Contemporary Management of Traumatic Duodenal Injuries

2021 ◽  
pp. 000313482199505
Author(s):  
Vincent Butano ◽  
Michael A. Napolitano ◽  
Vivien Pat ◽  
Taylor Wahrenbrock ◽  
Paul Lin ◽  
...  
Keyword(s):  
Trauma Center ◽  
Primary Repair ◽  
Management Strategies ◽  
Operative Management ◽  
Duodenal Injury ◽  
Patient Demographics ◽  
Grade 5 ◽  
Grade 3 ◽  
Contemporary Management ◽  
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.

scholarly journals Primary repair of duodenal injuries: a retrospective cohort study from a major trauma centre in South Africa

2019 ◽  
Vol 108 (4) ◽  
pp. 280-284 ◽  
Author(s):  
R. D. Weale ◽  
V. Y. Kong ◽  
W. Bekker ◽  
J. L. Bruce ◽  
G. V. Oosthuizen ◽  
...  
Keyword(s):  
South Africa ◽  
Primary Repair ◽  
Significant Risk ◽  
Trauma Centre ◽  
Duodenal Injury ◽  
Trauma Service ◽  
Retrospective Audit ◽  
Major Trauma Centre ◽  
Significant Difference ◽  
Duodenal Injuries

Background and Aims:The management of duodenal trauma remains controversial. This retrospective audit of a prospectively maintained database was intended to clarify the operative management of duodenal injury at our institution and to assess the risk factors for leak following primary duodenal repair.Materials and Methods:This was a retrospective study undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. Operative techniques used for duodenal repair were recorded. Our primary outcome was duodenal leak in the postoperative period. Patients from January 2012 to December 2016 were included. All duodenal injuries were graded according to the American Association for the Surgery of Trauma (AAST) grading. Only patients who had a primary repair were included in the final analysis.Results:During the five-year data collection period, a total of 562 patients underwent a trauma laparotomy; of which 94 patients sustained a duodenal injury. A primary pyloric exclusion and gastro-jejunostomy (PEG) was performed in three patients. These three were then excluded from further analysis. Of the 91 primary duodenal repairs, seven (8%) subsequently leaked. These were managed by PEG in three and by secondary repair and para-duodenal drainage in four. The two physiological parameters most associated with subsequent leak were lactate and pH level. There was a significantly higher mortality rate for those who leaked vs those who did not leak. Chi-squared test revealed a significant difference in the leak rate between AAST I (0%), AAST-II (1.6%) and AAST-3 (66.7%) grade injuries (p <0.01).Conclusion:The trend towards primary repair of duodenal injuries appears to be justified. However duodenal leak remains a significant risk in certain high risk patients and strategies to manage injuries in this subset requires further work.

Predictors of Morbidity and Mortality in Patients with Traumatic Duodenal Injuries

2005 ◽  
Vol 71 (9) ◽  
pp. 763-767 ◽  
Author(s):  
Sergio Huerta ◽  
Trung Bui ◽  
Diana Porral ◽  
Stephanie Lush ◽  
Marianne Cinat
Keyword(s):  
Injury Severity ◽  
Primary Repair ◽  
Univariate Analysis ◽  
Vena Cava ◽  
Multivariate Regression Analysis ◽  
Morbidity And Mortality ◽  
Duodenal Injury ◽  
Gun Shot ◽  
Duodenal Resection ◽  
Duodenal Injuries

