Duodenal
trauma is an infrequent injury, but linked to high morbidity and mortality. Surgical management of duodenal
injuries is dictated by: patient's hemodynamic status, injury severity, time of diagnosis, and presence of concomitant
injuries. Even though most cases can be treated with primary repair, some experts advocate adjuvant procedures. Pyloric exclusion (PE) has emerged as an ancillary method to protect
suture repair in more complex
injuries. However, the effectiveness of this procedure is debatable. The "Evidence Based Telemedicine -
Trauma & Acute Care Surgery" (EBT-TACS) Journal Club performed a critical appraisal of the literature and selected three relevant publications on the indications for PE in duodenal
trauma. The first study retrospectively compared 14 cases of duodenal
injuries greater than grade II treated by PE, with 15 cases repaired primarily, all of which penetrating. Results showed that PE did not improve outcome. The second study, also retrospective, compared primary repair (34 cases) with PE (16 cases) in blunt and penetrating grade > II duodenal
injuries. The authors concluded that PE was not necessary in all cases. The third was a literature review on the management of challenging duodenal
traumas. The author of that study concluded that PE is indicated for
anastomotic leak management after
gastrojejunostomies. In conclusion, the choice of the
surgical procedure to treat duodenal
injuries should be individualized. Moreover, there is insufficient high quality scientific evidence to support the abandonment of PE in severe duodenal
injuries with extensive tissue loss.