**Background:** Post-traumatic duodenal injuries in children are rare due to the duodenum's retroperitoneal location, but they pose diagnostic challenges because of non-specific clinical presentations. While non-operative management has become standard for duodenal wall hematomas, its role in duodenal perforations remains poorly described. This study aims to highlight the feasibility of conservative treatment in selected cases of duodenal perforation.
**Methods:** The authors conducted a retrospective review of pediatric surgical emergency registers from 2009 to 2022, identifying 6 children treated for duodenal injury following abdominal blunt trauma. Data on clinical presentation, diagnostic workup, injury grade (using the AAST Duodenal Organ Injury Scale), treatment modality, and outcomes were collected and analyzed.
**Key Results:** Six patients (3 girls, 3 boys; age range 5–15 years, mean 9 years) were included. Domestic accidents accounted for 5 cases and road accidents for 1 case. Time to consultation exceeded 24 hours in 5 of 6 patients. Abdominal pain was present in all 6, and 2 had bilious vomiting. Ultrasound diagnosed 2 cases (one hematoma, one effusion suggesting perforation). CT scan confirmed the diagnosis in 4 patients, revealing isolated duodenal hematoma (2 cases), hematoma with retroperitoneal air bubbles (1 case), and parietal hematoma with an 11 mm duodenal defect and pneumoperitoneum (1 case). Associated lesions were found in 3 patients: 2 with pancreatic swelling and 1 with right kidney laceration.
Three patients with isolated duodenal hematomas (Grade I–II) were managed non-operatively with nasogastric tube decompression, parenteral nutrition, and close clinical/radiological monitoring. Their hospital stays were 14, 20, and 15 days, all with good outcomes. A fourth patient with a duodenal hematoma and retroperitoneal air bubbles (Grade II) also received conservative treatment with favorable results (12-day stay). Radiological follow-up showed hematoma liquefaction on ultrasound (2 cases), hematoma regression on CT (1 case), and reduction of retroperitoneal bullae without contrast extravasation (1 case).
Two patients required surgery. The first (Grade II perforation, ~3 cm posterior D2 defect with biliary effusion) underwent primary 2-layer duodenal closure and was discharged after 10 days. The second (Grade III perforation involving 75% of D2 diameter with extensive hematoma and pancreatic swelling) underwent 2-layer closure with gastrojejunostomy and pyloric exclusion, plus external gallbladder drainage via Foley catheter (removed on postoperative day 15). This patient was discharged after 18 days. No deaths or duodenal fistulas were reported.
**Clinical Implications:** This small case series supports the established practice of non-operative management for duodenal hematomas in children. More notably, it suggests that in carefully selected, hemodynamically stable pediatric patients with localized retroperitoneal duodenal perforations (without free intraperitoneal air or generalized peritonitis), a trial of conservative treatment with antibiotics and rigorous monitoring may be feasible. However, the authors acknowledge that the small number of cases precludes definitive conclusions, and a multi-center study is needed to establish clear indications. The surgical approach of gastrojejunostomy with pyloric exclusion remains the recommended technique for severe duodenal injuries (Grade III–IV), with reported fistula rates below 5%.