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World Journal of Surgery

, Volume 32, Issue 1, pp 7–12 | Cite as

Safety of Repair for Severe Duodenal Injuries

  • George C. VelmahosEmail author
  • Constantinos Constantinou
  • George Kasotakis
Article

Abstract

Background

There is ongoing debate about the management of severe duodenal injuries (SDIs), and earlier studies have recommended pyloric exclusion. The objective of this study was to compare primary repair with pyloric exclusion to examine if primary repair can be safely used in SDIs.

Methods

The medical records of 193 consecutive patients who were admitted between August 1992 and January 2004 with duodenal injuries were reviewed. After excluding early deaths (n = 50), low-grade duodenal injuries (n = 81), and pancreatoduodenectomies for catastrophic trauma (n = 12), a total of 50 patients with SDIs (grade III, IV, or V) were analyzed. Primary repair (PR—simple duodenorrhaphy or resection and primary anastomosis) was performed in 34 (68%) and pyloric exclusion (PE) in 16 (32%). Characteristics and outcomes of these two groups were compared.

Results

PE and PR patients were similar for age, injury severity score, abdominal abbreviated injury score, physiologic status on admission, time to operation, and most abdominal organs injured. PE patients had more pancreatic injuries (63% vs. 24%, p < 0.01), a higher frequency of injuries to the first and second part of the duodenum (79% vs. 42%, p = 0.02), and a nonsignificant trend toward more grade IV and V injuries (37% vs. 18%, p = 0.11). There was no difference in morbidity (including complications specific to the duodenal repair), mortality, and intensive care unit and hospital length of stay between the two groups.

Conclusions

Pyloric exclusion is not necessary for all patients with SDIs, as previously suggested. Selected SDI patients can be safely managed by simple primary repair.