The aim of our study is to determine factors that predict morbidity and mortality in patients with traumatic duodenal injury (DI). A retrospective review from July 1996 to March 2003 identified 52 patients admitted to our trauma center (age 24.4 ± 2.1 years, ISS = 18.8 ± 1.76). The mortality rate for patients with duodenal injury was 15.4 per cent (n = 8). The mechanisms of injury were blunt (62%), gun shot wound (GSW) (27%), and stab wound (SW) (11%). There was no difference in mortality based on mechanism of injury. Management was primarily nonoperative [n = 30 (57%)]. Of those with perforation (n = 22), 64 per cent underwent primary repair (n = 14), 23 per cent duodenal resection (n = 5), 9 per cent duodenal exclusion (n = 2), and one patient pancreaticoduodenectomy. The method of initial surgical management was not related to patient outcome. Univariate analysis demonstrated that nonsurvivors were older, more, hypotensive in the emergency department, had a more negative initial base deficit, had a lower initial arterial pH, and had a higher Injury Severity Score. Nonsurvivors were also more likely to have an associated inferior vena cava (IVC) injury. Multivariate regression analysis revealed age, initial lowest pH, and Glasgow Coma Score to be independent predictors of mortality, suggesting that the physiologic presentation of the patient is the most important factor in predicting mortality in patients with traumatic DIs.

scholarly journals Primary Closure without Diversion in Management of Operative Blunt Duodenal Trauma in Children

2012 ◽  
Vol 2012 ◽  
pp. 1-4 ◽  
Author(s):  
Katherine Smiley ◽  
Tiffany Wright ◽  
Sean Skinner ◽  
Joseph A. Iocono ◽  
John M. Draus
Keyword(s):  
Trauma Center ◽  
Primary Closure ◽  
Injury Severity ◽  
Average Length ◽  
Primary Repair ◽  
Pediatric Trauma ◽  
Average Length Of Stay ◽  
Grade Ii ◽  
Drain Placement ◽  
Duodenal Injuries

Background. Operative blunt duodenal trauma is rare in pediatric patients. Management is controversial with some recommending pyloric exclusion for complex cases. We hypothesized that primary closure without diversion may be safe even in complex (Grade II-III) injuries. Methods. A retrospective review of the American College of Surgeons’ Trauma Center database for the years 2003–2011 was performed to identify operative blunt duodenal trauma at our Level 1 Pediatric Trauma Center. Inclusion criteria included ages years and duodenal injury requiring operative intervention. Duodenal hematomas not requiring intervention and other small bowel injuries were excluded. Results. A total of 3,283 hospital records were reviewed. Forty patients with operative hollow viscous injuries and seven with operative duodenal injuries were identified. The mean Injury Severity Score was 10.4, with injuries ranging from Grades I–IV and involving all duodenal segments. All injuries were closed primarily with drain placement and assessed for leakage via fluoroscopy between postoperative days 4 and 6. The average length of stay was 11 days; average time to full feeds was 7 days. No complications were encountered. Conclusion. Blunt abdominal trauma is an uncommon mechanism of pediatric duodenal injuries. Primary repair with drain placement is safe even in more complex injuries.

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

2008 ◽  
Vol 74 (10) ◽  
pp. 925-929 ◽  
Author(s):  
Joseph J. Dubose ◽  
Kenji Inaba ◽  
Pedro G.R. Teixeira ◽  
Anthony Shiflett ◽  
Bradley Putty ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Primary Repair ◽  
Multivariable Analysis ◽  
Data Bank ◽  
Abdominal Complications ◽  
National Trauma ◽  
Pyloric Exclusion ◽  
National Trauma Data Bank ◽  
Grade 3 ◽  
Duodenal Injuries

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 ≥ 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.

Review of Prelabor Rupture of the Membranes: Pathophysiologic Concepts and Novel Therapeutic Strategies

2020 ◽  
Vol 16 ◽  
Author(s):  
Saadia Ghafoor
Keyword(s):  
Management Strategies ◽  
Signs And Symptoms ◽  
Cochrane Library ◽  
Main Body ◽  
Scientific Publications ◽  
Timely Diagnosis ◽  
Narrative Literature Review ◽  
Contemporary Management ◽  
Online Library ◽  
Novel Therapeutic Strategies

