Severe Duodenal Injuries Research Articles

Feasibility of jejunal enteral nutrition for patients with severe duodenal injuries

ObjectiveThe aim of this study was to evaluate the feasibility of enteral nutrition (EN) for critically ill trauma patients with severe traumatic duodenal injuries who received placement of concurrent decompressing and feeding jejunostomies. MethodsAdult patients admitted to the trauma intensive care unit from January 2010 to December 2013, given concurrent afferent decompressing and efferent feeding jejunostomies for severe duodenal injury and provided EN or parenteral nutrition (PN), were retrospectively evaluated. Enteral feeding intolerance was defined as an increase in the decompressing jejunostomy drainage volume output, worsening abdominal distension, or cramping/pain unrelated to surgical incisions. Patients who failed initial EN were transitioned to PN. ResultsTwenty-six patients were enrolled. Of the 24 patients given EN within the first 2 wk posthospitalization, 18 (75%) failed EN within 2 ± 2 d of initiating EN. EN was discontinued when increases were seen in decompressing jejunostomy drainage volume output (n = 11) and output with abdominal pain and/or distension (n = 6), or abdominal pain/distension was seen without an increase in output (n = 1). Jejunostomy drainage volume output increased from 474 ± 425 mL/d to 1168 ± 725 mL/d (P < 0.001) during EN intolerance. More patients with blunt intestinal injury than those with penetrating injuries (75% versus 15%, respectively; P = 0.035) tolerated EN. Patients initially given PN (n = 13) received more calories (P < 0.005) and protein (P < 0.001) than those given initial EN (n = 13). ConclusionThe majority of patients with severe duodenal injuries and concurrent decompressing/feeding tube jejunostomies failed initial EN therapy.

Is there a role for pyloric exclusion after severe duodenal trauma?

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.

Application of damage control surgery idea in the treatment of severe pancreatic duodenal injury

To explore the significance of damage control surgery (DCS) in the treatments of severe pancreaticoduodenal injuries. Clinical data of 19 patients with severe pancreaticoduodenal injuries managed with DCS approach in Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine and the First Affiliated Hospital of Wenzhou Medical College from March 2005 to January 2013 were analyzed retrospectively. Three cases were cured after damage control operation and postoperative ICU resuscitation treatment. Twelve cases underwent definite operations (distal pancreaticojejunal Roux-en-Y anastomosis, proximal duodenojejunal Roux-en-Y anastomosis or pancreaticoduodenectomy) after damage control operation and postoperative ICU resuscitation treatment and cured. Four cases died after damage control operation due to multiple organ failure and the mortality was 21.1%. Application of DCS approach can improve the prognosis of patients with severe pancreaticoduodenal injuries.

Trauma Whipple: Do or Don’t After Severe Pancreaticoduodenal Injuries? An Analysis of the National Trauma Data Bank (NTDB)

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. 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. 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. 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.

Safety of repair for severe duodenal injuries

Safety of repair for severe duodenal injuries

Pyloric Exclusion in the Treatment of Severe Duodenal Injuries: Results from the National Trauma Data Bank

Pyloric exclusion (PEX) has traditionally been used in the management of complicated duodenal injuries to temporarily protect the duodenal repair and prevent septic abdominal complications. We used the American College of Surgeons National Trauma Data Bank (v 5.0) to evaluate adult patients with severe duodenal injuries [American Association for the Surgery of Trauma (AAST) Grade > or = 3] undergoing primary repair only or repair with PEX within 24 hours of admission. Propensity scoring was used to adjust for relevant confounding factors during outcomes comparison. Among 147 patients with severe duodenal injuries, 28 (19.0%) underwent PEX [15.9% (11/69) Grade III vs 34.0% (17/50) Grade IV-V]. Despite similar demographics, PEX was associated with a longer mean hospital stay (32.2 vs 22.2 days, P = 0.003) and was not associated with a mortality benefit. There was a trend toward increased development of septic abdominal complications (intra-abdominal abscess, wound infection, or dehiscence) with PEX that was not statistically significant. After multivariable analysis using propensity score, no statistically significant differences in mortality or occurrence of septic abdominal complications was noted between those patients undergoing primary repair only or PEX. The use of PEX in patients with severe duodenal injuries may contribute to longer hospital stay and confers no survival or outcome benefit.

