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García A, Sanchez AI, Ferrada P, Wolfe L, Duchesne J, Fraga GP, Benjamin E, Campbell A, Morales C, Pereira BM, Ribeiro M, Quiodettis M, Peck G, Salamea JC, Kruger VF, Ivatury R, Scalea T. Risk factors for the leakage of the repair of duodenal wounds: a secondary analysis of the Panamerican Trauma Society multicenter retrospective review. World J Emerg Surg 2023; 18:28. [PMID: 37016441 PMCID: PMC10074841 DOI: 10.1186/s13017-023-00494-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/19/2023] [Indexed: 04/06/2023] Open
Affiliation(s)
- Alberto García
- Division of Trauma and Acute Care Surgery, Department of Surgery, Department of Intensive Care, Fundación Valle del Lili, Cra 98 No. 18-49, 760032, Cali, Colombia.
- Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cali, Colombia.
- Department of Surgery, Universidad Icesi, Cali, Colombia.
| | - Alvaro I Sanchez
- Division of Thoracic Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Paula Ferrada
- Division of Trauma and Acute Care Surgery, Innova Fairfax Hospital, Falls Church, VA, USA
| | - Luke Wolfe
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Juan Duchesne
- Department of Surgery, Tulane University, LA, New Orleans, USA
| | - Gustavo P Fraga
- Department of Trauma and Acute Care Surgery, University of Campinas, Campinas, Brazil
| | | | - Andre Campbell
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Carlos Morales
- Department of Surgery, Universidad de Antioquia, Medellín, Colombia
| | - Bruno M Pereira
- University of Vassouras, Rio De Janeiro, Brazil
- Santa Casa de Campinas, Campinas, Brazil
| | - Marcelo Ribeiro
- Consultant General and Trauma Surgeon, Chair Division of Trauma, Burns, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Martha Quiodettis
- Division of Trauma and Acute Care Surgery, Hospital Santo Tomas, Panama City, Panama
| | - Gregory Peck
- Department of Surgery, Robert Wood Johnson Place, New Brunswick, NJ, USA
| | - Juan C Salamea
- Department of Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Vitor F Kruger
- Department of Trauma and Acute Care Surgery, University of Campinas, Campinas, Brazil
| | - Rao Ivatury
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Thomas Scalea
- Department of Surgery, Shock Trauma Center, University of Maryland, MD, College Park, USA
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Feliciano DV. 2022 Excelsior Surgical Society/Edward D Churchill Lecture: Extraordinary Evolution of Surgery for Abdominal Trauma. J Am Coll Surg 2023; 236:439-448. [PMID: 36730657 DOI: 10.1097/xcs.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- David V Feliciano
- From the Shock Trauma Center/Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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Reddavid R, Ballauri E, Aguilar HAR, Cardile M, Marchiori G, Sbuelz F, Degiuli M. Iatrogenic Duodenal Perforation After Surgery: a Systematic Review. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03718-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Abstract
Duodenal perforation consequent to prior surgery is a rare but severe complication carrying serious consequences if not promptly managed. This study aims to identify the best treatment pathway available to date. This is a systematic review registered to PROSPERO. The literature research was conducted on Ovid Medline, Embase, and Cochrane up to February 2022 to identify all papers reporting surgical-related duodenal perforations. Twelve articles were included. Most of these studies were case reports or case series. The most common cause of perforation was laparoscopic cholecystectomy (72.7%). The median time to symptom appearance was 2 days. Most of these perforations were severe injuries located in the first portion of the duodenum. Only one patient was treated with a non-interventional conservative management, which failed. Five patients were managed with interventional non-surgical treatments: 4 with endoscopy (50% failure) and one with a percutaneous occluder. Different surgical treatments were reported: direct suture (100% failure), direct suture and T-tube duodenostomy (75% failure), simple abdominal drainage, and suture with pyloric exclusion. Further extensive surgeries were also reported. The overall mortality rate was 13.6%, with a median hospital stay of 38.5 days. This review shows a wide spectrum of managements for patients with duodenal perforation related to prior surgery. The decision on which treatment to adopt must consider patient’s clinical setting and duodenal defect characteristics (size, site, and time to diagnosis). A tentative treatment flowchart is provided, although larger sample size studies are needed to obtain a treatment pathway based on evidence.
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Duodenal Injuries. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00345-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Alkhulaiwi H, Alsarrani FH, Alharbi AA. Duodenal transection following blunt abdominal trauma: a case report and literature review. J Surg Case Rep 2022; 2022:rjab610. [PMID: 36226133 PMCID: PMC9541283 DOI: 10.1093/jscr/rjab610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/08/2021] [Accepted: 12/13/2021] [Indexed: 11/06/2022] Open
Abstract
Isolated duodenal transection—a rare complication of abdominal trauma—is a challenging dilemma and difficult to diagnose. As blunt duodenal injuries vary from mild hematoma or perforation to complete transection or complex pancreaticoduodenal disruption. A 21-year-old male medically free victim of motor vehicle collision was admitted to our hospital and evaluated in ER according to ATLS protocol. Patient was stable with positive fast scan so we proceeded for abdomen computed tomography, which showed duodenal injury with possible pancreatic transection and active arterial extravasation. Based on that patient was taken for exploratory laparotomy and primary repair. Duodenal injuries can be a result of different mechanism. Typically, it was the result of crush injury, however, it can be due to shear or bursting forces. With its anatomical location, reaching the accurate diagnosis might be delayed, which is associated with higher mortality rate. Due to different scales of severity and different presentation, the management varies based on the location and the involved surrounding structures. Although complete duodenal transection is rare with blunt injuries, high clinical suspicion is necessary to detect such injury early. Studies have shown that the outcomes are highly dictated by early diagnosis and prompt management.
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Affiliation(s)
- Hani Alkhulaiwi
- General Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Faisal H Alsarrani
- General Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Alanood A Alharbi
- Correspondence address. PO Box 2511, Riyadh 11461, Saudi Arabia. Tel: 966559919930; E-mail:
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Time from Injury to Initial Operation May Be the Sole Risk Factor for Postoperative Leakage in AAST-OIS 2 and 3 Traumatic Duodenal Injury: A Retrospective Cohort Study. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060801. [PMID: 35744064 PMCID: PMC9229050 DOI: 10.3390/medicina58060801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Traumatic duodenal injury is a rare disease with limited evidence. We aimed to evaluate the risk factors for postoperative leakage and outcomes of pyloric exclusion after duodenal grade 2 and 3 injury. Materials and Methods: We reviewed a prospectively collected trauma database for the period January 2004-December 2020. Patients with grade 2 and 3 traumatic duodenal injury were included. To identify the risk factors for postoperative leakage, we used a stepwise multivariable logistic regression model and a least absolute shrinkage and selection operator (LASSO) logistic model. We constructed a receiver operator characteristic (ROC) curve to predict risk factors for postoperative leakage. Results: During the 17-year period, 179,887 trauma patients were admitted to a regional trauma center in Korea. Of these patients, 74 (0.04%) had duodenal injuries. A total of 49 consecutive patients had grade 2 and 3 traumatic duodenal injuries and underwent laparotomy. The incidence of postoperative leakage was 32.6% (16/49). Overall mortality was 18.4% (9/49). A stepwise multivariable logistic regression and LASSO logistic regression model showed that time from injury to initial operation was the sole statistically significant risk factor. The ROC curve at the optimal threshold of 15.77 h showed the following: area under ROC curve, 0.782; sensitivity, 68.8%; specificity, 87.9%; positive predictive value, 73.3%; and negative predictive value, 85.3%. There was no significant difference in outcomes between primary repair alone and pyloric exclusion. Conclusions: Time from injury to initial operation may be the sole significant risk factor for postoperative duodenal leakage. Pyloric exclusion may not be able to prevent postoperative leakage.
