Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of duodenal injuries

Blunt and Penetrating Injury to the Bowel: A Review

Traumatic injuries to the small and large bowel are common and can be highly morbid. Identifying these injuries, especially in stable patients who suffer blunt trauma, can be challenging. It is critical that traumatic bowel injuries are diagnosed in a timely fashion as delays in diagnosis and treatment are associated with worse outcomes. The literature outlining the management of traumatic bowel injuries is mostly comprised of retrospective data and case reports/series. We have compiled the existing literature and relevant guidelines into a single resource for providers who care for traumatically injured patients.

The Diagnosis and Management of Pediatric Blunt Abdominal Trauma-A Comprehensive Review

Blunt abdominal trauma in childhood has always been full of diagnostic and therapeutic challenges that have tested the clinical and radiological skills of pediatric surgeons and radiologists. Despite the guidelines and the studies carried out so far, to this day, there is no absolute consensus on certain points of view. Around the world, a paradigm shift towards non-operative treatment of hemodynamically stable children, with low complication rates, is noticeable. Children with blunt abdominal trauma require a standardized methodology to provide the best possible care with the best possible outcomes. This comprehensive review systematizes knowledge about all aspects of caring for children with blunt abdominal trauma, from pre-hospital to post-hospital care.

Trends in Duodenal Injury Severity, Repair, and Mortality Over Time

INTRODUCTION

Outcomes for patients with traumatic duodenal injury are determined by the location of the injury, injury severity, and associated injuries. We hypothesized that there is an association among the increased frequency of firearm injuries, the severity of duodenal injuries, trends in repair techniques, and mortality.

METHODS

Duodenal injuries managed at an adult level 1 hospital from 2000 to 2022 were identified. Demographics, injury type, the American Association for the Surgery of Trauma (AAST) grade, type of surgical repair, and mortality data were obtained and aggregated into two periods (2000 to June 2011 and July 2011 to 2022) to evaluate trends over time. P values < 0.05 were considered significant.

RESULTS

One hundred eighty eight cases were identified. Duodenal injuries due to firearms increased over time (30% versus 55%, P < 0.001). The distribution of AAST injury grade shifted over time with fewer grade 1 and more grade 2 to 4 injuries in the later period (P = 0.002). AAST grade 2 injuries or higher were more likely due to firearms (P < 0.001). Despite more high-grade injuries, there was no change in the use of primary repair with or without tube drainage (61% versus 70%, P = 0.35) and there was no change in mortality (15% versus 17%, P value 0.62) between the time periods.

CONCLUSIONS

There was a proportional increase in the number of duodenal injuries caused by firearms. Higher grade duodenal injuries were more common with firearm injuries and were predominately repaired with simple techniques with no increase in mortality.

Endoscopic repair of duodenal perforations, a scoping review

BACKGROUND

There is a discrepancy in the surgical and endoscopic literature for managing duodenal perforations. Although often managed conservatively, surgical repair is the standard treatment for duodenal perforations. This contrasts with the gastroenterology literature, which now recommends endoscopic repair of duodenal perforations, which are more frequently iatrogenic from the growing field of advanced endoscopic procedures. This study aims to provide a scoping review to summarize the current literature content and quality on endoscopic repair of duodenal perforations.

METHODS

The protocol for performing this scoping review was outlined by the Joanna Briggs Institute. All studies that reported primary outcomes of patients who had undergone endoscopic repair of duodenal perforations before February 2022, regardless of perforation etiology or repair type were reviewed, with studies after 1999 meeting inclusion criteria. The study excluded articles that did not report clinical outcomes of endoscopic repair, articles that did not describe where in the gastrointestinal tract the endoscopic repair occurred, pediatric patients, and animal studies.

RESULTS

7606 abstracts were screened, with 474 full articles reviewed and 152 studies met inclusion criteria. 560 patients had duodenal perforations repaired endoscopically, with a technical success rate of 90.4% and a survival rate of 86.7%. Most of these perforations (74.5%) were iatrogenic from endoscopic procedures or surgery. Only one randomized control trial (RCT) was found, and 53% of studies were case reports.

CONCLUSION

These results suggest that endoscopic repair could emerge as a viable first-line treatment for duodenal perforation and highlight the need for more high-quality research in this topic.