Safety of Repair for Severe Duodenal Injuries

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

Surgical management of duodenal injuries in children

Background. The goal of this study was to review current injury characteristics, severity, intervention, and outcome of duodenal injuries from a single, pediatric trauma facility. Methods. A retrospective review was performed of duodenal injuries in children less than 16 years of age from 1990 to 2000. Results. Twelve children had duodenal injuries as a result of blunt abdominal trauma. Six injuries were the result of motor vehicle crashes. Nonaccidental trauma (2) and contact injury (4) provided the remaining cases. Diagnosis was achieved by abdominal computed tomography. Severity of duodenal injury included grade I (1), II (8), and III (3). Seven patients had associated visceral or neurologic injuries. Average Injury Severity Score was 18. Duodenal repair was required in 9 of the 10 patients explored. Treatment included observation (3); primary repair, alone, (2) or with proximal decompression (4); and pyloric exclusion with gastrojejunostomy (3). Exclusion techniques had fewer complications (0% vs 57%) and fewer hospital days (19 vs 23). Conclusions. Blunt abdominal trauma remains the most prevalent mechanism for pediatric duodenal injuries. Patients undergoing pyloric exclusion for severe duodenal trauma had a lesser morbidity and a shorter hospital stay in this small series. Pyloric exclusion remains an alternative for the treatment of severe duodenal injuries in selected children. (Surgery 2002;132:748-53.)

Complex Repair for the Management of Duodenal Injuries

The management of duodenal injuries is a subject of ongoing debate. In this study we attempt to describe duodenum-related morbidity (DRM) after primary repair or complex repair (CR) and to identify risk factors for development of complications. The medical records of 145 consecutive patients admitted to Los Angeles County + University of Southern California Medical Center with duodenal injuries between January 1991 and December 1997 were reviewed. Fifty-four (37%) died within 24 hours of admission because of associated injuries. The remaining 91 were subjected to univariate and multivariate analysis. Of them, 66 (72.5%) developed complications and 3 (3%) died. CR was used in 32 (35%) patients and with increasing frequency as the grade of duodenal injury increased. DRM rate was overall low (9%) and not different between low-grade and high-grade duodenal injuries. This occurred despite a significant increase in Injury Severity Score and abdominal Abbreviated Injury Score in patients with more severe duodenal injuries. Patients with overall complications had higher Injury Severity Scores, higher abdominal Abbreviated Injury Scores, and more severe duodenal injuries. We conclude that duodenal injuries are frequently associated with other highly lethal injuries. Liberal use of CR in patients with more severe duodenal injuries prevents DRM.

An endoscopic comparison of gastroduodenal injury with over-the-counter doses of ketoprofen and acetaminophen

Objective: The objective of this study was to endoscopically assess in healthy subjects the gastrointestinal effects of over-the-counter (OTC) doses of ketoprofen. Ketoprofen is a potent nonsteroidal antiinflammatory agent (NSAID) recently approved for OTC use as an analgesic/antipyretic at doses of 75 mg versus the usual dose of ≤ 300 mg daily. In epidemiological studies, ketoprofen at prescription doses has consistently been in the higher relative risk group of NSAIDs in the occurrence of gastrointestinal complications of therapy. The gastrointestinal effects of the OTC (US) dose of ketoprofen have not been reported. Methods: In a randomized, double blind, three way crossover study, 24 healthy subjects received 7 days of therapy with ketoprofen 75 mg/day, acetaminophen 4000 mg/day, and placebo. Gastroduodenal endoscopy was performed before and at the end of each treatment period. The condition of the mucosa was graded compositely for the gastric antrum, fundus, body, and duodenum. Results: Significantly more frequent and severe gastric mucosal injury was observed after dosing with ketoprofen compared with acetaminophen ( p = 0.0001). The acetaminophen group showed no difference from placebo ( p = 0.8783). Two subjects developed frank gastric ulcers with ketoprofen therapy. Marginally more frequent ( p = 0.0703) and significantly more severe ( p = 0.0117) duodenal mucosal injury was seen. No significant differences were observed between treatment groups with respect to subjective symptoms of gastric discomfort or adverse events. Conclusion: These results indicate that even at lower (OTC) doses (75 mg/day) ketoprofen is associated with significant gastrointestinal irritation.