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Lee TG, Kim DH, Yun H, Ryu DH. Successful endoscopic vacuum therapy for the lateral duodenal fistula. Asian J Surg 2022; 45:1807-1808. [PMID: 35599128 DOI: 10.1016/j.asjsur.2022.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/06/2022] [Indexed: 12/01/2022] Open
Affiliation(s)
- Taek-Gu Lee
- Department of Surgery, Chungbuk National University Hospital, South Korea; Department of Surgery, Chungbuk National University College of Medicine, South Korea
| | - Dae Hoon Kim
- Department of Surgery, Chungbuk National University Hospital, South Korea; Department of Surgery, Chungbuk National University College of Medicine, South Korea.
| | - HyoYung Yun
- Department of Surgery, Chungbuk National University Hospital, South Korea; Department of Surgery, Chungbuk National University College of Medicine, South Korea
| | - Dong Hee Ryu
- Department of Surgery, Chungbuk National University Hospital, South Korea; Department of Surgery, Chungbuk National University College of Medicine, South Korea
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Kang SM, Kim IK, Lee JG. Management of Traumatic Duodenal Injuries: A Report from a Single-Center. JOURNAL OF ACUTE CARE SURGERY 2022. [DOI: 10.17479/jacs.2022.12.1.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Purpose: Traumatic duodenal injury is uncommon and due to its difficult diagnosis and accessibility there is an increased risk of mortality and morbidity.Methods: Electronic medical records of a single center were reviewed retrospectively from March 2008 to December 2020 and a total of 7 cases of traumatic duodenal injury were managed by surgical exploration. The site of duodenal perforation, injury mechanisms, operation method, and postoperative outcomes were assessed.Results: The mean age was 55.72 years (range, 34-78), and there were 5 men in the study. The most common mechanism was in-car traffic accident (4 cases), and 1 case each of pedestrian accident, accident during work, and self-injured stab wound. The most common site of injury was between the 3rd and 4th portion (3 cases), followed by the bulb and 1st portion (2 cases), and 2nd portion (2 cases). Segmental resection of the duodenum and primary anastomosis was performed in the 3rd and 4th portion perforation. In cases of 1st and 2nd portion, injury was managed by primary repair or pylorus preserving pancreaticoduodenectomy. Complications developed in 4 patients, and the most common complication was a problem with the wound; wound seromas developed in 4 cases, entero-cutaneous fistula in 1, and biliary complications in 2 cases. Two patients suffered from intraperitoneal abscess or fluid collection managed by percutaneous drainage. The mean duration of hospital stay was 34 days, and postoperative mortality did not develop.Conclusion: Favorable clinical outcomes were observed in patients with traumatic duodenal injury managed by various surgical approaches.
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Diggs LP, Gregory S, Choron RL. Review of Traumatic Duodenal Injuries: Etiology, Diagnosis, and Management. Am Surg 2022:31348211065091. [DOI: 10.1177/00031348211065091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Traumatic duodenal injuries are rare and often challenging to diagnose and treat. Management of these injuries remains controversial and continues to evolve. Here, we performed a review of the literature and guidelines for the diagnosis and management of traumatic duodenal injuries. A common recommendation in more recent literature is primary, tension-free repair of duodenal injuries when possible if surgical repair is necessary. Conversely, if duodenal injuries are unamenable to primary repair, more complex procedures such as Roux-en-Y duodenojejunostomy or pancreaticoduodenectomy may be necessary. Regardless of injury grade or type of surgical repair, the literature continues to support wide extraluminal drainage. Over time, the management of complex duodenal injuries has evolved to favor simple primary repair whenever possible. According to recent studies, more complex procedures are associated with higher rates of post-operative complications and should be reserved for severe injuries when primary repair is not possible.
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Affiliation(s)
- Laurence P. Diggs
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Stephanie Gregory
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Rachel L. Choron
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Sehgal M, Mahajan D, Singh A, Singh V, Dhua A, Agarwala S, Mitra A. Isolated Pyloroduodenal Transection in Children: a Spectrum of Presentation of an Uncommon Entity. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02454-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Correia Sousa Périssé JP, de Carvalho Miranda Rosati Rocha AL, Lessa Coelho R, Guerra Campanario B, Rosati Rocha LF. Duodenal Laceration Due to Blunt Trauma Caused by Horse Kick: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e927461. [PMID: 33277459 PMCID: PMC7726735 DOI: 10.12659/ajcr.927461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 13-year-old Final Diagnosis: Duodenal laceration Symptoms: Abdominal pain • diffuse abdominal pain Medication: — Clinical Procedure: Laparotomy Specialty: Surgery
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Somasekar RDR, Sankar AS, Krishna PS. Primary reinforcement with rectus abdominis muscle flap-a salvage technique for a tenuous post traumatic duodenal perforation- a case report. Int J Surg Case Rep 2020; 74:91-94. [PMID: 32836211 PMCID: PMC7452464 DOI: 10.1016/j.ijscr.2020.07.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The conventional techniques for management of complex duodenal injuries are duodenal diverticularisation, pyloric exclusion or triple tube decompression. We here present a salvage technique of primary reinforcement with pedicled rectus abdominis muscle flap (RAMF) for a tenuous post traumatic duodenal perforation (PTDP). The majority of the studies in the literature are on the use RAMF for the secondary repair of peptic duodenal perforations. PRESENTATION OF CASE A 38 year old male presented with an acute abdomen, three days after sustaining a blunt abdominal trauma. The clinical and radiological findings in the abdomen were subtle and not contributory. An emergency laparotomy with a high index of suspicion revealed a large perforation in the anterolateral wall of the second portion of the duodenum with a friable unhealthy wall and shearing of the serosa around the perforation site. The entire omentum was unhealthy, contused with areas of gangrene and omentectomy done. The perforation site was closed using 3.0 vicryl and reinforced with a pedicled right RAMF based on the superior epigastric artery. The patient recovered uneventfully and was discharged. DISCUSSION The addition of conventional diversion techniques to primary duodenorrhaphy is sophisticated, time consuming and adds morbidity. CONCLUSION RAMF is a good tissue substitute to buttress tenuous duodenal injuries presenting late with inflamed, friable perforation sites and associated tissue loss, where duodenorrhaphy alone may not be successful. RAMF is a valuable salvage technique when the omentum is not available and the local tissue condition negates the effectiveness of other simpler techniques.
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Affiliation(s)
- R D R Somasekar
- Department of Surgical Gastroenterology, GMKMCH, BRS Residency, Vidyalaya Road, Salem, 636007, India.
| | - A Siva Sankar
- Department of Surgical Gastroenterology, GMKMCH, Nitesh Hospitals, Sewapet, Salem, 636002, India.
| | - P Sai Krishna
- Department of Surgical Gastroenterology, GMKMCH, Room No 210, PG Hostel, Salem, 636002, India.
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Paulino J, Vigia E, Cunha M, Amorim E. Two-stage pancreatic head resection after previous damage control surgery in trauma: two rare case reports. BMC Surg 2020; 20:98. [PMID: 32397989 PMCID: PMC7216496 DOI: 10.1186/s12893-020-00763-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 04/30/2020] [Indexed: 12/15/2022] Open
Abstract
Background This study describes the successful treatment of two clinical settings of grade V pancreaticoduodenal blunt trauma only possible due to the prompt collaboration of a peripheral trauma hospital and a central hepatobiliary and pancreatic unit. Case presentation We reviewed the clinical records of two male patients aged 17 and 47 years old who underwent a two-stage pancreaticoduodenectomy after a previous Damage-Control Surgery (DCS). Both patients were transferred to our Hepatobiliopancreatic Unit 2 days after immediate DCS with haemostasis, debridement, duodenostomy, gastroenterostomy, external drainage and laparostomy. One day after, they both underwent a two-stage Whipple’s procedure with external cannulation of the main bile duct and the main pancreatic duct with seized calibre silicone drains through the skin. The reconstructive phase was performed two weeks later. The first patient had an uneventful post-operative course and was discharged on post-operative day 8. The second patient developed a high debt biliary fistula on post-operative day 5 being submitted to a relaparotomy with extensive peritoneal lavage. After conservative measures the fistula underwent a progressive closure in 15 days, and the patient was discharged at post-operative day 50 without any limitations. Conclusions Pancreaticoduodenectomy is a life-saving operation in selected grade V pancreaticoduodenal trauma lesions. DCS is a salvage approach, often performed in peripheral hospitals, making an early referral to an hepatobiliopancreatic centre mandatory to achieve survival in these severely injured patients. A two-staged Whipple’s operation for severe duodenal / pancreatic trauma can be performed safely and may represent a life-saving option under these very unusual circumstances.
