recovered Missed at laparotomy; died Recovered Recovered 2 deaths; 1 missed at laparotomy Recovered

Abscess

. . . Marginal ulcer

. Duodenal tistula Abscess Abscess Duodenal fistula; abscess Intestinal obstruction

Abscess Fistula Duodenal fistula

. Five complications

there appeared to be none caused by a shearing or tangential type force. The injury in the case to be presented is believed to have been due to the closed-loop type

of mechanism. The pathogenesis of duodenal injury in this type is interesting to speculate upon with the anatomy and physiology of the duodenum playing an important role. 835

Cocke and Meyer

peristalsis with_ _ closed pylorus

conceivably generate this pressure in a gasfilled, anatomic closed-loop of intestine [13]. There may or may not be actual rupture or perforation at the time of trauma. If not, it is believed that the wall is stretched and weakened and the intramural vessels are ruptured because of this sudden aneurysmal dilatation. As a result of this, intramural hematoma with or without infarction of the intestinal wall could occur. Both of these may lead to delayed perforation of the injured duodenal wall. The foregoing discussion is an effort to explain the paucity of retroperitoneal duodenal perforations in spite of increased exposure of the population to blunt trauma to the intact abdominal wall, the frequent delay in onset of clinical manifestations and hence in diagnosis and treatment and the absence of associated injuries to the pancreas, great vessels and other viscera in this area. Similar mechanisms have been reported in cases of blunt abdominal trauma in which the perforation occurred in a hernial sac of the intestine where a closed-loop type of situation existed [14]. Also, perforation of the interventricular septum after blunt trauma to the anterior thoracic wall has been reported [15, 161. In the latter instance, it was suggested that the heart was in the diastolic phase, and the valve cusps were positioned so that a “closed-loop” situation was present with resultant interventricular septal rupture.

of Treitz inserted

gas filled. drodcnum’ FIG. 1. Ideal anatomic

situation for duodenal perforation resulting from blunt trauma.

The duodenum is mobile at the pylorus and at the terminal portion, but fixed at the other points. The suspensory muscle or ligament of Treitz, present in 86 per cent of the population, extends from the right pillar of the diaphragm to blend in with the smooth muscle of the duodenal wall at the duodenojejunal flexure alone (5 per cent), the third or fourth portion of the duodenum, or a combination of the three (95 per cent) [11]. It contains smooth muscle in 85 per cent of people in whom it is present [11]. It is believed to have the same nerve supply as intestinal smooth muscle, since no specific nerve fibers have been found for this structure. As noted, in only 5 per cent of the general population does the ligament of Treitz join at the duodenojejunal flexure. It is in this small percentage of people that obstruction could occur at this point when this smooth muscle ligament contracts. This contraction would occur at the time of peristalsis. Physiologists believe that the pylorus is closed approximately one third of the time when a peristaltic wave passes over it into the duodenum [U]. As the peristaltic wave passes over the duodenum, with the resultant closure of the pylorus and contraction of the suspensory muscle of Treitz, a closed-loop effect would periodically be formed in a small percentage of the population. (Fig. 1.) If at this time a blow were delivered to the abdomen, be it a trivial one to the relaxed abdominal wall or one of great force, there would be present an anatomic and physiologic combination predisposing the unfortunate victim to a “blowout” of the duodenum. It has been reported that 14 cm. of mercury is needed to rupture the small intestine in man, and a sharp, well localized force could

DIAGNOSIS

The key to diagnosis is suspicion. The patient may give a vague history of trauma with no significant abnormal physical findings, including roentgenographic and other laboratory data [17]. Despite this, retroperitoneal duodenal perforation may actually be present or impending. However, many patients have a definite history of trauma and complain of abdominal pain or soreness at the site of injury. This pain is usually located in the epigastrium but may be in the right lower or upper abdominal quadrant. It may be associated with nausea and vomiting. Bright red blood in the vomitus is usually indicative of gastric or duodenal injury. Examination may reveal epigastric or right-sided tenderness with guarding. These findings may progress to those typical of a perforated viscus with abdominal wall rigidity, acute and generalized abdominal tenderness, absent bowel sounds and shock.

