1. Duodenal Injury Treatment Algorithm 1.0 www.SurgicalReview.net Version 1.01

2. Duodenal Grading system * Progress one grade if there are multiple lesions, up until grade III. AAST: American Association for the Surgery of Trauma. AIS- Abbreviate Injury Scale: www.surgicalreview.net 4 Extensive (>50%) rupture; stomach devascularized V 3 Large laceration involving vessels on greater or lesser curvature IV 3 Large (> 3cm) Laceration III 2 Intramural hematoma >3cm; small (<3 cm) laceration II 2 Intramural hematoma <30 cm; partial-thickness laceration I AIS-90 Score Injury Characteristics AAST Grade*

3. Duodenal Injury : Treatment by Grade Grade I: Single Segment hematomas: Treat Expectantly Partial-thickness laceration: Treat with closure of the seromuscular layer Grade II: Multisegment hematomas : Can be observed for 7 days. May repeat CT with oral contrast . If obstruction continues for more than 10 days, then surgical evacuation of hematoma is indicated (antimesenteric longitudinal incision) Lacerations : <50% of the total circumference of the duodenal segment treat with 2-layer transverse closure Grade III: Intact mesentery: 2 –layer transverse closure is appropriate (refer to diagram for grade III) Ragged Transected duodenum: Distal end of duodenum should be over sown and anastomosed to proximal end of jejunal loop. If lumen has high risk of being compromised with a primary closure then utilized retro colic Roux-en-Y jejunal limb. Grade IV: With intact ampullla and mesentery treat with primary closure If risk of luminal compromise with primary closure and bile duct and ampulla intact then perform Roux en Y duodenojejunostomy If the ampulla is disrupted but there is an uninjured pancreas . Reimplant distal bile duct and pancreated duct into posterior duodenal wall, and use pyloric exclusion Note: If ampulla and pancreatic duct are injured in the head of pancrease consider “trauma Whipple” Grade V: IF the duodenum is viable: treat with primary closure with either duodenal diverticularization or pyloric exclusion. OR consider pancreatico-duodenectomy IF evidence that the entire head of pancrease and duodenum are devascularized. Treat with Trauma whipple www.surgicalreview.net