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Affiliation(s)
- Jorge Paulino
- Centro Hepatobiliopancreático e de Transplantação, Centro Hospitalar Universitário de Lisboa Central, Hospital Curry Cabral, Universidade Nova de Lisboa, Lisboa, Portugal.
| | - Emanuel Vigia
- Centro Hepatobiliopancreático e de Transplantação, Centro Hospitalar Universitário de Lisboa Central, Hospital Curry Cabral, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Miguel Cunha
- Department of Surgery, Centro Hospitalar Universitário do Algarve - Unidade de Portimão, Portimão, Portugal
| | - Edgar Amorim
- Department of Surgery, Centro Hospitalar Universitário do Algarve - Unidade de Portimão, Portimão, Portugal
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Successful Endoscopic Closure of Pyeloduodenal Fistula Using an Over-the-Scope Clip. ACG Case Rep J 2020; 6:e00281. [PMID: 32309478 PMCID: PMC7145216 DOI: 10.14309/crj.0000000000000281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/30/2019] [Indexed: 11/17/2022] Open
Abstract
A 62-year-old woman underwent a series of urologic procedures for nephrolithiasis and was diagnosed with a pyeloduodenal fistula (PDF) on computed tomography urography. After the placement of a metallic ureteral stent and nephrostomy tube, an esophagogastroduodenoscopy was performed to evaluate for PDF resolution. Two areas of mucosal defects within the anterior duodenal sweep were closed using the over-the-scope clip system and hemostasis clips. We review the literature and discuss the etiologies, presentation, diagnosis, and treatment of PDF. This is the second documented case of endoscopic PDF closure using the over-the-scope clip system and the third case of endoscopically treated PDF.
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Po Chu Patricia Y, Ka Fai Kevin W, Fong Yee L, Kiu Jing F, Kylie S, Siu Kee L. Duodenal stump leakage. Lessons to learn from a large-scale 15-year cohort study. Am J Surg 2020; 220:976-981. [PMID: 32171473 DOI: 10.1016/j.amjsurg.2020.02.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/14/2020] [Accepted: 02/20/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Duodenal stump leakage is a challenging condition causing significant morbidity and mortality. The aim of this study is to identify the risk factors associated with duodenal leak and advocate modification to prevent the incident. METHODS A retrospective cohort study was performed to include patients who had gastrectomy with excluded duodenum in a single surgical centre in the period of Jan 2003-March 2017. Analysis of associated factors was performed. Patients with duodenal leak were further analyzed and the treatment strategy was reviewed. RESULTS During the study period, 678 patients had gastrectomy with excluded duodenum. 502 patients had elective gastrectomy and 176 patients had emergency gastrectomy. 52 patients had subsequent duodenal stump leakage (7.7%). The existence of duodenal ulcer, intra-operative contamination, lower pre-operative haemoglobin and duodenostomy were the independent associated factors for duodenal leak. CONCLUSION This is the largest cohort in studying associated factors regarding duodenal leak in both emergency and elective gastrectomy. The independent associated factors were identified. We advocate a conservative approach for duodenal leak with adequate drainage, nutrition and antibiotics.
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Affiliation(s)
| | | | - Lam Fong Yee
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
| | - Fung Kiu Jing
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
| | - Szeto Kylie
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
| | - Leung Siu Kee
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
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da Costa Ferreira CP, Lima NS, Mortati MCG, Ribeiro MA, Taha MIA, Perlingeiro JAG, Assef JC. Duodenal diverticulization as treatment of complex duodeno-pancreatic lesions: Case report. Int J Surg Case Rep 2019; 66:298-303. [PMID: 31896071 PMCID: PMC6941138 DOI: 10.1016/j.ijscr.2019.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Duodenal and pancreatic lesions are uncommon, but severe and responsible for high incidence in morbidity and mortality. Differences between the mechanisms of trauma, the severity of lesions and the time between trauma, diagnosis and treatment influence the evolution of the case. PRESENTATION OF CASE We report a case of a 20-year-old patient with several lesions in stomach, duodenum, pancreas and jejunum due to three gunshots treated at our service. Duodenal diverticulalization was used on treatment of complex duodeno-pancreatic lesions. The patient presented good evolution, with discharge conditions in the 10th PO. DISCUSSION We discussed the positives and negatives of this technique, with the approval of the Ethics Committee number 13736519.8.0000.5479. CONCLUSION The duodenal diverticulization leads to an irreversible change to the food transit. However, this is a feasible bypass option in cases of high chances of fistula and scar stenosis complex duodenal injury, particularly in the context of associated gastric injury.
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Affiliation(s)
| | - Natyele Soares Lima
- General Surgical Residency of the Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP), São Paulo, SP, Brazil
| | - Maria Carolina Galli Mortati
- General Surgical Residency of the Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP), São Paulo, SP, Brazil
| | - Mauricio Alves Ribeiro
- Emergency Service of the Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP), São Paulo, SP, Brazil
| | - Mohamed Ibrahim Ali Taha
- Emergency Service of the Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP), São Paulo, SP, Brazil
| | | | - Jose Cesar Assef
- Emergency Service of the Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP), São Paulo, SP, Brazil.
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Soon DSC, Leang YJ, Pilgrim CHC. Operative versus non-operative management of blunt pancreatic trauma: A systematic review. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408618788111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Motor vehicle crashes are common causes of blunt abdominal trauma in the 21st century. While splenic trauma occurs very frequently and thus there is a well-established treatment paradigm, traumatic pancreatic injuries are relatively infrequent, occurring in only 3–5% of traumas. This low incidence means physicians have reduced experience with this condition and there is still ongoing debate with regards to the best practice in managing pancreatic trauma. During severe trauma, the pancreas can be injured as a consequence of blunt and penetrating injury. This has an estimated mortality rate ranging from 9 to 34%. Methods A systematic review was performed using three scientific databases: Embase, Medline and Cochrane and in-line with the PRISMA statement. We included only articles published in English, available as full text and describing only adults. Keywords included: pancrea*, trauma, blunt, operative management and non-operative management. Results Three studies were found that directly compared operative versus non-operative management in blunt pancreatic trauma. Length of stay, mortality and rate of re-intervention were lower in the non-operative group compared to the operative group. However, the average grade of pancreatic injury was lower in the non-operative group compared to the operative group. Discussion Our results revealed that patients who undergo non-operative management tend to have lower grade of injuries and patients with higher grade of injury tend to be managed in an operative fashion. This could be likely due to the fact that higher grade of pancreatic injuries is often accompanied by other injuries such as hollow viscus injury and therefore require operative intervention. Conclusion Non-operative management is a safe approach for low-grade blunt pancreatic trauma without ductal injuries. However, more evidence is required to improve our understanding and treatment plans. We suggest a large international multicentre study combining data from multiple international trauma centres to collect adequate data.
