[Port-catheter perforation into the duodenum and other early complications after port implantation before intra-arterial infusion therapy of the liver with chemotherapeutic drugs]

Early complications following implantation of intraarterial hepatic port catheter systems from 1985 to 1988 in 24 patients are reported with special view to the perforation of a port catheter into the duodenum. In this case the primary postoperative angiographic control four weeks after implantation showed correct placement and perfusion of the liver. The perforation occurred before starting any cytostatic regimen. We observed a total of 21% irregularities and complications: dislocation of port membrane (n = 1), incorrect catheter displacement but regular liver perfusion (n = 1), catheter leakage (n = 1), subhepatic abscess (n = 1) and perforation of the catheter in the duodenum. When possible we combine port-implantation with resection of the liver.

Endoscopic sphincterotomy complications and their management: an attempt at consensus

Despite its relative safety (in comparison with surgery), and undoubted role in many clinical circumstances, biliary sphincterotomy is the most dangerous procedure routinely performed by endoscopists. Complications occur in about 10% of patients; 2 to 3% have a prolonged hospital stay, with a risk of dying. This document is an attempt to provide guidelines for prevention and management of complications, based on a workshop of selected experts, and a comprehensive review of the literature. We emphasize particularly the importance of specialist training, disinfection, drainage, and collaboration with surgical colleagues.

Decision for surgical management of perforation following endoscopic sphincterotomy

Duodenal perforation resulting from endoscopic sphincterotomy (ES) is a serious complication with a high mortality. Diagnosis is often problematic and the optimum treatment is controversial. Eight proven perforations occurred following 441 ES at University of Colorado Hospital, a rate of 1.8 per cent. Physical and laboratory findings were of little diagnostic value, whereas plain abdominal radiographs showed evidence of perforation in 86 per cent. All patients were operated on promptly after diagnosis of perforation. Delay in diagnosis of perforation beyond 24 hours in six patients was associated with a high morbidity and two deaths. Analysis of published series confirmed that delay in diagnosis and delay in operation after perforation were associated with a higher mortality rate than early diagnosis with or without operation. We recommend operative intervention in all patients with clinical evidence of perforation following ES.

[Perforation of the duodenum caused by a swallowed table knife. A case report]

A summary of the gastrointestinal problems associated with the ingestion of foreign bodies is presented. The authors describe their own observations in a patient who had swallowed a table knife that subsequently perforated the duodenum.

[Traumatic rupture of the duodenum in adults. Clinicopathologic and therapeutic considerations. Apropos of 9 cases]

Injuries to the duodenum are rare and their treatment is controversial. We have wanted to assess the results of treatment in 9 cases of duodenal trauma operated successively. 6 patients were operated at once because of associated lesions producing a state of shock. The other 3 had isolate lesions and were all operated after a waiting time. 5 patients had a simple suture after excision of the margins of the wound. 2 underwent controlled fistulization on a Pezzer probe associated to a feeding jejunostomy. In 2 cases, papillar disinsertion was treated by cupping the papilla with an ascended loop and by temporary pyloric exclusion. No patient died after surgery, and no duodenal fistula was noted. In case of controlled fistulization, the scar was obtained within 21 days. We think that duodenal wounds examined early can readily be sutured if there is no loss of substance. When the duodenal wound is isolate, the delay in treatment leads us to prefer controlled fistulization associated to feeding jejunostomy.

Conservative management of duodenal trauma: a multicenter perspective

The experience of eight trauma centers with duodenal injuries was analyzed to identify trends in operative management, sources of duodenal-related morbidity, and causes of mortality. During the 5-year period ending December 1988, 164 duodenal injuries were identified. Patient ages ranged from 5 to 78 years. There were 38 Class I, 70 Class II, 48 Class III, four Class IV, and four Class V injuries. Injury mechanism was penetrating in 102 (62%) patients and blunt in 62. Primary repair of the duodenal injury was performed in 117 (71%) patients, including 27 patients also managed with pyloric exclusion and 12 with tube duodenostomy. Duodenal resection with primary anastomosis was used in six (4%) patients and pancreatoduodenectomy was necessary in five (3%). There were 30 (18%) deaths. The cause of death was uncontrolled hemorrhage from severe hepatic or vascular injuries in 22 (73%) patients. In only two (1%) patients could death be attributed to the duodenal injury; each as the result of duodenal repair dehiscence and subsequent sepsis. Duodenal-related morbidity was documented in 29 (18%) patients, including 22 patients with intra-abdominal abscess, six with duodenal fistula, and five with frank duodenal dehiscence. In summary, this analysis demonstrated: 1) the great majority of duodenal injuries can be managed by simple repair; 2) tube duodenostomy is not a mandatory component of operative treatment; 3) pyloric exclusion is a useful adjunct for more complex injuries; 4) pancreatoduodenectomy is rarely necessary for civilian duodenal trauma; 5) morbidity following duodenal trauma is more dependent on associated intra-abdominal injuries than the extent of duodenal trauma; and 6) mortality following duodenal injuries is primarily related to associated vascular and hepatic trauma.

