Retroperitoneal Duodenal Injury due to Blunt Abdominal Trauma William A. Talbot, MD, Albuquerque,
Jerry M. Shuck, MD, DSc, Albuquerque,
High speed vehicular accidents often result in severe abdominal trauma. At one time, retroperitoneal duodenal rupture was au uncommon sequel to blunt abdominal injury, but such perforations or disruptions are no longer rare. Impact against the steering wheel has been the principal mechanism of injury. Hopefully, the lowered speed limits and newer collapsible steering wheels will reduce the number of cases of retroperitoneal duodenal trauma in the future. In the meantime, however, surgeons must be cognizant of the subtleties of the diagnosis and have a plan for management. Confusion about appropriate diagnostic and therapeutic measures was related to the application of a variety of tests and operations to small numbers of cases. A large personal series of duodenal ruptures has not been easy for any one surgeon to accumulate. At the Burn and Trauma Unit of the University of New Mexico, eight cases of retroperitoneal duodenal rupture from blunt abdominal trauma were personally observed and/or managed by one of us (JMS) during the past six years. A critical appraisal of that experience and a comparison with more extensive case collections from large centers constitute the basis for this report. From the Burn and Trauma Unit of the Bemalillo County Medical Center and the Department of Surgery, University of New Mexico School of Medicine. Albuquerque, New Mexico. Reprint requests should be addressed to Jerry M. Shuck, MD, Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico 87131. Presented at the Twenty-Seventh Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 21-24, 1975.
Volume 130. December 1975
Case Reports DuodenalPertoration wtthout Pancreatic Injury Case I. A seventeen year old boy’struck his abdomen on the steering wheel of his automobile in a collision. On admission the only physical evidence of injury was mild epigastric tenderness without rebound. Serum amylase was not elevated. Abdominal roentgenogrsms were noncontributory. Peritoneal lavage disclosed no blood or other fluid. After twenty-four hours of observation, increasing abdominal pain and rigidity developed. Surgical exploration disclosed a subcapsular hematoma of the liver and a hematoma surrounding the duodenum. An anterior perforation of the second portion of the duodenum was found after dissection of the retroperitoneum. Repair was accomplished by a single layer of interrupted silk sutures in a transverse direction. The retroperitoneum wae drained. Preoperative cephalothin was continued for six days. He was discharged on the seventh postoperative day. No complications were encountered.
Comment: Repeated physical examinations were the most helpful diagnostic studies in this case. The laboratory data and roentgenograms were of little value. The changing course during observation may have been noted at an earlier time, since operation was delayed for twenty-four hours, but the outcome was not adversely affected.
Case II. A twenty-one year old man struck his abdomen on the handlebar of his motorcycle in an accident. He was discharged from the emergency department since examination did not disclose tenderness and the initial abdominal pain had disappeared. Serum emylase was within normal limits; x-ray films of the abdomen
Talbot and Shuck
showed no abnormalities. Thirty hours later he returned because of nausea, vomiting, and midepigastric pain with radiation to the back. The abdomen was rigid on examination. At laparotomy, a posterior perforation of the second portion of the duodenum was closed transversely with silk sutures. The area was drained. Preoperative administration of penicillin and tetracycline was’continued for three days. The postoperative course was complicated by atelectasis of the lower lobe of the right lung. He went home on the eleventh postoperative day. Comment:
Any patient with a history of abdominal pain after trauma should be observed carefully. Delay in exploration may have been shortened by repeated examinations in an observation ward or specialized facility. Again, the unreliability of early physical, laboratory, and x-ray findings is pointed out. This was the only motorcyclist in this series. Case III. In an automobile accident, a thirty-seven year old man was hit in the abdomen by the steering wheel. Alcoholic intoxication made the initial evaluation difficult. Abdominal findings varied with different examiners. The serum amylase was 334 Caraway units (normal, 60 to 160 units). Retroperitoneal air was noted surrounding the right kidney on plain abdominal roent(Figure 1.) An intravenous pyelogram genograms. showed a bladder distorted by hematoma as well as the perinephric air. (Figure 2.) Seven hours after injury, laparotomy revealed a large retroperitoneal hematoma in the pelvis and right upper quadrant. Complete transection of the third portion of the duodenum was debrided and anastomosed in two layers. The area was drained. Preoperative administration of lincomycin and tetracy-
Figure 1. The arrows point out the perinephric and retroperitoneal streaks of ah from duodenal htforatlon ( case Ill).