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Affiliation(s)
- David SC Soon
- Department of Surgery, Peninsula Health, Frankston, Australia
| | - Yit J Leang
- Department of Surgery, Peninsula Health, Frankston, Australia
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James TW, Baron TH. EUS-guided gastrojejunostomy for relief of gastric outlet obstruction from a large duodenal hematoma. VideoGIE 2019; 4:76-77. [PMID: 30766948 PMCID: PMC6363769 DOI: 10.1016/j.vgie.2018.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Theodore W James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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19
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Aiolfi A, Matsushima K, Chang G, Bardes J, Strumwasser A, Lam L, Inaba K, Demetriades D. Surgical Trends in the Management of Duodenal Injury. J Gastrointest Surg 2019; 23:264-269. [PMID: 30215200 DOI: 10.1007/s11605-018-3964-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 09/03/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical management of traumatic duodenal injury remains challenging. While various surgical techniques have been described in the attempt to reduce complications and mortality, recent data suggests that surgical approach using less invasive procedures might be associated with improved patient outcomes. The purpose of this study was to determine the recent trend of surgical procedures performed for patients with duodenal injury and their outcome. METHODS A retrospective analysis of the National Trauma Data Bank (NTDB) from 2002 to 2014 was performed. A total of 2163 patients who sustained a traumatic duodenal injury requiring surgical intervention were included. Patient characteristics, injury data, procedures, and outcomes were examined. Types of duodenal procedures and patient outcomes were compared between two study periods (2002-2006 vs. 2007-2014). RESULTS The median age was 27 (IQR 20-39), 78.9% were male, and 63.8% sustained penetrating duodenal injury. The median injury severity score was 18 (IQR 13-26). In patients with isolated duodenal injury, the later study period (2007-2014) was significantly associated with the increased use of primary repair (OR 1.77; 95% CI 1.11-2.83, p = 0.017). Overall mortality was 11.7%. Patients in the later study group were significantly associated with lower odds of inhospital mortality (OR 0.47, 95% CI 0.22-0.95, p = 0.041). CONCLUSIONS A progressive trend toward less invasive procedures for duodenal injury was noted in the current study. Inhospital mortality has improved in the late study period.
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Affiliation(s)
- Alberto Aiolfi
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA.
| | - Gloria Chang
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - James Bardes
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Aaron Strumwasser
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Lydia Lam
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Demetrios Demetriades
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
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20
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Choron RL, Efron DT. Isolated and Combined Duodenal and Pancreatic Injuries: A Review and Update. CURRENT SURGERY REPORTS 2018. [DOI: 10.1007/s40137-018-0216-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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21
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Israr S, Rubalcava NS, Weinberg JA, Jones M, Gillespie TL. Management of Biliary Stricture Following Emergent Pancreaticoduodenectomy for Trauma: Report of Two Cases. Cureus 2018; 10:e2829. [PMID: 30131922 PMCID: PMC6101440 DOI: 10.7759/cureus.2829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Stricturing of the biliary-enteric anastomosis is a known complication of emergent pancreaticoduodenectomy (PD) performed for trauma. Percutaneous techniques have become the first-line option for the management of these strictures. In cases where percutaneous intervention fails, surgical revision of the biliary enteric anastomosis is necessary. We present two cases of young males with penetrating injuries to the pancreatic head managed with PD and subsequently developed post-operative biliary strictures. The biliary stricture was managed successfully with percutaneous intervention for one of the patients. The other patient required surgical revision of the biliary anastomosis. Pancreaticoduodenectomy is typically performed in patients with malignant or benign biliary obstruction with associated ductal dilatation. In the setting of trauma, the bile duct is typically non-dilated, creating greater susceptibility for anastomotic stricture. Although such strictures may be amenable to percutaneous cholangioplasty, strictures involving distal anastomoses may require operative revision. Thus, we suggest creating the more proximal hepaticojejunostomy during the initial operation, as this may benefit the success of percutaneous management should a stricture develop. Operative revision is the definitive management of post-PD biliary stricture.
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Affiliation(s)
- Sharjeel Israr
- General Surgery, St. Joseph Hospital and Medical Center, Phoenix, Arizona, Usa, Phoenix, USA
| | - Nathan S Rubalcava
- General Surgery, St. Joseph Hospital and Medical Center, Phoenix, Arizona, Usa, Phoenix, USA
| | - Jordan A Weinberg
- Trauma Surgery, St. Joseph Hospital and Medical Center, Phoenix, Arizona, Usa, Phoenix, USA
| | - Michael Jones
- General Surgery, St. Joseph Hospital and Medical Center, Phoenix, Arizona, Usa, Phoenix, USA
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22
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Romac JMJ, Shahid RA, Swain SM, Vigna SR, Liddle RA. Piezo1 is a mechanically activated ion channel and mediates pressure induced pancreatitis. Nat Commun 2018; 9:1715. [PMID: 29712913 PMCID: PMC5928090 DOI: 10.1038/s41467-018-04194-9] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 04/08/2018] [Indexed: 01/09/2023] Open
Abstract
Merely touching the pancreas can lead to premature zymogen activation and pancreatitis but the mechanism is not completely understood. Here we demonstrate that pancreatic acinar cells express the mechanoreceptor Piezo1 and application of pressure within the gland produces pancreatitis. To determine if this effect is through Piezo1 activation, we induce pancreatitis by intrapancreatic duct instillation of the Piezo1 agonist Yoda1. Pancreatitis induced by pressure within the gland is prevented by a Piezo1 antagonist. In pancreatic acinar cells, Yoda1 stimulates calcium influx and induces calcium-dependent pancreatic injury. Finally, selective acinar cell-specific genetic deletion of Piezo1 protects mice against pressure-induced pancreatitis. Thus, activation of Piezo1 in pancreatic acinar cells is a mechanism for pancreatitis and may explain why pancreatitis develops following pressure on the gland as in abdominal trauma, pancreatic duct obstruction, pancreatography, or pancreatic surgery. Piezo1 blockade may prevent pancreatitis when manipulation of the gland is anticipated. Manipulation of the pancreas during surgery can induce acute pancreatitis due to zymogen activation. Here the authors show that the mechanoreceptor Piezo1 is activated by pressure and its activation leads to calcium dependent pancreatic injury whereas its inhibition is protective against pancreatitis.
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Affiliation(s)
- Joelle M-J Romac
- Department of Medicine, Duke University and Durham VA Medical Centers, Durham, NC, 27710, USA
| | - Rafiq A Shahid
- Department of Medicine, Duke University and Durham VA Medical Centers, Durham, NC, 27710, USA
| | - Sandip M Swain
- Department of Medicine, Duke University and Durham VA Medical Centers, Durham, NC, 27710, USA
| | - Steven R Vigna
- Department of Medicine, Duke University and Durham VA Medical Centers, Durham, NC, 27710, USA.,Department of Cell Biology, Duke University and Durham VA Medical Centers, Durham, NC, 27710, USA
| | - Rodger A Liddle
- Department of Medicine, Duke University and Durham VA Medical Centers, Durham, NC, 27710, USA.
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23
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Laparotomy: The conquering of the abdomen and the historical journey of pancreatic and duodenal injuries. J Trauma Acute Care Surg 2018; 80:1023-31. [PMID: 26958791 DOI: 10.1097/ta.0000000000001010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Wang A, Lin T, Chen S. Isolated Traumatic Duodenal Rupture Due to Bicycle Handlebar Injury in an Adult Patient. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791502200206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Because of the well-developed abdominal musculature, the possibility of injury of the retroperitoneal organs such as the duodenum is not as high as that in children. Adult cases of isolated traumatic duodenal rupture caused by bicycle handlebar injury are extremely rare. We report a patient who experienced persistent abdominal pain after having a bicycle handlebar injury. Since the injury is hard to identify, abdominal computed tomography is performed to confirm the diagnosis. We also present a management flow chart to help physicians managing handlebar injuries in adults. (Hong Kong j.emerg.med. 2015;22:113-117)
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Affiliation(s)
- Ay Wang
- National Taiwan University Hospital, Department of Emergency Medicine, No. 7 Chung Shan South Road, Taipei 100, Taiwan
| | | | - Sc Chen
- National Taiwan University Hospital, Department of Emergency Medicine, No. 7 Chung Shan South Road, Taipei 100, Taiwan
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25
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Abstract
Hollow viscus injury is common with penetrating trauma to the torso and infrequent with a blunt traumatic mechanism of injury. The diagnosis in hemodynamically unstable patients is often made in the operating room. In hemodynamically stable patients, the diagnosis can be difficult due to additional injuries. Although computed tomography remains the diagnostic tool of choice in hemodynamically stable patients, it has lower reported sensitivity and specificity with hollow viscus injury. However, even short delays in diagnosis increase morbidity and mortality significantly. Operative management of stomach, duodenal, small bowel, and colon injuries is reviewed.
