[To study the factors of duodenal injury and to improve its diagnosis and treatment. Methods Retrospective summary of 28 cases of duodenal injury admitted from March 1968 to September 2007, and analysis of injury factors, diagnosis and treatment. Results: 78.6% of closed injuries, 21.4% of open injuries, 25 cases of combined injuries; 46.4% of injuries were in the second segment, followed by 21.4% in the third segment; 89.3% of combined injuries; 28.6% of postoperative complications, 3.6% of mortality, 96.4% of cure rate. Conclusion Duodenal injury is common in China with closed injury. Paying attention to preoperative examination, intraoperative exploration and selection of appropriate surgical style, and strengthening postoperative management can reduce the occurrence of death and complications. Duodenal injury is a serious abdominal injury, which is rare in clinical practice. Due to its anatomical structure and physiological peculiarities, diagnosis and management are difficult, and the rate of missed diagnosis, complications and mortality is high. This article reports the treatment experience of 28 cases of duodenal injury, and discusses the injury factors, diagnosis and treatment with the literature. (1) General information From March l968 to September 2007, 28 cases of duodenal injury were admitted to our hospital, 25 men and 3 women, aged between l0 and 62 years, mostly young and strong men. Open injury 6 cases (21.4% ), including 2 cases of gunshot wounds, 4 cases of stab wounds; closed injury 22 cases (78.6%), including car impact, crush injuries l2 cases, high-speed motorcycle fall injuries 8 cases, fall injuries 3 cases. Injury sites: 4 cases of duodenal bulb (14.3%), 13 cases of descending part (46.4%), 6 cases of transverse part (21.4%), 3 cases of ascending part (11%), 2 cases of extensive injury from bulb, descending part to transverse part (7%, including 1 case of intra-duodenal wall hematoma). There were 25 cases of combined injuries, including 38 cases of injured organs, 6 cases of pancreatic injury, 5 cases of gastric injury, 7 cases of liver rupture, 8 cases of spleen rupture, 4 cases each of small intestine and colon rupture, 4 cases of retroperitoneal hematoma, 3 cases of brain and spinal cord injury, and 1 case each of inferior vena cava and abdominal artery injury. (2) Treatment method This group of patients with duodenal injury chose different surgical methods according to the degree and location of injury. There were 8 cases of simple repair of duodenal rupture, 2 cases of duodenal hematoma removal and gastrointestinal rerouting, 5 cases of duodenal rupture repair and stoma decompression, 6 cases of duodenojejunal Roux-Y anastomosis, 1 case of BiI-type gastroduodenal anastomosis, and 6 cases of duodenal diverticulization or modified diverticulization surgery. (3) Results Postoperative complications occurred in 8 cases (28.6%), including 3 cases of external pancreatic fistula (all were combined pancreaticoduodenal injuries), 2 cases of duodenal fistula, 4 cases of abdominal abscess, 1 case of stress ulcer bleeding, and 1 case of acute respiratory distress syndrome. Treatment results: 27 cases (96.4%) were cured, and one case (3.6%) died of external duodenal fistula and abdominal infection complicated by acute respiratory distress syndrome. 2, discussion (1) the causes of duodenal injury In anatomy, the duodenum is largely located in the retroperitoneal position, C-shaped curved around the head of the pancreas, followed by the lumbar dorsal muscle, surrounded by the common bile duct, pancreas, stomach, liver, so duodenal injury is rare. The incidence of duodenal injury in abdominal injuries is not more than 5% [1]. Foreign open injuries are common, Asensio et al [2] summarized l5l3 cases of duodenal injury, open abdominal injuries accounted for 77.7%, the majority of injury factors to gunshot wounds, accounting for 75%, followed by knife wounds, accounting for 20%. Domestic cases have not been reported, combined with our hospital and recent literature, to the abdomen blunt closed injury is more common. This group of cases closed injury 78.6%, injury factors to crush impact injuries, high-speed motorcycle injuries and injuries from falling from height are common. The mechanism of duodenal injury is mainly due to the external impact of the duodenum extrusion on the spine, relying on shear force to tear the duodenum. Duodenal burst is due to the relative fixation of the duodenum, riding a high-speed carrier, sudden deceleration, the duodenum is thrown forward, which can cause a sudden rise in intestinal pressure and rupture. (2) the diagnosis of duodenal injury for open duodenal injury diagnostic steps are relatively brief, in the abdomen there are open wounds, such as gunshot wounds, knife stab wounds, etc., are the surgical indications for dissection. The exploration process is also a clear diagnostic process. In case of suspected duodenal injury, attention should be paid to the presence of air bubbles, bile and bleeding around the duodenum above the duodenum, pancreas and flexor ligament during the exploration, and once found, a Kocher incision should be made and the anterior and posterior walls of the duodenum should be explored to avoid missing duodenal penetrating injuries. In addition, special attention should be paid to the possibility of duodenal injury in patients with penetrating abdominal injuries combined with spinal fractures of the lower thoracic and upper lumbar segments. Because of the anatomical features of the duodenum, the diagnosis of closed duodenal injury