Table 1

Summary of AAST Organ Injury Scale for the duodenum and associated WTA management recommendations

AAST organ injury scale for duodenum
Grade	Description	WTA recommended management
I	Hematoma involving a single portion of the duodenum	Initial non-operative management. If non-resolving, drainage and simple repair.
I	Partial thickness laceration without perforation	Simple repair.
II	Hematoma involving >1 portion of the duodenum	Same as grade I hematoma.
II	Laceration <50% of circumference	Simple, tension-free repair, preferably transverse. If A not possible, see grade III.
III	Laceration 50–75% of circumference of D2 or 75–100% of circumference of D1/D3/D4	Simple, tension-free repair, preferably transverse If A is not possible or significant, contamination/delayed management: duodenoduodenostomy. If neither A nor B is possible and injury is distal to ampulla: perform Roux-en-Y duodenojejunostomy over injury. If neither A nor B is possible and injury is proximal to ampulla: close distal duodenum and perform Roux-en-Y duodenojejunostomy to the proximal end or anterectomy with gastrojejunostomy (Billroth II).
IV	Laceration >75% of circumference	Same as grade III.
IV	Laceration >75% of circumference, involving ampulla or distal CBD	Complex reconstruction with Roux-en-Y limb or pancreaticoduodenectomy.
V	Massive destruction of duodenopancreatic complex or duodenal devascularization	Complex reconstruction with Roux-en-Y limb or pancreaticoduodenectomy.

Adapted from Malhotra et al.2
AAST, American Association for the Surgery of Trauma; CBD, common bile duct; WTA, Western Trauma Association.