Surgical management of duodenal injury: experience from 92 cases

PURPOSE

Duodenal injury increases with traffic accidents, and delayed diagnosis or inappropriate operation increase mortality and complications. This study aimed to explore early recognition and timely surgical intervention.

METHODS

All patients with duodenal injuries treated operatively during the past 10 years were reviewed, and the data were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome.

RESULTS

A total of 92 patients with duodenal injuries accounted for 7.3% of 1258 patients with abdominal injury. Of the 92 patients, 71 (77.17%) experienced blunt trauma, with traffic accidents accounting for 59.2% (42/71). In 35 patients, a preoperative diagnosis was obtained by reviewing abdominal signs, peritoneocentesis, and imaging. The remaining 57 patients underwent urgent laparotomy, through which a definitive diagnosis of duodenal injury was confirmed during the operation. In all 92 patients, the surgical procedures involved simple sutures; pedicled jejunal piece coverings; and various anastomoses following resection of the injured duodenal portion, including the Whipple procedure and damage-control surgery principles. The overall mortality rate was 12.0% (11/92) with deaths mainly occurring due to associated injuries. When excluding 2 cases of intraoperative death, there were 47 cases in the double-tube gastrostomy group and 43 cases in the traditional triple-tube group, with mortality rates of 10.64% and 9.30% in the two groups, respectively (χ2 = 0.045, P > 0.05). Postoperative complications occurred in 15 patients (18.5%). There was a high incidence of duodenal (or pancreatic/biliary) leakage.

CONCLUSION

Early diagnosis and operation of duodenal injury are crucial to reducing complications and mortality. Surgical methods should be based on injury grade, associated injuries, and vital signs. Double-tube gastrostomy can reduce complications such as intestinal obstruction.

Management of Complex Duodenal Injuries After Penetrating Trauma

Penetrating injuries to the duodenum can present a complex case for trauma or acute care surgeons. The associated injuries and complications can have devastating results. This report presents the case of a 41-year-old male who presented with a gunshot wound to his abdomen and suffered a gastric injury, transverse colon injury, duodenal injury, renal injury, and pancreatic tail injury. In this case, the patient underwent a complex Roux-en-Y reconstruction. The patient had a good outcome and continues to recover at home.

Management of the complex duodenal injury

INTRODUCTION

Complex duodenal trauma is a rare injury with an incidence of 1-4.7% of all abdominal trauma. Historically, varied approaches have been used in the management of these complex injuries and the prevention of complications. This is a review of the current management methodology of complex duodenal injury.

METHODS

A review of the medical literature to include the past and current management of duodenal trauma was performed. Google scholar (1970-2022) and PubMed (1970-2022) were searched using the keywords: complex duodenal trauma, surgical management, and duodenal complications.

DISCUSSION

Complex duodenal trauma can be classified using the AAST grading scale as those encompassing grades III-V. Multiple studies and review articles characterize the difficulty in managing complex duodenal injuries. The tenets of operative management of duodenal trauma include the decision for damage control, resection of non-viable tissue, restoring gastrointestinal continuity, diversion of gastrointestinal contents, bile and pancreatic enzymes, allowing the repair to heal, and providing feeding access. The variety of both historic and current approaches attempt to address these tenets. The incidence of complications are as high as 65% with the most common complications including abscess formation, suture line dehiscence and fistula formation. The overall mortality ranges from 5 to 30%.

CONCLUSIONS

Many different approaches and strategies have been proposed to repair complex duodenal injuries, all of which address important tenets of its management. The risk of complications remains high, therefore, it is vital to have a thoughtful and multidisciplinary approach when treating these injuries.

"Repair by Primary Closure of Traumatic Blunt Duodenal Injuries: Simple is Not Always Safe"

INTRODUCTION

Recent literature on managing traumatic duodenal injuries suggests the superiority of primary repair. We hypothesized that duodenal trauma repair by primary closure might not be a safe strategy in an environment dealing predominantly blunt injuries with limited resources.

METHODS

Data analysis was done from the prospectively maintained trauma registry. The study period chosen was from January 1, 2014 to December 31, 2018. Data of 63 patients were analyzed for demographics, injuries, management, and outcome. Logistic regression was used to identify mortality predictors.