is difficult, and the rate of missed diagnosis and misdiagnosis is high. Foreign literature reports that even with the help of CT and laparotomy and other diagnostic aids, there are still about 20% of patients with initial diagnosis time greater than 6 hours [3]. And once the diagnosis is missed or delayed, the management time is delayed, the severity of the prognosis grows, and the morbidity and mortality rate increases significantly. According to our experience, in addition to the conventional medical history and physical examination, the following points need to be noted: (1) the situation at the time of injury. Such as the driver in a car accident injury when the steering wheel, insurance buckle on the right upper abdomen; fractures of the thoracolumbar vertebrae from a high fall, motorcycle fall after sudden deceleration are easy to cause duodenal injury factors. Especially for young patients after motorcycle accidents, the possibility of duodenal injury should be considered. In a retrospective study of a small foreign sample (52 cases), it was found that nearly 51% of patients with closed duodenal injury were caused by motorcycle accidents [3]. Clinical manifestations include only right upper abdominal pain, nausea, vomiting, increased heart rate, and increased body temperature, while the appearance of peritonitis symptoms is often delayed for several hours. (2) Peritoneal puncture or lavage: although it is an invasive test, it has a good reference significance in the diagnosis of duodenal injury, due to the low specificity of imaging, to help physicians make an early diagnosis. The puncture can draw out non-coagulated blood or bile-like fluid, and the positive rate of peritoneal lavage is 35%. If intestinal contents are punctured retroperitoneally, most of them are duodenal injuries. (3) CT examination: especially enhanced CT is very important for the determination of duodenal injury [3]. It can clearly show the retroperitoneal anatomy, which helps to determine whether the duodenal injury is ruptured or a hematoma is formed, and provides evidence for the dissection. It also provides a basis for the diagnosis of other organ injuries. In the case of perforated injury, CT examination shows the accumulation of free fluid outside the duodenal lumen and in the anterior space of the right kidney, blurred shadow of the right kidney outline, and the spillage of oral contrast agent outside the intestinal lumen. However, it is possible that smaller perforations are not shown, and in the case of contusion of the duodenal wall or intramural hematoma formation, thickening of the intestinal wall or signs of hematoma are seen without the display of contrast agent spilling out of the intestine. (4) Serum enzyme examination. Elevated serum amylase, especially if it is persistently elevated, is helpful in diagnosing pancreatic combined with duodenal injury. It can be further clarified when combined with CT examination. (5) Abdominal plain film. If you see blurred lumbar major muscle outline, right upper abdominal retroperitoneal pneumoperitoneum, lateral duodenum and right kidney outline, this is a sign of ruptured duodenal injury. (6) Intraoperative duodenal exploration. Given the low preoperative diagnosis rate of duodenal injury, especially closed injury, reported in the literature to be around 10% [4]. Therefore, the diagnosis of most patients is clarified during the dissection. In this group, 3 cases were diagnosed preoperatively, 8 cases were suspected preoperatively, and the other 17 cases were confirmed intraoperatively. (3) Selection of surgical procedure Because of the deep location of duodenum, except for the first part, which is located in the retroperitoneum, it is closely related to the stomach, biliary tract and pancreas, and the blood supply is poor (the duodenum has no mesentery, no vascular arch, and the blood supply is mainly the gastroduodenal artery and the terminal artery of its branches), so the surgery after duodenal injury is difficult, with poor healing ability, many complications (65%) and high mortality (20%) [1]. Therefore, the choice of surgical procedure is very important for the recovery and prognosis of patients. It should be considered according to the patient’s consultation time, the severity of the injury, the presence of combined pancreaticobiliary duct injury and the patient’s general condition. Since most duodenal wall hematomas occur in children, if the hematoma is small and is only a partial obstruction of the duodenum, conservative treatment, including fasting, gastrointestinal decompression and total parenteral nutrition, and close observation of the disease for 2 weeks or more, can be performed in most cases (94%) [5]. In those cases where the hematoma continues to increase in size or mechanization during the observation period, resulting in partial obstruction becoming complete obstruction, surgery should be the treatment of choice. In principle, a hematoma compressing 50% of the intestinal lumen must be removed; for a large hematoma compressing more than 75% of the intestinal lumen, gastrojejunostomy should be chosen, otherwise there is a possibility of postoperative intestinal obstruction, and a second operation is often required. In our group, one patient underwent this procedure directly, and another patient with duodenal hematoma, who underwent surgery after 3 weeks of conservative treatment, was found to have a mechanized hematoma, and was cured after partial resection of the stomach and gastrojejunostomy with Roux-Y anastomosis. It has also been reported in the