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A 7-year old girl is admitted after she was a restrained passenger in a T-bone motor vehicle crash with impact on her side of the car. She is tachycardic and has an acute abdomen. At surgery, she has an isolated duodenal perforation in the second portion opposite the ampulla of Vater involving 25% of the circumference. What is the best operative plan? A. Primary repair of the duodenum B. Pyloric exclusion C. Repair the duodenum, gastrostomy, jejunostomy, and duodenostomy D. Duodenal diverticularization E. Gastrojejunostomy, nasogastric decompression, nasojejunal feeding tube ANSWER: A The best operative plan for this 7-year old girl with an isolated duodenal perforation involving 25% of the circumference in the second portion opposite the ampulla of Vater would be to perform a primary repair of the perforation with omental patch. The primary repair of the perforation involves suturing the edges of the perforation together to close the defect. An omental patch can then be placed over the repair to reinforce it and provide additional blood supply to the area, which can aid in healing. In this case, it is important to address the perforation as soon as possible to prevent further complications such as peritonitis or sepsis. The use of an omental patch can also help reduce the risk of further complications and improve the chances of a successful outcome. It is important to note that the final operative plan should be determined by the surgeon based on the patient's individual condition and surgical expertise. Blunt injuries to the duodenum are uncommon in all ages. They account for approximately 3 to 5% of all intraabdominal injuries. Blowout injuries after blunt trauma can occur due to the retroperitoneal fixed nature of the duodenum and compression against the vertebral column. Five grades of duodenal injury were described in 1990 using a standardized organ injury scale . *Advance one grade for multiple injuries up to grade III. D1, first portion of duodenum; D2, second portion of duodenum; D3, third portion of duodenum; D4, fourth portion of duodenum. Duodenal Injury Scale (AAST-OIS). A grade I injury is a hematoma or laceration without perforation; a grade II laceration equates to a disruption of less than 50% of the duodenal circumference; grade III 50 to 75% circumference of D2 or 50 to 100% of D1, D3, or D4; and grade IV disruption more than 75% circumference of D2 involving the ampulla or distal common duct. A grade V injury involves massive disruption of the duodenopancreatic complex or duodenal devascularization. In a retrospective review at one institution, children with grade II, III, and IV injuries were successfully managed with primary repair, and children with grade II, III and IV injuries repaired primarily did as well as or better than children with similar injuries managed by pyloric exclusion or gastrojejunostomy. Duodenal diverticulization refers to suture closure of the duodenal injury, antrectomy with end-to-side gastrojejunostomy, and tube duodenostomy. It is a complex, time-consuming procedure that is generally unnecessary. The triple tube technique of drainage is unnecessary in a grade II injury.

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