cline was continued for seven days. The postoperative course was complicated by delirium tremens and ureteral obstruction from the pelvic hematoma. He was discharged on the thirtieth hospital day. Comment: In this case the plain abdominal film led to the correct preoperative diagnosis. In addition, the serum amylase level was elevated. Early operation allowed for successful reconstruction prior to bacterial proliferation, extensive necrosis, or abscess. Case IV. A thirty-nine year old man was struck in the abdomen by a steering wheel during a collision. Mild abdominal tenderness was noted, but there was no rebound or referred tenderness. Serum amylase level was within normal limits. Plain abdominal roentgenograms showed a compression fracture of the fourth lumbar vertebra. Because of hematuria, an excretory urogram was obtained that showed a “teardrop” deformity of the bladder from surrounding hematoma. Peritoneal irrigation returned no blood. On the third day of observation the patient vomited and became febrile. Again, serum amylase level was within normal limits, but two hour urine amylase was too high to be measured without dilution. At laparotomy an anterior perforation of the third portion of the duodenum was repaired by performing side to side duodenojejunostomy over the defect. The area was drained. Preoperative administration of penicillin, tetracycline, and clindamycin was continued for six days. He recovered uneventfully and was sent home on the tenth postoperative day. Comment: This case demonstrates a three day delay between injury and diagnosis. Abdominal findings were more difficult to interpret because of pelvic hematoma
Figure 2. Further air is seen around the right kMney (case III). The excretory urogram shows nothing abnormal.
The American Journal of Surgery
and vertebral fracture. Initial peritoneal irrigation was of no help. Serum amylase level was within normal limits. The urine amylase determination allowed for correct preoperative diagnosis although the test was performed rather late. This was the only patient to receive a jejunal anastomosis. The result was satisfying. Case V. In an automobile accident, a thirty-nine year old woman sustained a cerebral concussion and a wrist laceration with injury to the median nerve. In addition, the steering wheel struck the abdomen. Initial abdominal examination was noncontributory. Paracentesis returned no blood. Roentgenograms showed nothing abnormal. She was admitted to the neurosurgical service. As her sensorium cleared over two days, abdominal tenderness became apparent. The serum amylase was 695 units. Plain roentgenograms now showed retroperitoneal paraduodenal air bubbles. (Figure 3.) Gastrografine swallow demonstrated the retroperitoneal duodenal leak in the third portion. (Figure 4.) Exploration was carried out forty-eight hours post injury. An anterior perforation was repaired with an interrupted single layer of silk in a transverse direction. Preoperative administration of penicillin and tetracycline was continued for seven days. The recovery from surgery as well as from cerebral trauma was uneventful. She was discharged on the fifteenth postoperative day.
Duodenal Perforation with Pancreatic Injury Case VI. A forty-six year old man was admitted after an automobile accident in which he was the driver. In the emergency room he had cardiac arrest. Aggressive resuscitation measures partially restored the circulation. The abdomen became distended. No diagnostic studies were carried out. An immediate laparotomy revealed massive hemoperitoneum. The root of the mesentery was avulsed with division of the superior mesenteric artery and vein. The ascending and transverse colon as well as the third portion of the duodenum and head of the pancreas was transected. Multiple cardiac arrests occurred while hemostasis was being attempted. Repairs could not be completed.
Comment: The extensive injuries of this man could not be repaired because of rapid exsanguination and cardiac arrests. Colon exteriorization, pancreatoduodenectomy, and mesenteric arterial and venous reconstruction were contemplated and would have been necessary for survival.
Comment: In this case all appropriate maneuvers were carried out on admission. The cerebral injury complicated the picture. The delay was unfortunate but did not contribute significantly to morbidity. The demonstration of the elevated amylase level, retroperitoneal bubbles, and duodenal leak eventually pointed out the diagnosis.
Case VII. An eighteen year old man was transferred to the Bernalillo County Medical Center because of renal failure fifteen days after a truck accident in which he was the driver. Elsewhere, at immediate laparotomy, hematomas of the mesocolon, and gastrohepatic ligament were noted. A large right retroperitoneal hematoma was also seen. The operative note stated that the posterior portion of the duodenum was not explored and a Kocher maneuver not performed because of the possible occurrence of uncontrolled bleeding from the right retroperitoneal space. The note also stated that the duodenum was not entirely excluded from possible injury. No repairs were carried out.