RESULTS

The most common mechanism of injury was blunt (56/63, 88.9%). Forty (63.5%) patients had associated intraabdominal injuries. The most common American Association for the Surgery of Trauma grade of injury to the duodenum was three in 21 patients. Univariate analysis showed that mortality was associated with hypotension on presentation, higher duodenal grade, associated abdominal vascular injuries, primary closure, and duodenal leak. Logistic regression showed associated associated abdominal vascular injuries, primary closure, and leak remained significant predictors of mortality.

CONCLUSIONS

Primary repair was found to be an independent predictor of mortality. A patient's physiology is a critical determinant of the outcome. Liberal use of tube duodenostomy over primary repair seems reasonable for blunt duodenal injury management.

Retrospective analysis of different therapeutic approaches for retroperitoneal duodenal perforations

Surgical therapy of duodenal perforation into the retroperitoneum entails high morbidity. Conservative treatment and endoscopic negative pressure therapy have been suggested as promising therapeutic alternatives. We aimed to retrospectively assess outcomes of patients treated for duodenal perforation to the retroperitoneum at our department. A retrospective analysis of all patients that were treated for duodenal perforation to the retroperitoneum at our institution between 2010 and 2021 was conducted. Different therapeutic approaches with associated complications within 30 days, length of in-hospital stay, number of readmissions and necessity of parenteral nutrition were assessed. We included thirteen patients in our final analysis. Six patients underwent surgery, five patients were treated conservatively and two patients received interventional treatment by endoscopic negative pressure therapy. Length of stay was shorter in patients treated conservatively. One patient following conservative and surgical treatment each was readmitted to hospital within 30 days after initial therapy whereas no readmissions after interventional treatment occurred. There was no failure of therapy in patients treated without surgery whereas four (66.7%) of six patients required revision surgery following primary surgical therapy. Conservative and interventional treatment were associated with fewer complications than surgical therapy which involves high morbidity. Conservative and interventional treatment using endoscopic negative pressure therapy in selected patients might constitute appropriate therapeutic alternatives for duodenal perforations to the retroperitoneum.

Diagnosis and treatment of traumatic duodenal rupture in children

Background

The purpose of this study was to investigate the diagnosis and treatment experience of traumatic duodenal ruptures in children.

Methods

Clinical data were collected from four children suffering from a traumatic duodenal rupture who were admitted to and treated by our hospital from January 2012 to December 2020. The early diagnosis and treatment, surgical plan, postoperative management, complications, and prognosis of each child were analyzed. The key points and difficulties of the diagnosis and treatment for this type of injury are summarized.

Results

One child had an extreme infection caused by drug-resistant bacteria, which resulted in severe complications, including wound infection, dehiscence, and an intestinal fistula. One child developed an anastomotic stenosis after the duodenostomy, which improved following an endoscopic balloon dilatation. The other two children had no relevant complications after their operations. All four patients were cured and discharged from hospital. The average hospital stay was 48.25 ± 26.89 days. The follow-up period was 0.5 to 1 year. No other complications occurred, and all children had a positive prognosis.

Conclusions

The early identification of a duodenal rupture is essential, and surgical exploration should be carried out proactively. The principles of damage-control surgery should be followed as much as possible during the operation. Multidisciplinary cooperation and management are both important to reduce the occurrence of postoperative complications and improve cure rates.

Review of Traumatic Duodenal Injuries: Etiology, Diagnosis, and Management

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.

Pancreas sparing duodenectomy in the treatment of primary duodenal neoplasms and other situations with duodenal involvement

BACKGROUND

There are no clearly defined indications for pancreas-preserving duodenectomy. The present study aimed to analyze postoperative morbidity and the outcomes of patients undergoing pancreas-preserving duodenectomy.

METHODS

Patients undergoing pancreas-preserving duodenectomy from April 2008 to May 2020 were included. We divided the series according to indication: scenario 1, primary duodenal tumors; scenario 2, tumors of another origin with duodenal involvement; and scenario 3, emergency duodenectomy.

