traumatic duodenal injuries with significant tissue loss are rarely seen but are a potentially challenging problem when they occur in either children or adults [ 1 - 3 ] .
the incidence of duodenal injury in the literature ranges from 3.7% to 5.0% and it is often accompanied by other abdominal injuries because of its close anatomic relationship with the liver , pancreas , gallbladder , and ampulla of vater . in uncomplicated cases , the duodenal defect can simply be closed primarily . however , more complex injuries require pyloric exclusion with a gastrojejunostomy or a pancreaticoduodenectomy .
several experimental studies have also examined whether other approaches could reduce the morbidity and mortality that is associated with the management of complicated large duodenal defects .
several flaps have been used successfully to repair abdominal wall defects , including the rectus femoris muscle , antero - lateral thigh fasciocutaneous , and sartorius muscle or myocutaneous flaps .
however , the reconstruction of an abdominal wall defect that is associated with a large duodenal disruption is clinically challenging and technically demanding . in the present report , we describe an alternative technique for closing an abdominal wall defect that is associated with a large duodenal disruption : a free flap was used with the help of the temporary placement of a covered expandable metallic stent . to our knowledge , this is the first time this approach has been reported .
he had intra - abdominal exsanguinating bleeding , duodenal disruption , and multiple small bowel perforation .
duodenojejunostomy , the resection of about 150 cm of small bowel followed by anastomosis , and bleeding control were performed . despite of repeated reanastomosis due to anastomosis failure , he developed sepsis and multiorgan failure .
a surgical reexploration was performed and it revealed duodenojejunal disruption and multiple enteroenteric anastomosis failure ; there was a large amount of bilestained fluid in the abdomen .
since less than 1 m of the small bowel remained , pyloric exclusion or pancreaticoduodenectomy could no longer be considered .
therefore , we performed enteroenterostomy and duodenal primary repair , and placed a feeding tube distal to the perforated duodenum .
fortunately , after intensive care , the patient could be transferred to the general ward after ventilator weaning .
however , due to severe retraction of the duodenum , a duodenal disruption gap that was approximately 5 cm long developed .
however , because of persistent leakage of gastric , bile , and pancreatic juice through the duodenal defect , the abdominal wall defect could not be repaired directly with a free flap .
therefore , the bile and pancreatic juices were diverted first by placing separate pancreatic duct and bile duct drainage tubes by endoscopic retrograde cholangiopancreaticography .
thereafter , the interventional radiologist placed a 16-mm diameter , 90-mm long covered expandable metallic stent ( s&g biotech , seongnam , korea ) from the duodenal bulb to the jejunum .
bile and pancreatic juices were diverted through endoscopic nasobiliary drainage and endoscopic nasopancreatic drainage completely .
seven days after stent placement , the patient underwent debridement and closure of the abdominal wall defect with a free flap .
duodenostomy was performed by placing a drainage tube that decompressed the duodenum and prevented infection .
endoscopic images obtained 3 months after stent placement revealed a widely patent stent , although granulation tissue had formed above the stent .
the stent was electively removed 112 days after placement by using a stent removal set .
the pancreatic duct and bile duct drainage tubes were removed 13 days after stent removal .
on the 234 th postoperative day , an upper gastrointestinal water - soluble contrast study was performed and showed good passage of contrast with a small enterocutaneous fistula and no significant obstruction ( fig .
various treatment options have been reported to be effective for the surgical management of large duodenal defects .
these include duodenal resection with end - to - end anastomosis , roux - en - y duodenojejunostomy , diverticulization , polytetrafluoroethylene patching , omental plug closure , jejunal serosal patching , and pedicled grafts . in the present report
, a free flap was used with the help of a temporary stent to close a large duodenal defect and an abdominal wall defect . in this case , the patient had less than 1 m of small bowel left due to several previous small bowel resections .
the main advantage of the alternative technique described in the present report is that it did not involve intestinal resection .
it also prevented the possible risk of gastrointestinal contamination , peritoneal soiling , and organ injury . in our case ,
severe retraction of the duodenum led to a duodenal disruption that was approximately 5 cm long .
contact between the free flap and the bowel appeared to be an important factor in duodenal prefabrication .
an expandable metallic stent successfully reestablished duodenal continuity until the abdominal wall defect had been repaired .
the stent was removed 112 days after its placement because of granulation tissue formation above the stent .
a postoperative upper gastrointestinal water - soluble contrast study revealed good repair of the abdominal wall defect and the large duodenal disruption .
however , the repaired duodenal wall is surrounded with a free flap , and we remain concerned that a fibrotic stricture could occur . in recent years , expandable metallic stents have been used in many hospitals for the palliative treatment of inoperable malignant gastroduodenal strictures .
however , intestinal stent implantation remains potentially controversial because these stents can not always be removed easily after placement .
stents used to treat a benign gastrointestinal stricture should be designed to be retrievable to prevent long - term complications such as granulation tissue formation and stent migration . in this patient with large duodenal disruption and abdominal wall defect , we placed a fully covered expandable stent to prevent leakage of bile juice and to establish duodenal continuity . we could remove the stent through per - oral route after repair of abdominal wall defect .
although further clinical trials and extended follow - up studies are needed , the present case indicates that combining a free flap with a covered expandable metallic stent can effectively and successfully repair an abdominal wall defect that is associated with a large duodenal disruption .
 abdominal wall defect with large duodenal disruption after penetrating abdominal injury is a rare emergency situation that can result in life - threatening complications . 
 we report on a 64-year - old man who had abdominal wall defect with large duodenal disruption after penetrating abdominal injury . 
 the patient presented with intra - abdominal exsanguinating bleeding , duodenal disruption , and multiple small bowel perforation . 
 the rarity of this complex injury and its initial presentation as a posttraumatic large duodenal disruption with abdominal wall defect warrant its description . 
 the present case indicates that combining a free tissue flap with a covered expandable metallic stent can effectively and successfully repair an abdominal wall defect that is associated with a large duodenal disruption . 
INTRODUCTION
CASE REPORT
DISCUSSION