Figure 3. The air bubbles around the duodenum suggest extraluminal gas in the retroperltoneum ( case V) .
Figure 4. lhe Gastrografln swallow in case IV clearly demonstrates the leak of contrast material from the duodenum into a retroperitoneal pocket ( case V).
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Talbot and Shuck
At that hospital three days later, a Gastrografin swallow showed a leak from the third portion of the duodenum. At repeated laparotomy, bile-stained fluid was in the retroperitoneum. The ampulla of Vater was avulsed. The duodenum was totally disrupted. Pancreatuduodenectomy was considered but was thought to be too dangerous because of the friable tissues. Closure of both duodenal ends, cholecystojejunostomy, gastroenterostomy, jejunojejunostomy, vagotomy, and appendectomy were carried out. On the tenth postinjury day, a third laparotomy was carried out for gastrointestinal bleeding. Gastrotomy showed a few small ulcers which were oversewn. Three days later he was transferred for dialysis because of renal failure. At the Bernalillo County Medical Center, dialysis was performed. Abdominal wound dehiscence required exploration six days after transfer. All anastomoses were leaking and many abscesses were drained. He died six days later. Comment: The only chance this man had was at the first operation. Appropriate reconstruction of the duo-
denum or even pancreatoduodenectomy can only be considered if the anatomic abnormalities are meticulously identified. This requires exploration of the periduodenal and peripancreatic hematomas. The entire duodenum must be seen. The course of this patient might have been entirely different if the Kocher maneuver and duodenal dissection had been carried out initially. Case VIII. A forty-four year old man sustained bilateral tibia1 and femoral fractures, fractured ribs, and pulmonary contusion in an automobile accident. The patient was the driver. On examination the entire abdomen was tender, and guarding was diffuse. Paracentesis revealed bloody fluid. At laparotomy a posterior perforation of the third portion of the duodenum was closed transversely with a single layer of silk sutures. A small laceration of the head of the pancreas at the inferior edge, bleeding moderately, was sutured and drained. Fractures were reduced and held in skeletal traction. When his condition was stable and he was eating four days later, he was transferred to the Veterans Administration Hospital. There, gastric stasis and acalculous cholecystitis necessitated an operation on the eighteenth postinjury day. Cholecystectomy and gastroenterostomy were performed. Subsequently the gastroenterostomy was converted to antrectomy and Billroth II gastrojejunostomy on the forty-third postinjury day. Persistent pulmonary insufficiency required long-term ventilatory support. Candida pneumonia was the cause of death eighty-five days post injury. At autopsy, the duodenal and pancreatic repairs were intact. Comment: This man died of the complications of associated injuries despite successful repair and drainage of the pancreas and duodenum. The importance of multiple fractures, pulmonary contusion, and other injuries cannot be overstated.
Comments The patients were all adults and drivers of their vehicles at the time of injury. Seven persons sustained blunt abdominal trauma from striking a steering wheel; one (case II) struck the handlebar of his motorcycle. Injury to other intra-abdominal organs occurred in three of the eight; the pancreas was involved in all three. In five patients, however, visceral injury was limited to the duodenum. The susceptibility of the duodenum to blowout from seemingly minor trauma has been postulated to occur as a result of three possible mechanisms. Cocke and Meyer [I] proposed a “closed loop” mechanism as responsible. They postulated that contraction of the fibromuscular ligament of Treitz and closure of the pylorus may occur simultaneously with a blow to the abdomen. The resultant forces within a duodenum closed proximally and distally would be enough to produce rupture. It has been shown that intestinal rupture can result from an intraluminal pressure of merely 14 cm of water. Pressures from blunt trauma must be much higher. Secondly, Cocke and Meyer [I] stated that contusion of the wall of the duodenum could injure vessels to the point of producing an infarcted segment of duodenum with later perforation. Thirdly, Resnicoff, Morton, and Bloch  proposed that a blow to the abdomen would cause an upward displacement of the liver and diaphragm with traction on the fixed duodenum by the ligament of Treitz leading to tearing of the duodenum. Regardless of the exact mechanism, the association with steering wheel injuries is becoming increasingly clear. Cleveland and Waddell’s review  showed that seventeen of thirty-seven cases of duodenal rupture were secondary to automobile steering wheel trauma whereas nine of twentythree blunt duodenal injuries in a recent series by Conley, Norcross, and Shoemaker  were drivers of automobiles. In the present series, the second and third portions of the duodenum were the areas exclusively involved. (Figure 5A.) Cleveland and Waddell  note that two thirds of the injuries involved the second and third portions of the duodenum. In three patients in the current report, immediate laparotomy was mandated by clear physical evidence of peritonitis or obvious intraperitoneal bleeding responsib!e for shock. These patients sustained multiple severe injuries. All of these patients died, although one patient had successful duodenal repair.