RESULTS

We included 35 patients. Total duodenectomy was performed in 1 patient of adenomatous duodenal polyposis, limited duodenectomy in 7, and third + fourth duodenal portion resection in 27. The indications for scenario 1 were gastrointestinal stromal tumor (n = 13), adenocarcinoma (n = 4), neuroendocrine tumor (n = 3), duodenal adenoma (n = 1), and adenomatous duodenal polyposis (n = 1); scenario 2: retroperitoneal desmoid tumor (n = 2), recurrence of liposarcoma (n = 2), retroperitoneal paraganglioma (n = 1), neuroendocrine tumor in pancreatic uncinate process (n = 1), and duodenal infiltration due to metastatic adenopathies of a germinal tumor with digestive hemorrhage (n = 1); and scenario 3: aortoenteric fistula (n = 3), duodenal trauma (n = 1), erosive duodenitis (n = 1), and biliopancreatic limb ischemia (n = 1). Severe complications (Clavien-Dindo ≥ IIIb) developed in 14% (5/35), and postoperative mortality was 3% (1/35).

CONCLUSIONS

Pancreas-preserving duodenectomy is useful in the management of primary duodenal tumors, and is a technical option for some tumors with duodenal infiltration or in emergency interventions.

The Frequency of Parenchimatous Lesions in Patients with Traumatic Retroperitoneal Hematoma

Objective: The retroperitoneum represent the anatomical region with the highest mortality rates, in which lesions in this region need special relevance. The aim of this study is to find out the frequency of different parenchimatous injuries related to different zones.

Methods: In this retrospective study, all cases who presented to the emergency room and/or admitted to our center with retroperitoneal hematoma (RPH) complicated with parenchimatous lesions from January 2016 to December 2019 were included (4-years data). Data collected included age, hematoma zones, the production mechanisms, mortality, surgical interventions, parenchymatous lesions, complications and biochemical and hematological analysis (e.g. hemoglobin (Hb), hematocrit (Ht), platelets (PLT), leukocytes (Leu), aspartate aminotransferase level (AST), alanine aminotransferase level (ALT) and creatinine (Cr). All RPHs were diagnosed using computed tomography scan.

Results: A total number of 119 RPH cases with parenchimatous lesions were included with a mean age of 45.56±2.52. The most common type of RPH was located in lateral zone (zone II) with 65 cases, followed by pelvic zone (zone III) with 36 cases. The main production mechanism for parenchimatous lesions was by road accident (n=57). The highest prevalence of parenchimatous lesions was seen in both lung and splenic lesions (n=54), followed by liver lesion (n=36) and kidney lesions (n=11), without any statistical significance. The complications showed a statistical significance when 2016 year was compare with 2018 (p=0.013). Regarding the biochemical and hematological analysis, a statistical significance was seen at PLT (when 2016 was compared with 2017, p=0.03 and 2018, p=0.008). Only 67 patients were treated by surgical interventions, and the highest mortality was registered in 2019 (n=11).

Conclusion: There is a lack of evidence in the frequency of different parenchimatous lesions in RPH cases. We conclude on the basis of our study that mandatory exploration of zone II and III haematoma in parenchimatous lesions should be early diagnosed in order to reduce the morbidity and mortality of the patients.

Contemporary Management of Traumatic Duodenal Injuries

BACKGROUND

Traumatic duodenal injury is a rare, potentially devastating condition with challenging management decisions. Contemporary literature on operative management of duodenal injury is lacking. The purpose of this study is to assess optimal management strategies based on outcomes of patients with traumatic duodenal injury at a single trauma center.

METHODS

A retrospective study of patients with traumatic duodenal injury from 2013-2020 at a level 1 trauma center was performed. Patient demographics, grade of injury as noted on CT scan or intraoperatively, surgical procedure(s) performed, and resultant outcomes were extracted.

RESULTS

After excluding one patient due to death on arrival, 23 patients met inclusion criteria. Injuries consisted of grade 1 (n = 7), grade 2 (n = 2), grade 3 (n = 12), and grade 5 (n = 2); there were no grade 4 injuries. Patients were predominantly male (83%) with a median age of 30 years old. Nineteen patients (82%) underwent surgery. Four of nine patients (44%) with grade 1/2 injuries had hematomas and were managed non-operatively. The remaining five patients (56%) with grade 1/2 injuries underwent operation, which included primary repair (n = 3), duodenal exclusion (n = 1), and periduodenal drainage (n = 1). Of 12 patients with grade 3 injury, 6 underwent primary repair and 6 underwent resection. Three patients who underwent primary repair and one who underwent resection developed a duodenal leak. All patients with grade 5 injury (n = 2) underwent pancreaticoduodenectomy.