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26
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Telfah MM. Isolated duodenal rupture: primary repair without diversion; is it safe? Review of literature. BMJ Case Rep 2017; 2017:bcr-2016-215251. [PMID: 28433976 DOI: 10.1136/bcr-2016-215251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Isolated duodenal rupture is a rare injury encountered among children following blunt abdominal trauma. Early diagnosis and treatment are essential to decrease the associated morbidity and mortality. The debate is about the optimum operative management. We report a 6-year-old child who presented with acute abdominal pain due to isolated duodenal injury following blunt abdominal trauma. Emergency laparotomy revealed duodenal rupture at the junction of the first and second part of duodenum and absence of any other visceral injuries. The duodenal injury was defined as grade III, that is, involving 75% of the circumference. We opted to perform primary repair of the injured duodenum in two layers alone without diversion. The abdominal cavity was drained using an open system drain next to the repair. Nasogastric and jejunostomy tubes were used postoperatively for gastric decompression and enteral feeding, respectively. The child had an uneventful recovery, was discharged well on the 10th postoperative day and no stenosis was found on long-term follow-up. The debate was whether to repair the defect primarily or to combine the repair with diversion. Early diagnosis, the isolated nature of the duodenal injury and the possibility of minimal contamination favoured primary repair of the defect without diversion. The good outcome attributed to these factors were in agreement with most of the literature.
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Affiliation(s)
- Muwaffaq Mezeil Telfah
- Department of Surgery, Al Jumhoori Teaching Hospital, College of Medicine, University of Mosul, Mosul City, Iraq
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27
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Johnston LR, Wind G, Bradley MJ. Duodenal trauma. TRAUMA-ENGLAND 2017. [DOI: 10.1177/1460408616684866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Duodenal trauma represents a unique challenge to the surgeon due to its relative rarity, anatomic location, and often the difficulty in diagnosing and managing these injuries. Despite these challenges, significant advances have been made over the previous century, and mortality has fallen to as low as 17%. The CT scan is the primary modality for diagnosis in the blunt trauma patient, and thorough surgical exploration at laparotomy is the mainstay for penetrating injuries. Management is guided by the grade of injury, with low-grade hematomas managed by observation, intermediate grade injuries by primary repair, and high-grade injuries with a damage control surgery approach. While pyloric exclusion remains the most common technique to augment primary repair in intermediate and higher grade injuries, the utility of this procedure has come into question in current literature, and an overall ‘less-is-more’ surgical approach has been advocated in recent publications. Complications following duodenal trauma are common and include fistulae, duodenal obstruction, and infectious complications. However, the overall morbidity and mortality have improved with these injuries. Future investigation is needed to determine the optimal management approach for these challenging patients.
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Affiliation(s)
- Luke R Johnston
- Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, USA
- Naval Medical Research Center, Silver Spring, MD, USA
| | - Gary Wind
- Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Matthew J Bradley
- Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, USA
- Naval Medical Research Center, Silver Spring, MD, USA
- Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
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28
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Cruvinel Neto J, Pereira BMT, Ribeiro MAF, Rizoli S, Fraga GP, Rezende-Neto JB. Is there a role for pyloric exclusion after severe duodenal trauma? Rev Col Bras Cir 2016; 41:228-31. [PMID: 25140657 DOI: 10.1590/s0100-69912014000300016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 06/08/2014] [Indexed: 11/22/2022] Open
Abstract
Duodenal trauma is an infrequent injury, but linked to high morbidity and mortality. Surgical management of duodenal injuries is dictated by: patient's hemodynamic status, injury severity, time of diagnosis, and presence of concomitant injuries. Even though most cases can be treated with primary repair, some experts advocate adjuvant procedures. Pyloric exclusion (PE) has emerged as an ancillary method to protect suture repair in more complex injuries. However, the effectiveness of this procedure is debatable. The "Evidence Based Telemedicine - Trauma & Acute Care Surgery" (EBT-TACS) Journal Club performed a critical appraisal of the literature and selected three relevant publications on the indications for PE in duodenal trauma. The first study retrospectively compared 14 cases of duodenal injuries greater than grade II treated by PE, with 15 cases repaired primarily, all of which penetrating. Results showed that PE did not improve outcome. The second study, also retrospective, compared primary repair (34 cases) with PE (16 cases) in blunt and penetrating grade > II duodenal injuries. The authors concluded that PE was not necessary in all cases. The third was a literature review on the management of challenging duodenal traumas. The author of that study concluded that PE is indicated for anastomotic leak management after gastrojejunostomies. In conclusion, the choice of the surgical procedure to treat duodenal injuries should be individualized. Moreover, there is insufficient high quality scientific evidence to support the abandonment of PE in severe duodenal injuries with extensive tissue loss.
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Affiliation(s)
- José Cruvinel Neto
- Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | | | | | - Gustavo Pereira Fraga
- Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
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29
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Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of duodenal injuries. J Trauma Acute Care Surg 2016; 79:1096-101. [PMID: 26680146 DOI: 10.1097/ta.0000000000000870] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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30
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Skipenko OG, Chekunov DA, Bedzhanyan AL, Bagmet NN. [External duodenal fistula]. Khirurgiia (Mosk) 2016. [PMID: 28635703 DOI: 10.17116/hirurgia2016886-88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- O G Skipenko
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - D A Chekunov
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - A L Bedzhanyan
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - N N Bagmet
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
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31
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Contemporary Management of Secondary Aortoduodenal Fistula. Ann Vasc Surg 2015; 29:1614-8. [DOI: 10.1016/j.avsg.2015.06.090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 06/23/2015] [Accepted: 06/28/2015] [Indexed: 11/20/2022]
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32
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Creation of a neopylorus after pyloric exclusion using a "double-endoscope" technique. Surg Endosc 2015; 30:3133-7. [PMID: 26487238 DOI: 10.1007/s00464-015-4573-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 09/19/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Pyloric exclusion may be implemented in the setting of a high-grade duodenal or pancreatic injury. After exclusion, the pylorus should spontaneously open in 3-6 weeks. However, we present the case of a critically ill 17-year-old male with a gunshot wound to the abdomen that underwent stapled pyloric exclusion with gastrostomy and jejunostomy tube placement who did not achieve pyloric patency after 5 months, and describe an innovative "double-endoscope" technique to correct it. METHODS A gastroscope was inserted through the mouth into the stomach, and an endoscope was inserted retrograde through the jejunostomy site to the duodenum. The closed pylorus was seen from both ends with transillumination. A needle knife was pushed through the membrane with clear visualization from the contralateral side. A balloon dilation catheter was then passed over a guidewire, and the neopylorus was sequentially dilated. A gastrojejunostomy tube was placed to ensure patency of the neopylorus. Postoperative imaging showed no evidence of leak or pneumoperitoneum. Serial endoscopic dilations were performed every 1-4 weeks to prevent restricturing. RESULTS The patient recovered well. After the first follow-up endoscopic dilation, he was eating a regular diet and had no retained food products. After four endoscopic dilations, the patient remained symptom free and the pylorus was widely patent. His gastrostomy and jejunostomy tubes were removed. CONCLUSIONS Here we presented a rare complication of pyloric exclusion and an innovative approach that used a "double-endoscope" technique and serial endoscopic dilations to establish and maintain a neopylorus, avoiding the morbidity of a major surgical procedure.