The American Journal of Surgery
Figure 5. A, a composit& diagram represents the sttes and numbers of perforattons and transectkns of the duodenum. 6, methods of repalr are dtagrammatkatty depkted on thts compostte drawing. The five operatkns for tsoiated duodenal injuty are shown.
In the five surviving patients, initial physical examination did not provide sufficient indication for operation. In two cases, repeated physical examination showed changes that led to exploration. Roentgenograms, amylase determinations, and/or abdominal paracentesis suggested the diagnosis in the other three. (Table I.) Plain abdominal roentgenograms in one patient (case III) clearly demonstrated retroperitoneal air. In another patient (case V), the suggestion of retroperitoneal air could not at first be distinguished from colonic gas. This, however, prompted a contrast study to be performed that clearly demonstrated the duodenal leak. Free intraperitoneal air was not noted in any case in which x-ray films were obtained. In five patients, initial abdominal
in Blunt Duodenal Trauma Peritoneal Aspirate
Retroperitoneal air Normal
Normal (urine elavated) Elevated
Age (yr) Case
Late abdominal rigidity Late abdominal rigidity Equivocal
Equivocal, later tender abdomen
Shock, abdominal distention Tender abdomen
volume 130, December 1975
films were interpreted as showing nothing abnormal. Serum amylase determinations performed in six patients were found elevated in three. Positive elevations of serum amylase in the absence of pancreatic trauma or intestinal perforation are reported as high as 90 per cent in injured patients . Only in case IV did’the amylase determination influence treatment of the patient. Serum amylase was elevated in one patient with associated pancreatic injury and not obtained in the other two cases of pancreatoduodenal trauma. In three of five patients with duodenal injury alone, serum amylase was elevated; in two it was normal. In four of the five surviving patients, the development of increasing abdominal pain and perito-
Retroperi9toneal air; Gastrografin showed leak
Postoperatively, Gastrografin showed leak Normal
Time before Exploration
72 hr 48 hr
Immediate exploration Immediate exploraation; reoperation 3 days later
Talbot and Shuck
neal signs led to exploration. Physical examination was the most reliable diagnostic tool in this series. Peritoneal aspiration is a routine procedure on the Burn and Trauma Unit when abdominal findings are equivocal or when evaluation is hampered by other injury such as cerebral concussion. In four cases the diagnosis could not be made on careful physical examination, roentgenograms, or laboratory tests; paracentesis was therefore performed. In one patient with multiple injuries (case VIII), a bloody aspirate provided the criterion for urgent laparotomy. The remainder of the paracenteses yielded no blood or other fluid. Even when operation is performed, unless careful exploration of the entire region of the duodenum and head of the pancreas is carried out, a retroperitoneal perforation may be overlooked. The diagnosis has been overlooked at the first operation in as many as 10 to 20 per cent of cases, leading to a mortality of 77 per cent for this oversight . The one patient who underwent initial laparotomy without duodenal dissection (case VII) eventually died after late unsuccessful attempts at repair. The operations performed for duodenal injury alone were simple closures (three patients), resection with end-to-end duodenoduodenostomy (one patient), and duodenojejunostomy (one patient). (Figure 5B.) All repairs included drainage; all patients survived. Direct suture at the defect with drainage of the retroperitoneum is the most commonly employed approach in reported cases. In the series by Cleveland and Waddell , patients who had suture and drainage all survived. Complications of this type of repair were three duodenal fistulas and one subphrenic abscess in eighteen patients . Resnicoff, Morton, and Bloch  reported nine cases of retroperitoneal duodenal rupture from blunt trauma, all treated by simple closure without mortality. There were two duodenal fistulas, one subhepatic abscess, and one major wound infection. In the series by Roman, Silva, and Lucas  of duodenal perforations with pancreatic injury, all seven patients survived. Three were treated by suture and drainage alone; three, by suture and drainage with the addition of gastrojejunostomy and vagotomy. Complications consisted of one episode each of duodenal obstruction, atelectasis, pneumonitis, and pancreatitis . The importance of adding a procedure to partially defunctionalize the duodenum has been stressed by some. Series are too small to draw conclusions regarding the necessity of duodenal bypass procedures. However,