CONCLUSION

Grade 1 and 2 duodenal hematomas can be managed non-operatively, while lacerations require operative repair. Outcomes may be better following resection in patients with grade 3 injury.

Duodenal Laceration Due to Blunt Trauma Caused by Horse Kick: A Case Report and Literature Review

Patient: Male, 13-year-old

Final Diagnosis: Duodenal laceration

Symptoms: Abdominal pain • diffuse abdominal pain

Medication: —

Clinical Procedure: Laparotomy

Specialty: Surgery

Combined stomach and duodenal perforating injury following blunt abdominal trauma: a case report and literature review

Background

Gastrointestinal injury following blunt abdominal trauma is uncommon; a combined stomach and duodenal perforating injury is even more rare. Because these two organs are located in different spaces in the abdomen, such injuries are difficult to identify.

Case presentation

A young woman involved in a motor vehicle crash presented to our emergency department with concerns of severe peritonitis. Contrast-enhanced computed tomography of the abdomen revealed pneumoperitoneum and retroperitoneal hematoma in zone 1. An emergency laparotomy was performed, revealing a stomach-perforating injury, which was resolved with primary repair. No obvious injury was observed on retroperitoneal exploration. However, peritonitis presented again on the second postoperative day, and a second laparotomy was performed, revealing a duodenum-perforating injury in its third portion. We performed primary repair with multi-tube-ostomy. The patient recovered well without permanent tube placement or internal bypass.

Conclusions

Assessing associated injuries in blunt abdominal trauma is crucial because they may be fatal if timely intervention is not undertaken. These types of complicated injuries require a feasible surgical strategy formulated by experienced surgeons, which gives the patient a better chance of survival.

Imaging findings and clinical features of atypical retroperitoneal abscess caused by duodenal perforation: a case report and review of the literature

Introduction

A retroperitoneal abscess caused by duodenal perforation is a relatively rare disease clinically. We report the case of a patient with a local high-density shadow at the head of the retroperitoneal pancreas.

Case presentation

A 28-year-old Chinese man presented with fever and abdominal pain after overeating and heavy drinking. On physical examination, he had mild tenderness in his upper abdomen. Laboratory examination results showed a white blood cell count of 24.06 10⁹/L and a neutrophil absolute value of 18.81 10⁹/L, and a computed tomography scan showed an irregular soft tissue mass with uneven enhancement of the cystic wall in the retroperitoneal space. Gastroscopy showed that there was a fistula in the anterior wall of the duodenal bulb. Endoscopic anastomosis clip system (over-the-scope clip) of the duodenal fistula was performed successfully. After the operation, nasal feeding was provided with a nutrition tube, and empiric anti-infection, acid-inhibiting, and stomach-protecting treatments were administered. Our patient’s body temperature gradually returned to normal, and his abdominal pain decreased.

Conclusions

A retroperitoneal abscess caused by duodenal perforation can be diagnosed by clinical symptoms and abdominal computed tomography imaging. The choice of treatment should be based on accurate and timely clinical and imaging data.

Management of duodenal trauma: A retrospective review from the Panamerican Trauma Society

INTRODUCTION

The operative management of duodenal trauma remains controversial. Our hypothesis is that a simplified operative approach could lead to better outcomes.

METHODS

We conducted an international multicenter study, involving 13 centers. We performed a retrospective review from January 2007 to December of 2016. Data on demographics, mechanism of trauma, blood loss, operative time, and associated injured organs were collected. Outcomes included postoperative intra-abdominal sepsis, leak, need for unplanned surgery, length of stay, renal failure, and mortality. We used the Research Electronic Data Capture tool to store the data. Poisson regression using a backward selection method was used to identify independent predictors of mortality.