836

Retroperitoneal

Duodenal

In most patients, initial roentgenograms and examination of the blood are of no aid in diagnosis [18]. Free air was demonstrated in only three of the collected cases [19-211. Blurred psoas shadows or retroperitoneal gas patterns, such as perirenal air, were visualized in seventeen additional patients [4,22-241. Fracture of one or more of the transverse processes of the lumbar vertebrae was noted in three patients, who had sustained a crushing force to the abdominal wall [25-27 1. Although not done in our case, ingestion or instillation into the Levine tube of a watersoluble contrast medium may be helpful in the diagnosis of a perforated viscus, be it retroperitoneal or free peritoneal [28-321. These substances are not contraindicated in patients suspected of having perforation as is barium sulfate [28,33]. It is likely that the patient will have few clinical manifestations when first seen. For this reason, patients with blunt abdominal trauma must be carefully observed much in the same way as patients with closed head trauma are observed for a possible head injury [5].

Rupture

4’

‘Lirrcision

FIG. 2. This demonstrates the inferior mesenteric vein as it courses near the point of incision necessary to visualize the duodenum.

curves up and behind the duodenojejunal junction to join the splenic vein. (Fig. 2.) The duodenum can then be further mobilized by actually transecting the fibromuscular ligament of Treitz at the suoerior aspect of the duodenal wall. Small vessels may be present in the ligament. The duodenum can then be freed posteriorly by blunt dissection and elevated so that complete visualization is obtained. Complete duodenal visualization is stressed because among our collected cases four of the five patients with perforations missed at laparotomy died [36-391. It may be helpful in some cases to instill 20 to 30 cc. of methylene blue into the Levine tube to help locate the site of perforation 1401.If this is done and perforation is present, one must be prepared to work in a blue field. Simple two-layered closure is usually all that is necessary but end to end anastomosis is carried out if duodenal transection is complete. In one case gastrojejunostomy was carried out after development of a postoperative marginal ulcer [Zl]. A feeding jejunostomy, as recommended by some, did not prevent postoperative complications in this series [35,41]. Parenteral administration of antibiotics and retroperitoneal drainage did not decrease the incidence of deaths or other complications. In the three reported cases in which it was specifically mentioned that thorough peritoneal and retroperitoneal irrigation was carried out, there were no complications or deaths [17,36]. This is considered an important part of the procedure.

TREATMENT

Once the diagnosis is made, laparotomy is obligatory. Search should be made for associated injuries (laceration with or without perforation of other viscera, parenchymal organs or major vessels). The only associated injuries in the cases collected from the literature were pancreatitis in two cases [34], small mesenteric hematomas in two cases [35] and fractures of the wrist and femur in one case [20]. In one patient perforation of the diaphragm was found at necropsy [20]. If all other organs are normal, the most important step during exploration is mobilization and visualization of the entire retroperitoneal duodenum. One can mobilize and visualize the right part of the duodenum by downward traction on the colon and incision of the peritoneum lateral to the descending portion of the duodenum @ocher’s maneuver). The duodenum can then be rotated mesially along with the head of the pancreas. To visualize the left or distal portion of the retroperitoneal duodenum, one must divide the peritoneal folds close to the wall of the duodenojejunal junction. Care must be exercised not to cut the inferior mesenteric vein as it

837

Cocke and Meyer CASE REPORT On September 9, 1962 a boy, aged eight years, was brought to the Ochsner Foundation Hospital Emergency Room. Shortly before admission he had ridden his bicycle into a pile of sand, The handlebar unexpectedly twisted and jammed into his abdomen, striking him in the upper quadrant to the left of the midline. He vomited once. On examination slight tenderness and ecchymosis over the left rectus muscle were the only positive physical findings. On roentgenography no abnormalities were detected. The patient lived close to the hospital and was sent home to be observed by his parents. He was brought back to the hospital thirteen hours later and fourteen hours after injury. This time the child complained of severe abdominal pain with vomiting. The pulse rate was 90 and blood pressure 108/60 mm. Hg. There was general-