Keywords

Injury Severity Score Primary Repair Primary Anastomosis Pancreatic Injury Duodenal Injury 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Berg AA (1923) Duodenal fistula: its treatment by gastrojejunostomy and pyloric exclusion. Ann Surg 78:725–744Google Scholar
  2. 2.
    Adkins RB Jr, Keyser JE 3rd (1985) Recent experiences with duodenal trauma. Am Surg 51:121–131PubMedGoogle Scholar
  3. 3.
    Ivatury RR, Nallathambi M, Gaudino J, et al. (1985) Penetrating duodenal injuries: analysis of 100 consecutive cases. Ann Surg 202:153–158PubMedCrossRefGoogle Scholar
  4. 4.
    Flynn WJ, McCoy M, Richardson DJ (1990) Reappraisal of pancreatic and duodenal injury management based on injury severity. Arch Surg 125:1539–1541PubMedGoogle Scholar
  5. 5.
    Cogbill TH, Moore EE, Feliciano DV, et al. (1990) Conservative management of duodenal trauma: a multicenter prospective. J Trauma 30:1469–1475PubMedCrossRefGoogle Scholar
  6. 6.
    Nassoura ZE, Ivatury RR, Simon RJ, et al. (1994) A prospective reappraisal of primary repair of penetrating duodenal injuries. Am Surg 60:35–39PubMedGoogle Scholar
  7. 7.
    Kline G, Lucas CE, Ledgerwood AM, et al. (1994) Duodenal organ injury severity score and outcome. Am Surg 60:500–504PubMedGoogle Scholar
  8. 8.
    Berne CJ, Donovan AJ, White EJ, et al. (1974) Duodenal “diverticulization” for duodenal and pancreatic injury. Am J Surg 127:503–507PubMedCrossRefGoogle Scholar
  9. 9.
    Moore EE, Cogbill TH, Malangoni MA, et al. (1990) Organ injury scaling. II. Pancreas, duodenum, small bowel, colon, and rectum. J Trauma 30:1427–1429PubMedGoogle Scholar
  10. 10.
    Yellin AE, Rosoff L (1975) Pancreatoduodenectomy for combined pancreatoduodenal injuries. Arch Surg 110:1177–1183PubMedGoogle Scholar
  11. 11.
    Orescovich MR, Carrico CJ (1984) Pancreativoduodenectomy for trauma: a viable option? Am J Surg 147:618–623CrossRefGoogle Scholar
  12. 12.
    Feliciano DV, Martin TD, Cruse PA, et al. (1987) Management of combined pancreatoduodenal injuries. Ann Surg 205:673–680PubMedCrossRefGoogle Scholar
  13. 13.
    McKone TK, Bursch LR, Scholten DJ (1988) Pancreaticoduodenectomy for trauma: a life-saving procedure. Am Surg 54:361–364PubMedGoogle Scholar
  14. 14.
    Heimansohn DA, Canal DF, McCarthy MC, et al. (1990) The role of pancreaticoduodenectomy in the management of traumatic injuries to the pancreas and duodenum. Am Surg 56:511–514PubMedGoogle Scholar
  15. 15.
    Morton Jr, Jordan GL Jr (1968) Traumatic duodenal injuries: review of 131 cases. J Trauma 8:127–139PubMedCrossRefGoogle Scholar
  16. 16.
    Stone HH, Fabian TC (1979) Management of duodenal wounds. J Trauma 19:334–339PubMedGoogle Scholar
  17. 17.
    DeSantis M, Dvereux D, Thompson D (1987) Pyloric exclusion: suture material of choice. Am Surg 53:711–714PubMedGoogle Scholar
  18. 18.
    Kashuk JL, Moore EE, Cogbill TH (1982) Management of the intermediate severity duodenal injury. Surgery 92:758–764PubMedGoogle Scholar
  19. 19.
    Feliciano D, Moore EE, Pachter HL, et al. (1986) Symposium—pancreaticoduodenal trauma. Contemp Surg 29:107–128Google Scholar
  20. 20.
    Martin TD, Feliciano DV, Mattox KL (1983) Severe duodenal injuries: treatment with pyloric exclusion and gastrojejunostomy. Arch Surg 118:631–635PubMedGoogle Scholar
  21. 21.
    Ginzburg E, Carrillo EH, Sosa JL, et al. (1997) Pyloric exclusion in the management of duodenal trauma: is concomitant gastrojejunostomy necessary? Am Surg 63:964–966PubMedGoogle Scholar
  22. 22.
    Buck JR, Sorensen JJ, Fath HM, et al. (1992) Severe pancreatoduodenal injuries: the effectiveness of pyloric exclusion with vagotomy. Am Surg 58:557–561PubMedGoogle Scholar
  23. 23.
    Degiannis E, Krawczykowski D, Velmahos GC, et al. (1993) Pyloric exclusion in severe penetrating injuries of the duodenum. World J Surg 17:751–754PubMedCrossRefGoogle Scholar
  24. 24.
    Velmahos GC, Kamel E, Chan LS, et al. (1999) Complex repair for the management of duodenal injuries. Am Surg 10:972–975Google Scholar
  25. 25.
    Jurkovich GJ (2000) The duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE (eds) Trauma. 4th edition. New York: McGraw-Hill. p 735–762Google Scholar
  26. 26.
    Weigelt JA (1990) Duodenal injuries. Surg Clin North Am 70:529–539PubMedGoogle Scholar
  27. 27.
    Jansen M, Du Toit DF, Warren BL (2002) Duodenal injuries: surgical management adapted to circumstances. Injury 33:611–615PubMedCrossRefGoogle Scholar
  28. 28.
    Lopez PP, Benjamin R, Cockburn M, et al. (2005) Recent trends in the management of combined pancreatoduodenal injuries. Am Surg 71:847–852PubMedGoogle Scholar
  29. 29.
    Asensio JA, Petrone P, Roldan G, et al. (2003) Pancreaticoduodentomy: a rare procedure for the management of complex pancreaticoduodenal injuries. J Am Coll Surg 197:937–942PubMedCrossRefGoogle Scholar
  30. 30.
    Huerta S, Bui T, Porral D, et al. (2005) Predictors of morbidity and mortality in patients with traumatic duodenal injuries. Am Surg 71:763–767PubMedGoogle Scholar
  31. 31.
    Tyburski JG, Dente CH, Wilson RF, et al. (2001) Infectious complications following duodenal and/or pancreatic trauma. Am Surg 67:230–231Google Scholar
  32. 32.
    Asensio JA, Petrone P, Roldan G, et al. (2002) Pancreatic and duodenal injuries: complex and lethal. Scand J Surg 91:81–86PubMedGoogle Scholar
  33. 33.
    Degiannis E, Boffard K (2000) Duodenal injuries. Br J Surg 87:1473–1479PubMedCrossRefGoogle Scholar
  34. 34.
    Talving P, Nicol AJ, Navsaria PH (2006) Civilian duodenal gunshot wounds: surgical management made simpler. World J Surg 30:488–494PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2007

Authors and Affiliations

  • George C. Velmahos
    • 1
    • 2
    Email author
  • Constantinos Constantinou
    • 1
    • 3
  • George Kasotakis
    • 1
    • 4
  1. 1.Division of Trauma and Critical Care, Department of SurgeryLos Angeles County and University of Southern California Medical CenterLos AngelesUSA
  2. 2.Department of SurgeryMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  3. 3.Department of SurgeryGeisinger Medical CenterDanvilleUSA
  4. 4.Department of SurgeryCreighton University Medical CenterOmahaUSA

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