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33
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Siboni S, Benjamin E, Haltmeier T, Inaba K, Demetriades D. Isolated Blunt Duodenal Trauma: Simple Repair, Low Mortality. Am Surg 2015. [DOI: 10.1177/000313481508101010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Optimal surgical management of traumatic duodenal injury (DI) remains controversial. The National Trauma Data Bank was queried for all blunt trauma patients with DI. Patients with isolated injury were identified by excluding chest and head Abbreviated Injury Score > 3 and non-duodenal intra-abdominal Organ Injury Scale ≥ 3. Demographics, OIS, and operative intervention were collected. Outcomes included mortality and hospital length of stay (HLOS). During the study period, 3,456,098 blunt trauma patients were entered into the National Trauma Data Bank, 388,137 of which had abdominal trauma. Overall, 1.0 per cent patients with abdominal trauma had DI with isolated DI in only 0.6 per cent (n = 2220). The majority of isolated DI was low grade with only 158 patients sustaining severe injury and overall mortality was 5.2 per cent. Overall 743 patients were operated, of which 353 (47.5%) patients underwent duodenal operation, 280 (37.7%) had primary repair (PR), and 68 (9.2%) had gastroenterostomy (GE). Patients with PR had similar mortality to those with GE (6.6% vs 4.5%, P = 0.777); however, HLOS was shorter (median 11 days, vs 18 days, P < 0.001). In only OIS 4 and 5 injuries, PR was also associated with shorter HLOS ( P = 0.004) and similar mortality ( P = 1.000) when compared with GE. Isolated DI after blunt abdominal trauma is rare. In severe injuries, PR is associated with a shorter HLOS without effecting mortality when compared with GE.
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Affiliation(s)
- Stefano Siboni
- From the Division of Trauma and Acute Care Surgery, Los Angeles County Medical Center, University of Southern California, Los Angeles, California
| | - Elizabeth Benjamin
- From the Division of Trauma and Acute Care Surgery, Los Angeles County Medical Center, University of Southern California, Los Angeles, California
| | - Tobias Haltmeier
- From the Division of Trauma and Acute Care Surgery, Los Angeles County Medical Center, University of Southern California, Los Angeles, California
| | - Kenji Inaba
- From the Division of Trauma and Acute Care Surgery, Los Angeles County Medical Center, University of Southern California, Los Angeles, California
| | - Demetrios Demetriades
- From the Division of Trauma and Acute Care Surgery, Los Angeles County Medical Center, University of Southern California, Los Angeles, California
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34
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Sul YH, Cheon KS, Jang CE, Lee KH, Lee SI, Song IS. Isolated Duodenal Injury following Blunt Abdominal Trauma. JOURNAL OF TRAUMA AND INJURY 2015. [DOI: 10.20408/jti.2015.28.1.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Young Hoon Sul
- Department of Surgery, Eulji University Hospital, Daejeon, Korea
| | - Kwang Sik Cheon
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Chang Eun Jang
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Kyung Ha Lee
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Sang Il Lee
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - In Sang Song
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
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35
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Singh B, Kaur A, Singla AL, Kumar A, Yadav M. Combined gastric and duodenal perforation through blunt abdominal trauma. J Clin Diagn Res 2015; 9:PD30-2. [PMID: 25738037 DOI: 10.7860/jcdr/2015/11206.5499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 12/20/2014] [Indexed: 11/24/2022]
Abstract
Blunt abdominal traumas are uncommonly encountered despite their high prevalence, and injuries to the organ like duodenum are relatively uncommon (occurring in only 3%-5% of abdominal injuries) because of its retroperitoneal location. Duodenal injury combined with gastric perforation from a single abdominal trauma impact is rarely heard. The aim of this case report is to present a rare case of blunt abdominal trauma with combined gastric and duodenal injuries.
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Affiliation(s)
- Bimaljot Singh
- Junior Resident, Department of Surgery, Government Medical College and Rajindra Hospital , Patiala , Punjab, India
| | - Adarshpal Kaur
- Senior Resident, Department of Surgery, Government Medical College and Rajindra Hospital , Patiala , Punjab, India
| | - Archan Lal Singla
- Assistant Professor, Department of Surgery, Government Medical College and Rajindra Hospital , Patiala , Punjab, India
| | - Ashwani Kumar
- Professor, Department of Surgery, Government Medical College and Rajindra Hospital , Patiala , Punjab, India
| | - Manish Yadav
- Junior Resident, Department of Surgery, Government Medical College and Rajindra Hospital , Patiala , Punjab, India
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36
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37
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Motor vehicle collision patient with simultaneous duodenal transection and thoracic aorta injury: a case report and review of the literature. Case Rep Surg 2015; 2015:519836. [PMID: 25688322 PMCID: PMC4321849 DOI: 10.1155/2015/519836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 01/12/2015] [Indexed: 11/28/2022] Open
Abstract
Blunt polytrauma can present complex management decisions. Here we report the case of a 31-year-old male involved in a high speed motor vehicle collision resulting in both duodenal and thoracic aorta injury that was managed collaboratively between the trauma, vascular, and cardiothoracic surgical teams. The patient went on to a full recovery. We also review the management of such injuries which has evolved over the past two decades resulting in less morbidity and mortality.
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38
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Bankar SS, Gosavi VS, Hamid M. Duodenal Transection without Pancreatic Injury following Blunt Abdominal Trauma. J Surg Tech Case Rep 2015; 6:67-9. [PMID: 25598947 PMCID: PMC4290044 DOI: 10.4103/2006-8808.147264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
With the inventions of faster cars and even more faster motorbikes there is a worldwide increase in road traffic accidents, which has increased the incidence of blunt abdominal trauma but still duodenal injury following a blunt abdominal trauma is uncommon and can pose a formidable challenge to the surgeon and failure to manage it properly can result in devastating results. It may typically occur in isolation or with pancreatic injury. Here, we report a case of an isolated transection of the third part of the duodenum with normal pancreas following a blunt abdominal trauma. The initial clinical changes in isolated duodenal injury may be extremely subtle before life-threatening, peritonitis develops. Hence, a high index of suspicion, on the basis of mechanism of injury and physical examination is the key in early detection of duodenal injury especially in a rural hospital like ours where the facilities for computed tomography scan are not available.
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Affiliation(s)
| | - Vikas S Gosavi
- Department of General Surgery, Government Medical College, Miraj, India
| | - Mohd Hamid
- Department of General Surgery, Government Medical College, Miraj, India
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39
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van der Wilden GM, Yeh DD, Hwabejire JO, Klein EN, Fagenholz PJ, King DR, de Moya MA, Chang Y, Velmahos GC. Trauma Whipple: do or don’t after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB). World J Surg 2014; 38:335-40. [PMID: 24121363 DOI: 10.1007/s00268-013-2257-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy for trauma (PDT) is a rare procedure, reserved for severe pancreaticoduodenal injuries. Using the National Trauma Data Bank (NTDB), our aim was to compare outcomes of PDT patients to similarly injured patients who did not undergo a PDT. METHODS Patients with pancreatic or duodenal injuries treated with PDT (ICD-9-CM 52.7) were identified in the NTDB 2008–2010 Research Data Sets. We excluded those who underwent delayed PDT (>4 days). The PDT group (n = 39) was compared to patients with severe combined pancreaticoduodenal injuries (grade 4 or 5) who did not undergo PDT (non-PDT group, n = 38). Patients who died in the emergency department or did not undergo a laparotomy were excluded. Our primary outcome was death. Secondary outcomes were intensive care unit length of stay (LOS), hospital LOS, and total ventilator days. A multivariate model was used to determine predictors of in-hospital mortality within each group and in the overall cohort. RESULTS The non-PDT group had a significantly lower systolic blood pressure and Glasgow Coma Scale values at baseline and more severe duodenal, pancreatic, and liver injuries. There were no significant differences in outcomes between the two groups. The Injury Severity Score was the only independent predictor of mortality among PDT patients [odds ratio (OR) 1.12, 95 % confidence interval (CI) 1.01–1.24] and in the entire cohort (OR 1.06, 95 % CI 1.01–1.12). The operative technique did not influence any of the outcomes. CONCLUSIONS Compared to non-PDT, PDT did not result in improved outcomes despite a lower physiologic burden among PDT patients. More conservative procedures for high-grade injuries of the pancreaticoduodenal complex may be appropriate.