RESULTS

We collected data of 372 patients with duodenal injuries. Although the duodenal trauma was complex (median Injury Severity Score [ISS], 18 [interquartile range, 2-3]; Abbreviated Injury Scale, 3.5 [3-4]; American Association for the Surgery of Trauma grade, 3 [2-3]), primary repair alone was the most common type of operative management (80%, n = 299). Overall mortality was 24%. On univariate analysis, mortality was associated with male gender, lower admission systolic blood pressure, need for transfusion before operative repair, higher intraoperative blood loss, longer operative time, renal failure requiring renal replacement therapy, higher ISS, and associated pancreatic injury. Poisson regression showed higher ISS, associated pancreatic injury, postoperative renal failure requiring renal replacement therapy, the need for preoperative transfusion, and male gender remained significant predictors of mortality. Duodenal suture line leak was statistically significantly lower, and patients had primary repair over every American Association for the Surgery of Trauma grade of injury.

CONCLUSIONS

The need for transfusion prior to the operating room, associated pancreatic injuries, and postoperative renal failure are predictors of mortality for patients with duodenal injuries. Primary repair alone is a common and safe operative repair even for complex injuries when feasible.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

Diagnosis and management of duodenal perforations: a narrative review

Duodenal perforation is a rare, but potentially life-threatening injury. Multiple etiologies are associated with duodenal perforations such as peptic ulcer disease, iatrogenic causes and trauma. Computed tomography with intravenous and oral contrast is the most valuable imaging technique to identify duodenal perforation. In some cases, surgical exploration may be necessary for diagnosis. Specific treatment depends upon the nature of the disease process that caused the perforation, the timing, location and extent of the injury and the clinical condition of the patient. Conservative management seems to be feasible in stable patients with sealed perforations. Immediate surgery is required for patients presenting with peritonitis and/or intra-abdominal sepsis. Minimally invasive techniques are safe and effective alternatives to conventional open surgery in selected patients with duodenal perforations. Here we review the current literature on duodenal perforations and discuss the outcomes of different treatment strategies.

Surgical Trends in the Management of Duodenal Injury

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.

Pediatric Trauma Update

Trauma is the leading cause of mortality in children, accounting for over 11,000 deaths and more than 8 million nonfatal injuries in 2015 for ages 1-19 years.1 Current issues garnering particular attention and research efforts include traumatic brain injury (TBI), blunt solid organ injuries, imaging guidelines and trauma-induced coagulopathy. This article reviews the evaluation and management of the pediatric trauma patient while focusing on recent updates.

Surgical Management of Abdominal Trauma: Hollow Viscus Injury

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.

Surgical Management and Outcomes of Combined Pancreaticoduodenal Injuries: Analysis of 75 Consecutive Cases

BACKGROUND

Combined pancreaticoduodenal injuries (CPDI) are complex and result in significant morbidity and mortality. Survival in CPDI after initial damage-control laparotomy (DCL) and pancreaticoduodenectomy was evaluated in a large cohort treated in a Level I trauma center. We hypothesized that bivariate analyses would accurately identify factors influencing morbidity and mortality.

STUDY DESIGN

The records from a prospective database of 453 consecutive patients treated for pancreatic injuries between January 1990 and April 2015 were reviewed to identify those with CPDI. Primary and secondary end points assessed were death and morbidity.

RESULTS

Seventy-five patients (69 men, median age 27 years, range 14 to 56 years) with CPDI, underwent 161 operations (range 1 to 9 operations). Twenty-nine patients with complex CPDI underwent a DCL and 46 had definitive treatment during the initial operation. Nineteen had a pancreaticoduodenectomy, either during the initial operation (n = 13) or after the DCL (n = 6). Postoperative complications occurred in 63 (84%) patients. Twenty-one (28%) patients died, including 15 (43%) of 35 patients with associated vascular injuries. Sixteen (84%) of the 19 patients who had a pancreaticoduodenectomy survived. Significantly more complications related to bleeding, disseminated intravascular coagulation, and hypovolemic shock occurred in those patients who eventually died and significantly more abdominal sepsis and fistulas occurred in patients who survived. Mortality was related to associated vascular injuries overall (p < 0.01), major visceral venous injuries (p < 0.011), and the combination of vascular plus the total number of associated organs injured (p < 0.046).

CONCLUSIONS

Despite using DCL in CPDIs, morbidity (84%) and mortality (28%) remain substantial. Careful selection of patients undergoing pancreaticoduodenectomy resulted in 84% survival. Associated vascular injuries, major visceral venous injuries, and combined vascular and associated organs injured influenced outcomes and mortality.