these reports also describe many successful cases with simple suture alone [3,4,8]. Of the three patients with associated pancreatic injury, one died of rapid exsanguination before any repair could be attempted. (Table II). In one (case VIII), death occurred almost three months post injury and autopsy showed that the repairs of the duodenal perforation and small pancreatic laceration remained intact. The patient died from complications of associated injuries. In case VII, repair was delayed three days because it was not recognized at initial laparotomy. From the description of the second operation, which was sent with the patient, pancreatoduodenectomy was considered but abandoned because of extensive contamination from leaking duodenal content. Closure of the transected duodenal ends and multiple bypass procedures with anastomoses were performed, however. All anastomoses disrupted and the patient died of sepsis and renal failure. In contrast to isolated duodenal injury, the extremely high mortality for combined pancreatic and duodenal injury is noted widely [9-111. This combination has been associated with a mortality as high as 73 per cent [II]. The use of pancreatoduodenectomy has been advised in combined injury to the duodenum and pancreas [7,10]. Most investigators limit this extensive operation to those patients with severe injury to both organs when distal pancreatic resection is not a practical definitive procedure . In the present series, two patients (cases VI and VII) might have qualified for pancreatoduodenectomy. It is routine practice in the Burn and Trauma Unit to institute antibiotic therapy prior to abdominal exploration for trauma. Fullen, Hunt, and Altemeier  have clearly shown a reduced infection rate in penetrating abdominal injuries when antibiotic therapy is instituted preoperatively. In each surviving patient, that is, those with duodenal injury alone, antibiotics were used preoperatively and continued postoperatively for various periods of time. Septic complications and duodenal fistulas were not seen. The use of pre- and postoperative antibiotics is strongly recommended. The single most important factor in deciding to operate on the surviving patients was the development of peritoneal irritation. The unreliability of x-rays films, laboratory evaluation, and peritoneal aspirates has been noted. These are helpful if positive, however. The average delay from time of injury to operation in surviving patients was thirty-six hours. A 65 per cent mortality has been reported if
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Trauma Associated Injuries
Location of Duodenal Injury
Liver hematoma Hemoperitoneum Duodenal perforation
Second anterior Second posterior Third transection
Simple closure Simple closure Second layer anastomosis
Facial lacerations None
Duodenal or pancreatic injury
Pelvic hematoma, fracture of fourth lumbar vertebra Central nervous system contusion, hematuria, median nerve laceration Avulsion of root of mesentery and transverse colon, fracture of head of pancreas Avulsion of common bile duct, renal artery thrombosis, fracture of pancreas
Case I II III
Bypass of oversewn ends of duodenum at second opertion Simple closure
repair is delayed over twenty-four hours whereas only 5 per cent died when repair was carried out less than twenty-four hours after injury . The recent series by Conley, Norcross, and Shoemaker  showed an average time interval of 115.4 hours from injury to diagnosis in cases of blunt trauma. Of fifteen living patients, the average interval was 86.6 hours. For the eight deaths, the average interval was 169.2 hours. Although a prolonged delay in treatment could be expected to result in higher mortality, four of five patients presented were operated on beyond twenty-four hours without altering the clinical results. The mortality in the present series was 37.5 per cent. The three deaths involved pancreatic injury as well as other significant injuries. In the five cases of duodenal perforation without pancreatic injury, there were no deaths. The mortality for blunt injury to the duodenum alone has been re-
Vdume 130. Dewmber 1975
Multiple long bone fractures, pulmonary contusions, pancreatic laceration
Left ureteral obstruction, delirium tremens None
Died in operating room
Dehiscence, fistulas, abscesses
Died of sepsis and renal failure in 21 days
Respiratory distress syndrome, acalculous cholecystitis
Died of pulmonary insufficiency, pneumonia at 85 days