ized abdominal tenderness with board-like rigidity and absent bowel sounds. Free peritoneal air was demonstratedroentgenographically.The white blood cell count was 9,250 per cu. ml. Laparotomy was immediately performed through aleft upper paramedianincision. When the peritoneal cavity was entered, turbid, purulent, free peritoneal fluid was found. This material appeared to be coming from the region of the ligament of Treitz down the left gutter. The paraduodenal tissue and the ligament of Treitz were cut and the duodenum was mobilized. A 3 cm. perforation was visualized at the fourth portion of the duodenum. The perforation was extended longitudinally and closed transversely in two layers. The peritoneal cavity was thoroughly lavaged with a bacitracin-kanamycin saline solution, and the abdomen was closed in layers without drainage. Postoperatively, antibiotics were not administered. Postoperative recovery was uneventful and the patient was dischargedon the seventh postoperative day. He has continued to do well. Nonhemolytic streptococcus, pneumococcus, hemophilus, aerobic gram-positive rods and alpha streptococcus were recovered from cultures of the peritoneal fluid. COMMENTS

In the forty-eight collected cases, the number of hours from injury to operation apparently had no bearing on mortality or morbidity rates. This may be explained in that the time of injury is not necessarily the time of perforation. The size of the perforation, the portion of the duodenum in which the injury is located, the presence or absence of free peritoneal bile or blood-stained fluid, the type of suture material, the type of closure, use of drains and administration of antibiotics did not seem to affect the mortality or morbidity rates.

838

The ideal condition for a blow-out type perforation is abdominal trauma occurring while the pylorus is closed and the duodenojejunal angle is acutely flexed by contraction of the ligament of Treitz. It is a relatively rare injury because there has to exist a rare combination of factors; but if present, a minor blow to the abdomen would result in this type of injury as it did in the case herein reported. SUMMARY

The surgeon should be aware of this problem and should carefully observe patients who have a history of blunt abdominal trauma for progression of clinical manifestations of a perforated viscus. If a diagnosis is made, laparotomy should be performed immediately. Complete duodenal visualization and mobilization must be done. Closure in two layers is usually all that is necessary. Thorough irrigation of the peritoneal and retroperitoneal area is recommended. Drainage and parenteral administration of antibiotics are optional. If the lesion is not recognized and not surgically corrected, or if the patient is operated on and the perforation not found, the patient’s chances for survival are slim. REFERENCES 1. JOHNSON, M. L. Traumatic retroperitoneal rupture of the duodenum-presentation of a case and review of the literature. Arch. Surg., 48: 372, 1944. 2. COHN, I., JR., HAWTHORNE, H. R. and FROBESE, A. S. Retroperitoneal rupture of the duodenum in non-penetrating abdominal trauma. Am. J. Surg., 84: 293, 1952. 3. ADNOPOZ, A. and FORTUNA,A. B. Retroperitoneal rupture of the duodenum. Arch. Surg., 83: 937, 1961. 4. BRABRAND, G. Retroperitoneal rupture of the duodenum following non-penetrating trauma. Ada chir. scan&met., 119 : 20, 1960. 5. LAWRIE,T. Traumatic retroperitoneal rupture of the duodenum. NW Zealand M. J., 54: 711, 1955. 6. MABRY, E. H. Trauma of the duodenum. South. M. J., 52: 511, 1959. 7. STRODE,J. E. and GILBERT, F. I., JR. Retroperitoneal rupture of the duodenum following non-penetrating injuries to the abdomen. Arch. suvg., 70: 343, 1955. 8. BONILLA,K. B. and BOWERS,W. F. Traumatic rupture of the proximal jejunum. Am. J. Surg., 100: 731, 1960. 9. FIELD, R. J., SR., FIELD, S. E., SR. and FIELD, R. J., JR. Retroperitoneal rupture. Mississippi Doctor, 37: 95, 1959. 10. JOYNT, G. H. C. Perforation of the small intestine from non-penetrating trauma. Canad. J. Surg., 2: 40, 1958.

Retroperitoneal

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