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Sahoo SP, Pattanayak SP, Mallick SN, Nayak SK, Pramanik S. A modified approach to decompression of primary repair of the duodeno-jejunal flexure transection after blunt trauma. TRAUMA-ENGLAND 2014. [DOI: 10.1177/1460408614538943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Small bowel injuries in general are uncommon after blunt abdominal trauma and are usually due to high-energy deceleration injuries, often in relation to motor vehicle accidents and affect fixed segments such as duodenum, duodeno-jejunal (DJ) flexure, proximal jejunum and terminal ileum. High morbidity and mortality are associated with this type of injury when the diagnosis is delayed. Untimely management of such injuries, especially transection of the DJ flexure, results in high-output entero-cutaneous fistula. In total, eight cases of DJ flexure transection with/without associated multiple injuries were reviewed retrospectively. For DJ flexure transection in all cases, the flexure was adequately mobilised, and end-to-end duodenojejunostomy performed with two-layer interrupted sutures. A large calibre nasojejunal tube was placed through the anastomotic site before completion to protect the anastomotic area from the proteolytic action of large volumes of upper gastrointestinal secretions. In case of associated injuries, appropriate procedures were done. In DJ flexure transection, a timely management by end-to-end anastomosis with administration of nasojejunal tube beyond the site of anastomosis is an alternate, simple and safe procedure in comparison to difficult procedures such as pyloric exclusion and gastrojejunostomy in patients with delayed presentation.
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Affiliation(s)
- Sarada P Sahoo
- Department of Surgery, MKCG Medical College, Berhampur, Odisha, India
| | - Siba P Pattanayak
- Department of Surgery, MKCG Medical College, Berhampur, Odisha, India
| | - Sworupa N Mallick
- Department of Surgery, MKCG Medical College, Berhampur, Odisha, India
| | - Sanjit K Nayak
- Department of Surgery, MKCG Medical College, Berhampur, Odisha, India
| | - Subrata Pramanik
- Department of Surgery, MKCG Medical College, Berhampur, Odisha, India
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Revisiting the pancreaticoduodenectomy for trauma: a single institution's experience. J Trauma Acute Care Surg 2013; 75:225-8. [PMID: 23823615 DOI: 10.1097/ta.0b013e31829a0aaf] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Major pancreaticoduodenal injury can be devastating even if identified and controlled early. To date, both morbidity and mortality have resisted the improvements achieved with many other life-threatening injuries, with reported mortalities of 31% to 50%. We sought to elucidate the impact of the initial operation in the management of severe pancreaticoduodenal injury. METHODS A retrospective review of all patients presenting to a single Level I trauma center who required pancreaticoduodenectomy for trauma from 1996 to 2010 was performed. We collected demographic and in-hospital data and compared subjects based on their initial operation. RESULTS Fifteen patients (median age, 29 years; 93% male; median Injury Severity Score [ISS], 35) underwent pancreaticoduodenectomy following blunt (n = 5) or penetrating trauma (n = 10). Twelve patients (80%) underwent damage-control surgery (DCS) with or without the initial stage of Whipple resection as their first operation. Three patients (20%) underwent a complete Whipple procedure, including reconstruction, as their first operation. Overall, 87% of patients (13 of 15) were acidotic, hypothermic, and coagulopathic during their first operation. Average operative time was longer for the completion pancreaticoduodenectomy versus DCS (460 [98] minutes vs. 243 [112] minutes). There were no overall differences in complication rates, although the two patients who did not experience a complication had DCS. In-hospital mortality was 13% (n = 2). CONCLUSION We present both the largest series of patients to date who underwent a DCS or staged Whipple procedure for complex pancreaticoduodenal trauma and the largest series with blunt trauma. Using a staged approach, we report the lowest mortality rate for such injuries in the literature, less than half of that reported in the most recent series (33%). Given the frequent occurrence and recognized detrimental impact of acidosis, hypothermia, and coagulopathy in patients with severe pancreaticoduodenal trauma as well as the proven benefits of DCS, we propose that these patients should undergo initial DCS and staged reconstruction.
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Park JH, Hong SK, Song HY, Kim EK, Lee SK, Jung YJ. Abdominal wall defect with large duodenal disruption treated by a free tissue flap with a help of temporary expandable metallic stent. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 85:240-3. [PMID: 24266016 PMCID: PMC3834024 DOI: 10.4174/jkss.2013.85.5.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/20/2013] [Accepted: 06/03/2013] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Jung-Hoon Park
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kutlu OC, Garcia S, Dissanaike S. The successful use of simple tube duodenostomy in large duodenal perforations from varied etiologies. Int J Surg Case Rep 2012; 4:279-82. [PMID: 23357008 DOI: 10.1016/j.ijscr.2012.11.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 11/21/2012] [Accepted: 11/29/2012] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Tube decompression of the duodenum is an old but underutilized technique known to decrease morbidity and mortality in patients with difficult to manage duodenal injuries. Broad arrays of techniques have been described in the literature and are reviewed, but most are complex procedures not appropriate for the management of an unstable patient. PRESENTATION OF CASE In this paper we describe the technique of tube duodenostomy and the successful application in three cases of large defects (>3cm) which two of these cases had failed previous repair attempts. The defects were caused by very different etiologies, including blunt trauma, peptic ulcer disease and erosion from cancer. All were finally managed by application of tube duodenostomy with success. DISCUSSION Patients with "difficult to manage duodenum" usually present with hemodynamic instability with hostile abdomen. Complex procedures in an unstable patient are associated with adverse outcomes. In patients with significant comorbidities and instability the damage control principle of trauma surgery is gaining popularity. Tube duodenostomy technique described in this paper fits in well with that principle. CONCLUSION Application of tube duodenostomy instead of a complex procedure in an unstable patient provides an opportunity to stabilize the patient, converting an impending catastrophe to a future scheduled surgery.
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Affiliation(s)
- Onur C Kutlu
- Department of Surgery, Texas Tech University Health Sciences Center, United States
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Fujikuni N, Tanabe K, Yamamoto H, Suzuki T, Tokumoto N, Ohdan H. Triple-tube-ostomy: a novel technique for the surgical treatment of iatrogenic duodenal perforation. Case Rep Gastroenterol 2011; 5:672-9. [PMID: 22235196 PMCID: PMC3254034 DOI: 10.1159/000335742] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Although duodenal perforation is currently an infrequent complication of medical procedures, its incidence in the future predictably will increase as endoscopic treatment of duodenal neoplasms becomes more frequently used. In some cases, duodenal perforation is difficult to treat even surgically. We report here a novel technique called ‘triple-tube-ostomy’ for the treatment of iatrogenic duodenal perforation. Since November 2009, there have been three cases of iatrogenic perforation of the duodenum, due to various causes, which we have treated with our novel technique. The main principles of the technique are biliary diversion, decompression of the duodenum, and early enteral nutrition. All patients who underwent the triple-tube-ostomy procedure had good postoperative courses, with few complications. The novel surgical technique we describe in this report is safe, reliable, easy to learn and perform, and led to a good postoperative course in all cases where we performed it.