Summary and Conclusions 1. Eight cases of retroperitoneal duodenal rupture from blunt abdominal trauma are presented. 2. Steering wheel impact is increasingly recognized as an etiologic factor in retroperitoneal rupture of the duodenum. 3. The recognition of retroperitoneal duodenal rupture is often delayed because the results of the diagnostic measures are unpredictable. 4. The most reliable avenue for diagnosis is the detection of progressive peritoneal irritation by frequent physical examination. 5. With isolated duodenal rupture, simple suture and drainage are effective treatment. 6. Pre- and postoperative antibiotics may re-
Talbot and Shuck
duce the incidence la formation
of septic complications
carries an extremely
is due to associated
References 1. Cocke, WM. Meyer KK: Retroperitoneal duodenal injury. Proposed mechanism, review of literature and report of a case. Am J Surg 108: 834, 1964. 2. Resnicoff SA, Morton JH. Bloch AL: Retroperitoneal rupture of the duodenum due to blunt trauma. Surg Gynecol Gbstet 125: 77, 1967. 3. Cleveland HC, Waddell WR: Retroperitoneal rupture of the duodenum due to nonpenetrating trauma. Surg C/in North Am 43: 413, 1963. 4. Conley RD. Norcross WJ, Shoemaker WC: Traumatic injuries to the duodenum: a report of 96 patients. Ann Surg 181: 92. 1975. 5. Moretz JA Ill. Campbell DP, Williams GR: The significance of serum amylase in evaluating pancreatic trauma. Am J surg 130: 739, 1975. 6. Hawkins ML, Mullen JT: Duodenal perforation from blunt abdominal trauma. J Trauma 14: 290. 1974. 7. Roman E, Silva YJ. Lucas C: Management of blunt duodenal injury. Surg Gynecol Obstet 132: 7. 1971. 8. Cohn I, Hawthorne HR. Frobese AS: Retroperitoneal rupture of the duodenum in non-penetrating abdominal trauma. Am J Surg 84: 293, 1952. 9. Smith AD. Wolverton WC. Weichert RF. Draoanas T: Operative management of pancreatic and duodenal injuries. J Trauma 11: 570, 1971. 10. Nance FD. DeLoach DH: Pancreaticoduodenectomy following abdominal trauma. J Trauma 11: 577, 1971. 11. Kerry RL, Glas WG: Traumatic injuries of the pancreas and duodenum: a clinical and experimental study. Arch Sufg 85: 813, 1962. 12. Fullen WD, Hunt J, Altemeier WA: Prophylactic antibiotics in penetrating wounds of the abdomen. J Trauma 12: 282. 1972.
Discussion William R. Waddell (Denver, CO): I think Doctor Talbot did not say quite enough about the problem of diagnosis. In these patients with a high mortality, atten-
tion has been directed towards the head injury and nobody puts his hand on the abdomen for several days. Suddenly the patient is very sick, in shock, and eventually dead. The tipoff is a little hematoma around the duodenum, sometimes with a little bile, but essentially the situation demands exploration of the entire duodenum to eliminate a very serious injury with any of these relatively minor findings. Charles Morris (Dallas, TX): My only comment is that there have been some recent publications on the use of a serosal patch as augmentation to the closure in duodenal injuries, particularly since in blunt trauma there may be some injury to the tissue that is not too evident at the time of the initial exploration. Another point is the creation of a feeding jejunostomy to maintain positive nitrogen balance. Albert J. Kukral (Denver, CO): Of the two cases I had, one apparently perforated or broke down with a blunt injury more than sixty-two hours after injury and this patient was watched carefully all along the line. The other one occurred at approximately twenty-eight to thirty hours. I should like to have some answer to those problems. Jerry M. Shuck (closing): The only time we swung the jejunum up, we went right ahead and performed an anastomosis instead of an overlay type of patch. I think if you are operating in the abdomen of any patient who is injured you have to have a lot of these technics available to you. The feeding jejunostomy has taken a prominent place in managing these patients and in total parenteral nutrition as advocated by Doctor Dudrick. Most of us are back again using the enteric tract whenever we possibly can for nutritional support. In reviewing the literature we found that our time of thirty-three hours after injury was rather short. I think it is quite common to have these very long delays and one of the mechanisms is injury or contusion to the bowel with necrosis and later disruption. Retroperitoneal injury in patients with combined multiple system trauma was one of the reasons that the burn and trauma unit was devised. Now all patients are evaluated and watched in one area.
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