COMPLEX DUODENAL INJURIES

Duodenal trauma, with early diagnosis and prompt treatment, can be managed effectively by simple surgical techniques. Severe duodenal injuries and those associated with major destruction of adjacent structures (the pancreaticobiliary complex or abdominal vessels) require a more thoughtful strategy that incorporates a careful consideration of the physiologic stability of the patient and the extent of local destruction. Figure 8 summarizes these concepts in an algorithm.

Gunshot injuries of the head of the pancreas: conservative approach.

This study is comprised of 48 patients with gunshot injuries of the head of the pancreas, many of which were high velocity injuries. The purpose of this study was to evaluate our management policy for these injuries based on our recent wide experience. Patients with grade II and III injuries underwent conservative surgery, with 0% and 21% postoperative mortality, respectively, directly related to the pancreatic injury. For patients in whom the duodenum was involved, pyloric exclusion was applied depending on the grade of the duodenal injury. We concluded that moderate gunshot injuries of the head of the pancreas (grade II) can be safely treated by débridement and suture repair, with or without drainage. Severe (grade IV) injuries warrant a pancreaticoduodenectomy. Most grade III injuries can be treated by débridement and drainage unless an associated severe duodenal injury is present, in which case resection may be indicated.

Frequency of Gastroduodenal Lesions in Asymptomatic Patients on Chronic Aspirin or Nonsteroidal Antiinflammatory Drug Therapy

Endoscopy in 49 patients without upper gastrointestinal symptoms and who were receiving chronic aspirin or nonsteroidal antiinflammatory drug therapy showed the frequency of gastric and duodenal mucosal lesions to be 76 and 27%, respectively. Fifteen (31%) had gastric ulcers, 31 (63%) had gastric erosions, and 10 (20%) had gastric mucosal hemorrhages. Gastric mucosal lesions were noted in 9 (90%) patients taking plain aspirin, in 25 (74%) receiving nonsteroidal antiinflammatory agents, and in 3 (60%) patients taking enteric-coated aspirin. Duodenal lesions were noted in 30 and 26% of patients taking plain aspirin and nonsteroidal antiinflammatory drugs, respectively. Patients taking enteric-coated aspirin had less severe duodenal injury than patients receiving ibuprofen or indomethacin, but the difference was not statistically significant. Endoscopy in 20 normal subjects not taking aspirin or nonsteroidal antiinflammatory drugs showed no gastroduodenal ulcers, erosions, or hemorrhage. Patients chronically taking antiarthritic drugs, including enteric-coated aspirin, have a high frequency of asymptomatic gastroduodenal lesions.

Injuries of the duodenum

The records of 115 patients with a duodenal injury have been reviewed. The majority of the patients (83 percent) were treated with primary repair of the injury. Twelve patients underwent duodenal diverticulization. The mortality rate in all 115 patients was 12 percent, in 105 patients who survived more than 48 hours 4 percent, and in 26 patients with pancreaticoduodenal injury 15 percent. Vascular injury was the major cause of early death. Enteric perforations were present in 75 percent of the patients with sepsis. The majority of patients with associated pancreatic injury had primary repair and did not have pancreaticoduodenal complications. Duodenal fistula continues to be a serious postoperative complication. Primary repair with drainage is the preferred treatment. Gastrostomy and feeding jejunostomy are useful adjuncts. A more complex operation should be reserved for a highly select group of patients with severe duodenal injury.

Severe duodenal injuries. Treatment with pyloric exclusion and gastrojejunostomy.

During a 12-year period, 313 patients with duodenal injuries were treated. Primary repair, pyloric exclusion, and gastrojejunostomy were used in 128 patients (41%) with severe duodenal and pancreaticoduodenal injuries, to reduce "duodenal" morbidity and mortality. The duodenal fistula rate was 2.2% overall, and 5.5% in the patients undergoing exclusion. Only two deaths were due to fistulas. Forty-two patients underwent upper gastrointestinal tract examinations after operation. In patients examined 21 days or more after operation, 94% had a patent pylorus. Marginal ulceration was infrequent (four patients), as were complications associated with the procedure (3%). Pyloric exclusion with gastrojejunostomy is a quick and simple procedure that allows return of pyloric patency and is associated with a low incidence of duodenal fistulas. When fistulas do develop, they are usually easily controlled and are associated with a low mortality. We believe pyloric exclusion with gastrojejunostomy to be the procedure of choice in patients with severe duodenal and pancreaticoduodenal trauma.