Background:: Prelabor rupture of membrane (PROM) refers to the breakage of fetal membranes before the onset of labor, resulting in the leakage of amniotic fluid. PROM affects approximately 3% and 8% of preterm and term pregnancies. Because of associated high maternal and perinatal mortality, correct and timely diagnosis together with effective management is highly recommended to prevent adverse fetal and maternal outcomes. Objective:: To provide an overview of the novel concepts in the understanding of PROM including etiology, pathophysiology, risk factors, complications, assessment, diagnostic modalities, and contemporary management strategies for PROM at preterm and term. Methodology:: This narrative literature review was conducted through a literature search using the Cochrane library and electronic databases including PubMed, Web of Science, Medline, Scopus, Crossref, Google Scholar, Wiley online library, ScienceDirect with specific search terms in scientific publications published from March 1980 to March 2020. Main Body:: Preterm PROM has the potential to cause prenatal morbidity and mortality. It is imperative to monitor the signs and symptoms of an impending infection due to the risk of infectious morbidity with PROM at preterm and preterm. PROM at preterm and term requires prompt diagnosis followed by an appropriate management strategy. Conclusion:: The correct and timely diagnosis of PROM is essential for efficacious management. Furthermore, it can reduce avoidable emergent health care visits and related costs in a clinical setting subjected to pregnancy with suspected PROM. Further studies are needed to fill the gaps in identifying better diagnostic predictive tools in high- risk pregnancies.

scholarly journals Adenosine-induced Asystole during AVM Embolization

2021 ◽  
Author(s):  
V. Hellstern ◽  
P. Bhogal ◽  
M. Aguilar Pérez ◽  
M. Alfter ◽  
A. Kemmling ◽  
...  
Keyword(s):  
Demographic Data ◽  
Clinical Results ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Residual Shunt ◽  
Grade 5 ◽  
Martin Grade ◽  
Grade 3 ◽  
Brain Avms

Abstract Background Adenosine induced cardiac standstill has been used intraoperatively for both aneurysm and arteriovenous malformation (AVM) surgery and embolization. We sought to report the results of adenosine induced cardiac standstill as an adjunct to endovascular embolization of brain AVMs. Material and Methods We retrospectively identified patients in our prospectively maintained database to identify all patients since January 2007 in whom adenosine was used to induce cardiac standstill during the embolization of a brain AVM. We recorded demographic data, clinical presentation, Spetzler Martin grade, rupture status, therapeutic intervention and number of embolization sessions, angiographic and clinical results, clinical and radiological outcomes and follow-up information. Results We identified 47 patients (22 female, 47%) with average age 42 ± 17 years (range 6–77 years) who had undergone AVM embolization procedures using adjunctive circulatory standstill with adenosine. In total there were 4 Spetzler Martin grade 1 (9%), 9 grade 2 (18%), 15 grade 3 (32%), 8 grade 4 (18%), and 11 grade 5 (23%) lesions. Of the AVMs six were ruptured or had previously ruptured. The average number of embolization procedures per patient was 5.7 ± 7.6 (range 1–37) with an average of 2.6 ± 2.2 (range 1–14) embolization procedures using adenosine. Overall morbidity was 17% (n = 8/47) and mortality 2.1% (n = 1/47), with permanent morbidity seen in 10.6% (n = 5/47) postembolization. Angiographic follow-up was available for 32 patients with no residual shunt seen in 26 (81%) and residual shunts seen in 6 patients (19%). The angiographic follow-up is still pending in 14 patients. At last follow-up 93.5% of patients were mRS ≤2 (n = 43/46). Conclusion Adenosine induced cardiac standstill represents a viable treatment strategy in high flow AVMs or AV shunts that carries a low risk of mortality and permanent neurological deficits.