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Affiliation(s)
- Nobuaki Fujikuni
- Department of Surgery, Division of Frontier Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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Celik A, Altinli E, Koksal N, Onur E, Sumer A, Uzun MA, Kayahan M. Management of isolated duodenal rupture due to blunt abdominal trauma: case series and literature review. Eur J Trauma Emerg Surg 2010; 36:573-8. [PMID: 26816313 DOI: 10.1007/s00068-010-0055-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Accepted: 09/20/2010] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Duodenal injuries are uncommon and are associated with significant morbidity and mortality due to delayed diagnosis (in the case of blunt trauma) or associated major vascular injuries (in the case of penetrating trauma). Isolated blunt injuries may have a subtle clinical presentation, and are particularly difficult to diagnose when the perforation is located in the retroperitoneal part of the duodenum. MATERIALS AND METHODS This paper presents in company with three cases of successfully treated isolated duodenal injuries due to blunt trauma, focusing on with their preoperative diagnosis, surgical management and final out comes. CONCLUSIONS Early diagnosis and successful surgical planning require experience and clinical suspicion on the part of the surgeon, as well as meticulous laparotomy results.
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Affiliation(s)
- A Celik
- 2nd Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey. .,Libadiye Cad. Soyak Goztepe Sitesi, 46. Blok, D: 813, Uskudar, 34700, Istanbul, Turkey.
| | - E Altinli
- 2nd Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - N Koksal
- 2nd Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - E Onur
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - A Sumer
- Department of General Surgery, Yuzuncu Yil University, Van, Turkey
| | - M Ali Uzun
- 2nd Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - M Kayahan
- 2nd Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
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Kambaroudis A, Antoniadis N, Papadopoulos S, Spiridis C, Gerasimidis T. Reconstruction of a traumatic duodenal transection with a pedicled ileal loop: a case report. J Med Case Rep 2010; 4:343. [PMID: 20977717 PMCID: PMC2987957 DOI: 10.1186/1752-1947-4-343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 10/26/2010] [Indexed: 12/03/2022] Open
Abstract
Introduction Blunt duodenal injuries do not occur often. A patient with damage to the duodenal tissue around the pancreatic and common bile duct presents a challenge to surgeons. The choice of procedure must be tailored to the nature of the defect and the amount of tissue lost. Case presentation We describe the case of a 16-year-old Caucasian boy with a blunt duodenal injury after a motor vehicle accident. On admission, the patient had stable vital signs and a normal laboratory workup. Gradually his clinical condition deteriorated and a computed tomography scan showed a retroperitoneal haematoma at the level of his duodenum. A fully circumferential rupture of the second part of his duodenum was found during laparotomy, with the intact Vater's papilla lying adjacent to the defect and a superficial laceration of the head of his pancreas. The retroperitoneal haematoma was thoroughly drained and a pedicled ileal loop was interposed between the duodenal stumps to restore the continuity of the patient's duodenum. Apart from a mild postoperative pancreatitis, the patient's postoperative course evolved with no further problems. The patient was discharged on the 22nd postoperative day in excellent condition and has remained so to date (after five years). Conclusion In our case report, where the second part of the patient's duodenum was completely transected, our choices for reconstruction were limited. Important factors for the successful management of this patient were prompt surgical intervention and the accurate assessment of the nature of the duodenal and associated injuries. We believe that the technique we used was a reasonable choice because the anatomical continuity of the patient's duodenum was restored.
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Affiliation(s)
- Apostolos Kambaroudis
- 5th Surgical Clininc, Hippokrateion General Hospital, 49 Konstantinoupoleos str,, P,O, 54642, Thessaloniki, Greece.
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Cruz RJ, Vincenzi R. Modified duodenal diverticulization technique for the management of duodenal fistulas. Am J Surg 2010; 199:e29-33. [DOI: 10.1016/j.amjsurg.2009.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2008] [Revised: 03/31/2009] [Accepted: 04/06/2009] [Indexed: 10/20/2022]
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Controlled tube duodenostomy in the management of giant duodenal ulcer perforation: a new technique for a surgically challenging condition. Am J Surg 2009; 198:319-23. [PMID: 19306982 DOI: 10.1016/j.amjsurg.2008.09.028] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 09/23/2008] [Accepted: 09/23/2008] [Indexed: 12/22/2022]
Abstract
BACKGROUND Giant duodenal ulcer (GDU) perforation remains an extremely uncommon but a rather challenging condition to manage wherein routine surgical procedures are fraught with an extremely high incidence of failure and mortality. It therefore follows that this condition must be identified and managed differently at laparotomy than are most duodenal perforations. We describe a method by which to deal with this condition using triple-tube-ostomy. METHODS In a prospective setting, 20 patients underwent surgery using the technique described in the article. During the same period, 20 patients with GDU perforation, who were managed in the conventional manner, were evaluated. The outcomes of the 2 groups were compared. RESULTS The success rate was 100% in the study group compared with 30% in the control patients. CONCLUSIONS Based on the ease of the technique and the high success of the procedure in our experience in this select group, we recommend this procedure for the management of GDU perforation as a safe, reliable, and easy technique to learn.
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Abstract
BACKGROUND Complex duodenal injury remains a challenging problem for the trauma surgeon. Although primary repair of small injuries is often possible, extensive damage requires complex enteric reconstruction and drainage procedures. We sought to determine the efficacy of a bioprosthetic repair for large duodenal wounds in a porcine model. METHODS A 60% circumferential wall defect in the second portion of the duodenum was created in eight female Yorkshire swine (38 kg +/- 5 kg). After 30 minutes of peritoneal soilage, a bioprosthetic repair using 1.5 mm porcine acellular dermal matrix was performed. Animals were recovered and resumed a normal diet on day 3. Repeat abdominal exploration and anastomotic bursting pressure strength was performed at 1-, 2-, 3-, and 6-week intervals. Pathologic analysis of all specimens was performed. RESULTS All animals tolerated a normal diet postoperatively, with progressive weight gain and normal bowel function. On re-exploration, no animal had evidence of duodenal stenosis, proximal dilation, or abscess formation. Pathologic analysis demonstrated progressive in-growth of native bowel tissue, with almost complete incorporation at 6 weeks. Mean bursting pressure (202 mm Hg +/- 60 mm Hg) occurred at native bowel, not patch repair site, in three of eight animals. CONCLUSION Bioprosthetic repair of enteric wall defects, even in proximity to upper intestinal secretions, allows successful recovery of bowel function and injury repair without extensive anatomic reconstruction. This technique may provide a more conservative approach to the treatment of complex duodenal injuries after trauma.
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Milias K, Deligiannidis N, Papavramidis TS, Ioannidis K, Xiros N, Papavramidis S. Biliogastric diversion for the management of high-output duodenal fistula: report of two cases and literature review. J Gastrointest Surg 2009; 13:299-303. [PMID: 18825468 DOI: 10.1007/s11605-008-0677-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Accepted: 08/20/2008] [Indexed: 01/31/2023]
Abstract
High-output duodenal fistula occurs as a result of a duodenal wall defect caused by gastroduodenal surgery, endoscopic sphincterotomy, duodenal injury, and tumors with high morbidity and mortality rate. A new technique for its management is reported along with literature review. This procedure consists of transection of the duodenum 2 cm distally to the pylorus, transection of the common bile duct, and end duodenostomy with or without suturing the duodenal wall defect. The continuity of the alimentary tract is reinstated by an end-to-end duodenojejunostomy, end-to-side choledochojejunostomy, and end-to-side Roux-en-Y jejunojejunostomy, obtaining biliogastric diversion from the duodenum and closure of the fistula. This technique was performed in two patients with excellent results.
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Affiliation(s)
- Konstantinos Milias
- 2nd Surgical Department, 424 General Military Hospital, Thessaloniki, Greece.
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