JEJUNAL REPLACEMENT OF THE SECOND PART OF THE DUODENUM FOLLOWING SEVERE TRAUMA

Intestine can be devitalized by crushing injuries as readily as other soft tissues. The management of a patient with severe duodenal injury is presented. The importance of resecting avascular segments, rather than hoping for the best, is stressed.

Surgical management of acute pancreatic injuries in children

This study was undertaken to review traumatic injuries of the pancreas in children. Fifty-one children from 2 to 16 yr of age underwent 52 operations for pancreatic injuries over a 37-yr period at Jefferson Davis Hospital, Ben Taub General Hospital, and Methodist Hospital in Houston. Nineteen sustained penetrating injuries, and 32 received blunt trauma. Twenty-one of the children with blunt trauma and none of those with penetrating injuries had elevated serum amylase concentrations on admission. Forty-seven patients were operated on acutely, and 1 patient was operated on 10 days following injury. Four patients were operated on for complications of pancreatic injury following previous laparotomy. Immediately following injury 19 children were found to have through-and-through perforation or laceration, 21 were found to have pancreatic contusion, and 11 were found to have complete transection of the pancreas. Findings at operation for complications of pancreatic injury included three pseudocysts and one pancreatic fistula with complete transection of the pancreas. One hundred and fifty-one associated injuries, including 16 vascular injuries, were found; they ranged from 1 to 10 per patient. Seven operative procedures were employed. In 32 children external drainage only was performed; pancreatorrhaphy and external drainage were performed in 6 children; distal pancreatectomy was used in 7 children following complete pancreatic transection. Two patients, one with postoperative fistula formation with transection of the pancreas, required distal pancreatojejunostomy and oversewing of the proximal pancreatic stump. Two patients with severe duodenal injury and transection of the head of the pancreas underwent Whipple procedures. Two patients with pseudocysts had cystogastrostomies, and 1 patient had external drainage. Operative deaths occurred in 4 children and were the result of complications unrelated specifically to pancreatic injury. Fourteen patients developed complications of pancreatic injury: 11 pancreatic fistulas and 3 pseudocysts. Surgical indications, operative technique, and complications are presented in detail. The management of pancreatic injuries in children begins with diagnosis. All patients sustaining penetrating abdominal injuries should be explored, and those with blunt trauma should be evaluated on physical findings, with peritoneal lavage and determinations of serum amylase concentration serving as supportive evidence. The presence of a pancreatic injury always warrants external drainage, preferably with soft Penrose drains. Salvage of the distal gland following transection is preferred if the patient's condition permits, if the spleen is intact, and if the distal gland is not in need of debridgement. Pancreatic fistula is the most common complication of pancreatic trauma, but it rarely presents a management problem and usually is closed by the second postoperative week.

The use of pyloric exclusion in the management of severe duodenal injuries

The Journal of Trauma: Injury, Infection, and Critical Care: June 1978 - Volume 18 - Issue 6 - p 475

The use of pyloric exclusion in the management of severe duodenal injuries

Repair of severe duodenal injuries often constitutes a technical challenge, and a variety of special technics have been described. For the past seven years we have utilized temporary pyloric exclusion and gastrojejunostomy to produce “diverticulization” of the duodenum. This procedure was utilized in seventy-five patients selected from 175 consecutive patients presenting with duodenal trauma. The mortality was 19 per cent and the rate of fistula formation was 5 per cent in this series and 14 per cent and 2 per cent, respectively, in the overall series. Follow-up studies of gastric physiology and functional anatomy show no evidence of alteration of these parameters. We thus believe that patients presenting with severe duodenal trauma and often multiple devastating associated organ injuries can be adequately treated with this procedure with a significant decrease in mortality and with marked improvement of postoperative morbidity.

Duodenal “diverticulization” for duodenal and pancreatic injury

Duodenal “diverticulization” has been achieved in thirty-four cases of combined duodenal and pancreatic or severe duodenal or pancreatic injury. The operation consists of gastric antrectomy with end to side gastrojejunostomy, tube duodenostomy, closure of the duodenal perforation, and drainage. The combined mortality for these thirty-four cases and a previously reported series of sixteen cases is 16 per cent. Regional complications that developed after duodenal diverticulization were generally well tolerated and not lethal. All duodenal and pancreatic fistulas closed spontaneously.