literature that laparoscopic drainage of duodenal hematoma can be achieved through laparoscopy, which is minimally invasive and facilitates postoperative recovery [6]. ② Duodenal rupture suture repair It is generally considered that early (within 12 hours), light abdominal contamination, rupture less than 50% of the intestinal circumference, and no concomitant pancreatic or bile duct injury can be used for simple repair. Simple suture repair sutures should be used laterally and in layers to reduce the tension of the suture opening. Suture repair (simple repair and repair + stoma) is feasible in about 80% of duodenal ruptures [7] [8]. However, because of the large amount of bile, pancreatic juice and other digestive juices flowing through the duodenum, when intestinal paralysis occurs after trauma and surgery, the pressure in the duodenal cavity is elevated and located outside the peritoneum, with poor passive dilatation ability and slow peristalsis, which can lead to the occurrence of intestinal fistula due to erosion or propping up of the repaired intestinal wall.Stone et al [9] reported 237 cases of duodenal injury repair after routine application of duodenal decompression, only 1 In 23 cases without duodenal decompression, 7 cases of intestinal fistula occurred, which is more than 3O% . This shows the importance of duodenal decompression. Therefore, various measures should be taken to reduce the pressure in the digestive fluid and intestinal cavity when performing the repair. For example, the gastric tube is placed in addition to the duodenum or gastrostomy, duodenostomy, etc. Currently, there are reports in the literature [7] that the “three tube” method and the “four tube” method are more effective in decompressing the duodenum. The “three-tube” method is to cut several lateral holes in the head of the nasogastric tube down to the upper 2 cm of the duodenal repair, 15 cm from the Treitz ligament jejunostomy retrograde placement of the 14-gastric tube with several lateral holes in the head to the lower 2 cm of the duodenal repair anastomosis, 20 cm from the Treitz ligament A three-tube decompression can adequately drain gastric fluid, duodenal fluid, biliopancreatic fluid, and gas and fluid from the upper jejunum in the early postoperative period. The “four-tube” method is to perform a “T” tube to drain bile on top of the three tubes. The digestive fluid from the decompression tube can also be returned to the intestine through the jejunostomy tube. This reduces the incidence of postoperative duodenal fistula, electrolyte disturbance and malnutrition, and facilitates wound healing. In our group, 13 patients underwent simple repair or repair plus stoma decompression, among which one case had duodenal fistula and one case had stress ulcer, which was cured after treatment. Roux-Y anastomosis for duodenal rupture Roux-Y anastomosis is suitable for cases in which the ruptured duodenum is larger than 50% to 75% of the circumference of the intestine, where the treatment time is late, local edema is obvious, and simple repair is difficult, and the jejunal portion can be used to repair this defect. The duodeno-jejunal end-lateral or lateral anastomosis can avoid the occurrence of duodenal fistula. The advantages of duodenal-jejunal Roux-en-Y anastomosis are good jejunal blood flow, high mobility, no tension, no duodenal stenosis, and effective decompression by diverting duodenal intestinal fluid. In this group of 6 cases with this procedure, no complications such as duodenal fistula occurred and all of them were cured. In 1968, Berne [10] and his colleagues first used this procedure, which includes suture repair of duodenal injury, decompression of duodenostomy, and partial gastrectomy Bi-II gastrojejunostomy. In 1977, Vaughan et al [11] modified the procedure by performing only pylorus closure and gastrojejunostomy without resection of the gastric sinus. If the patient’s general condition is poor, a modified Cogbill diverticulization procedure is also feasible, in which the gastric mucosa is closed with interlocking sutures at 1 cm from the pylorus, and then the jejunum is inserted upward and downward at 15-25 cm from the Treitzs ligament, with the upward insertion near the rupture to decompress and the downward insertion of the fistula as jejunal nutrition. In this group, 4 patients underwent Berne diverticulization surgery, among which 1 patient (62 years old) died of external duodenal fistula combined with abdominal abscess and secondary ARDS, 2 cases had external pancreatic fistula combined with abdominal abscess, which were cured after treatment; 2 cases underwent modified Berne diverticulization surgery, 1 case had external pancreatic fistula and combined abdominal abscess, which were cured after treatment. ⑤ Pancreaticoduodenectomy should be used with caution because this procedure has a mortality rate of 30% to 60% in emergency surgery [4]. asensio et al [12] suggested that this procedure should be selected mainly for (1) massive uncontrolled post-pancreatic bleeding and (2) injury to the head of the pancreas, main pancreatic duct or distal bile duct that cannot be repaired or reconstructed. No patient in this group of cases took this procedure. In conclusion. Regardless of the surgical approach, careful and comprehensive intraoperative exploration, adequate duodenal decompression, thorough abdominal drainage and reasonable management of combined injuries to surrounding organs are essential and indispensable to reduce the incidence of postoperative complications and promote recovery of patients.