Pneumoscrotum following endoscopic sphincterotomy

Perforation is an infrequent complication of endoscopic sphincterotomy. We report here a man who developed a pneumoscrotum following a retroperitoneal perforation of the duodenum after endoscopic sphincterotomy. The mechanism of this unusual complication is discussed.

Reappraisal of pancreatic and duodenal injury management based on injury severity

We evaluated the effectiveness of treatment protocols for pancreatic and duodenal injuries according to the severity of injury. Of 81 patients, 65 survived initial injury. Pancreatic injuries without ductal involvement occurred in 21 patients and were treated by drainage. No late deaths occurred. Pancreatic injuries with ductal disruption occurred in 18 patients and were treated by pancreatic resection. Abscesses developed in seven (39%) of the patients, but no late deaths occurred. Nineteen patients had duodenal injuries without pancreatic injury, and no duodenal complications occurred. Simple closure sufficed for injuries affecting up to 40% of the duodenal circumference. Wounds affecting up to 40% of the duodenal circumference can be treated by suture closure alone. Adjunctive duodenal tube decompression should be reserved for wounds affecting greater than 40% of the duodenal circumference, closure under tension, and associated injuries to the head of the pancreas. Pyloric exclusion was rarely necessary in our patients.

Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum

The Organ Injury Scaling (O.I.S.) Committee of the American Association for the Surgery of Trauma (A.A.S.T.) has been charged to devise injury severity scores for individual organs to facilitate clinical research. Our first report (1) addressed O.I.S.'s for the Spleen, Liver, and Kidney; the following are proposed O.I.S.'s for Pancreas (Table I), Duodenum (Table II), Small Bowel (Table III), Colon (Table IV), and Rectum (Table V). The grading scheme is fundamentally an anatomic description, scaled from 1 to 5, representing the least to the most severe injury. We emphasize that these O.I.S.'s represent an initial classification system which must undergo continued refinement as clinical experience dictates.

[Retroperitoneal ruptures of the duodenum. Our experience]

The authors describe a case of retroperitoneal rupture of the duodenum following blunt abdominal trauma. The aetiology, symptomatology of these lesions are discussed and treatment is stressed. Duodenal fistula continues to be a serious postoperative complication. Primary repair with drainage is the preferred treatment. Gastrostomy, internal decompression and feeding jejunostomy are usefully added in the most severe duodenal injuries.

[Diagnosis and treatment of traumatic injuries of the duodenum and pancreas: 21 cases]

Twenty one consecutive patients who sustained injuries to the duodenum or/and pancreas were admitted to our hospital over a ten year period. Sixteen blunt injuries and 5 penetrating injuries were encountered. Penetrating injuries were always suspected and treated by time; following blunt injury diagnostic delay was encountered in 7 patients and insufficient surgical procedure because of intraoperative misinterpretation in 2 patients. Most of the patients had associated intra-abdominal organ injuries. Adjuncts to diagnosis such as abdominal roentgenograms, serum amylase levels and gastroduodenography were not helpful. CT-Scan and ultrasound allowed to confirm the suspected diagnosis in 3 cases only. Intraoperative diagnosis was also challenging. Complete mobilization of the structures surrounding the duodenum and the pancreas to provide entire exposure was necessary. In 6 patients treated first in a peripheral hospital, diagnosis of the injury have been missed at first laparotomy and reoperation was necessary in all of them. Suture closure of the duodenum and drainage of the pancreatic region were the most common reparative technique used. More complicated procedures with pancreatic and/or duodenal resection were performed in 6 patients. Overall mortality in patients surviving more than 24 hours was 14% (suture line dehiscence after delayed operation and one death due to brain injury).

[Traumatic perforation of the duodenum. Diagnostic and therapeutic problems]

The treatment of traumatic ruptures of the duodenum is one of the greatest controversies in surgery. The injury mechanisms, diagnostic criteria and factors underlying the prognosis are analysed and indications suggested for the various types of intervention. The problem relating to the operating technique are specified.

[Traumatic perforation of the duodenum: report of 5 cases]

The results of surgery in 5 cases of traumatic rupture of the duodenum are presented. The site of the laceration, the time between trauma and operation, associated lesions, diagnostic routine and type of operation are specified. The mortality encountered (40%) should be related to the seriousness of the lesions.

