Delayed Duodenal Injury Following Abdominal Gunshot Wound

A29-year-old male who sustained two abdominal gunshot wounds became hemodynamically unstable in the traumabay and was thus taken immediately to the operating room for exploratory laparotomy. Massive hemoperitoneum was discovered upon abdominal entry. After packing four quadrants, controlling hemorrhagic vessels branching from the superior mesenteric artery and superior mesenteric vein, packing a large liver laceration, performing partial small bowel resection and right hemicolectomy, a Grade 3 laceration along the second portion of the duodenum was discovered and closed primarily (Fig. 1). With an open abdomen, the patient was stabilized in the surgical intensive care unit. Reexplorationwas performed on hospital day (HD) 3; transverse colectomy, reanastomosis of the small bowel, feeding jejunostomy, and end ileostomy were performed. The repaired duodenal injury was evaluated and appeared viable. The abdomen was not yet amenable to closure.On further exploration on HD5, a bilious fluid collectionwas discovered in the duodenal region. The distal second portion of the duodenum and the third and fourth portions of the duodenum were found to be necrotic secondary to complete devascularization (Fig. 2). The previously repaired site and the adjacent pancreas appeared to be unaffected. What Would You Do? A. Pancreaticoduodenectomy B. Resection of the affected duodenum with primary duodenojejunal anastomosis and placement of a transgastric jejunal feeding tube C. Duodenal diverticularization with pyloric exclusion, gastrojejunostomy, vagotomy, biliary drainage, and placement of feeding jejunostomy D. Resection of the affected duodenum with antrectomy, side gastrojejunostomy with vagotomy, biliary drainage, and placement of feeding jejunostomy Figure 1. Initial duodenal injury. Figure 2. Devascularization of D3 to D4. CHALLENGE OF ACS