Small bowel injuries following blunt abdominal trauma. Early recognition and management

We reviewed the cases of 15 patients with intestinal perforation following blunt abdominal trauma, which occurred between 1971 and 1988. Twelve patients were treated at The Mary Imogene Bassett Hospital (Cooperstown, NY); three other patients were treated at surrounding area hospitals. These injuries included 11 motor vehicle accidents, three low-velocity impact injuries, and one blast injury. There were four duodenal, ten jejunal, and two ileal injuries. Five patients who were operated on within 12 hours had classic signs of peritonitis or gross blood on diagnostic peritoneal lavage. Four patients were operated on after 12 hours, and six after 24 hours; physical signs were subtle in this group. Pain was a universal finding but was usually moderate; nausea and vomiting were frequent early findings in the ten patients with late recognition. An altered sensorium due to intoxication or head injury was present in three of ten patients operated on after 12 hours. Laboratory determinations, including a white blood cell count and amylase analysis, as well as abdominal radiographs, were often not helpful. Diagnostic peritoneal lavage is an important test, but when it is performed within four hours post-injury, it may yield false negative findings in up to 50% of patients and may need to be repeated. Computer tomographic scanning should employ oral and intravenous contrast to increase accuracy; perforation of a hollow viscus may not be immediately recognized. Four of the five patients operated on within 12 hours had an uncomplicated course. Complications occurred in all six patients operated on beyond 24 hours and included intraabdominal abscesses in five, and death for one patient.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of pancreaticoduodenectomy in the management of traumatic injuries to the pancreas and duodenum

Pancreaticoduodenectomy has been decried as a means of managing combined pancreatic and duodenal trauma. In order to test this harsh assessment, we have reviewed our experience with this procedure in this setting. Six young males with a mean injury severity score of 15.4 underwent pancreaticoduodenectomy for trauma. Four patients sustained penetrating trauma and two patients suffered blunt injuries; each was felt by clinical assessment to have pancreatic ductal disruption combined with significant duodenal injury. Four patients underwent pancreaticoduodenectomy primarily, while two patients underwent initial drainage and diverticulization. The four patients undergoing immediate resection had a mean hospital stay of 28 days (18-42 days) and did not require further surgical intervention. All are alive and well six months to nine years later. The two patients with drainage and repair of their injuries had a mean hospital stay of 115 days (84-147 days) and required additional laparotomies for pancreatic leaks, enterocutaneous fistulae, or drainage of abscesses. Pancreaticoduodenectomy was ultimately performed in each case, and both have survived. Pancreaticoduodenectomy continues to have a role in the management of combined pancreatic and duodenal injuries.

Retroperitoneal perforation during ERCP and endoscopic sphincterotomy: causes, clinical features and management

Eleven patients with retroperitoneal perforation complicating endoscopic management of bile duct obstruction were seen over a seven-year period. In nine patients endoscopic sphincterotomy or pre-cut papillotomy had been performed, but in two who had not undergone sphincterotomy perforation occurred because of the penetration of a guidewire during attempts to negotiate a malignant bile duct stricture. Eight out of eleven patients remained asymptomatic, and all recovered with conservative management. Asymptomatic retroperitoneal perforation can complicate therapeutic ERCP even when sphincterotomy is not performed, but conservative management is usually effective if the complications is recognized immediately.

Duodenal injuries

The lethal potential of duodenal trauma relates to the severity of the defect, associated injuries, expedient diagnosis, and adequacy of repair. A high index of suspicion must be used in patients sustaining blunt abdominal trauma. An aggressive approach to penetrating abdominal trauma will detect the majority of duodenal injuries in a timely fashion. The unique anatomic and physiologic characteristics of the duodenum demand careful selection of the operative repair to fit the injury. A classification scheme is reviewed that should help the surgeon select the appropriate procedure from a multitude of choices. Standard postoperative care is required. Adherence to these principles should result in acceptable morbidity and mortality in patients with duodenal injuries.

Second annual W.R. Ghent lecture on trauma. Abdominal organ injury: diagnosis, treatment and education

In this lecture the author reviews aspects of education in the care of traumatized patients, with particular attention to abdominal injuries. He notes the lack of education in this aspect of medical care during the medical school years and the variable quality of trauma care education during residency training. The author outlines an organized approach to the teaching of trauma care, focusing on cognitive, psychomotor and affective education and the establishment of a uniform core curriculum for residents with the ultimate goal of enhancing patient care.

Pancreaticoduodenectomy for trauma: delayed reconstruction: a case report

Experience and success with packing, resuscitation, and re-exploration for severe traumatic liver injury stimulated application of this concept to more complicated problems. In the case presented, these principles were utilized in managing a combined major hepatic and pancreaticoduodenal disruption. We emphasize stabilization, temporization, and delayed reconstruction.

Management of duodenal injuries

Between 1975 and 1986, 42 patients with duodenal trauma were seen at six major hospitals serving the province of Saskatchewan. Twenty-six patients had blunt trauma and 16 penetrating trauma. The mean age of the patients was 25 years and 38 were male. An assessment of patient management revealed an unacceptable rate of duodenal fistulas (17%) and death (14%). Detailed analysis suggests that duodenal injuries must be diagnosed early with prompt and appropriate surgical correction.