The combination of venetoclax, lenalidomide, and rituximab in patients with newly diagnosed mantle cell lymphoma induces high response rates and MRD undetectability.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 7505-7505
Author(s):  
Tycel Jovelle Phillips ◽  
Alexey Valeryevich Danilov ◽  
David Alan Bond ◽  
Alex Francisco Herrera ◽  
Kami J. Maddocks ◽  
...  
Keyword(s):  
Phase 1 ◽  
Safety Data ◽  
Standard Of Care ◽  
Primary Objective ◽  
Clinical Activity ◽  
Newly Diagnosed ◽  
Grade 5 ◽  
Unrelated Condition ◽  
Mantle Cell ◽  
Grade 3

7505 Background: MCL is a rare lymphoma without a standard of care but several regimens have demonstrated clinical activity, the majority based on traditional chemotherapy. We hypothesized that adding venetoclax (V) to R2 would be safe and effective in MCL pts irrespective of age, morphology or stage. Here we present safety and efficacy data from the on-going phase 1b study of R2 + V in pts with newly diagnosed MCL. Methods: This multi-center phase 1 study (NCT03523975) enrolled pts aged ≥18 yrs with untreated MCL. The primary objective was to characterize the safety and tolerability of R2 + V and determine the MTD. During induction (12 months (m)) pts received lenalidomide (L) 20 mg daily on day 1-21, Rituximab (R) was given weekly during c1 then on day 1 of every even cycle, V was escalated over 4 weeks to 400 mg beginning day 8. Each cycle is 28 days (d). The DLT period was 42 d beginning C1D8. In maintenance, R every 8 weeks for 36m, L at 10 mg or half of last dose during induction for 24 m and V for minimum 12 m. No pts have been transplanted. Pts with progression (PD) came off study. MRD was analyzed in parallel with scans during induction by clonoSEQ assay (Adaptive Biotechnologies). Results: As of Feb. 1st, 2021, we have enrolled all 28 planned pts on study. Pt characteristics/responses are summarized in Table. Among the 28 pts who have received at least one dose, the median treatment duration so far is 278d (IQR 170-560), with 24 pts still on treatment (Tx). 1 pt is off from a unrelated condition. All pts escalated to V 400 mg w/o any DLTs noted. Treatment-emergent adverse events (TEAEs) were reported in 100% of pts, and grade 3+ TEAEs were reported in 26 (93%) patients. The most common all-grade TEAEs (≥50% of pts), regardless of relationship to study Tx, were fatigue, neutropenia and diarrhea. Grade ≥3 TEAEs reported in ≥50% pts were neutropenia (68%) and thrombocytopenia (50%). No pts have withdrawn or d/c Tx due to AEs. There was one grade 5 event, in a non-evaluable pt, related to a PE that occurred prior to DLT period. In the 28 evaluable pts the ORR (CR/PR) was 96% (27/28 pts) with CR/CRu of 89%. Of the responding pts, two had PD, one w/ CR and one w/ PR. All pts with PD had baseline TP53 mutation. MRD testing was successful in all pts. At time of submission 20 of 28 (71%) were MRD - at 10-6. Conclusions: Interim results show that at the MTD the combination of V 400 mg daily, L 20 mg, with R is safe with a manageable toxicity profile and a high ORR and MRD - in pts with newly diagnosed MCL. Safety data is consistent with the AE profile noted for each drug without any unexpected or unique AEs. Updated results including BH3 profiling will be presented at the meeting. Clinical trial information: NCT03523975. [Table: see text]

Phase I INSIGHT platform trial: Advanced safety and efficacy data from stratum D evaluating feasibility and safety of eftilagimod alpha (soluble LAG-3 protein) combined with avelumab in advanced solid tumors.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 2518-2518
Author(s):  
Thorsten Oliver Goetze ◽  
Daniel Wilhelm Mueller ◽  
Mohammad-Reza Rafiyan ◽  
Dragan Kiselicki ◽  
Timursah Habibzade ◽  
...  
Keyword(s):  
Adverse Events ◽  
Renal Insufficiency ◽  
Diffuse Myocardial Fibrosis ◽  
Pleural Mesothelioma ◽  
Advanced Solid Tumors ◽  
Clinical Progression ◽  
Grade 5 ◽  
Common Grade ◽  
Acute Renal Insufficiency ◽  
Grade 3

2518 Background: Stratum D of the INSIGHT platform trial evaluates s.c. eftilagimod alpha (efti, IMP321) combined with avelumab in advanced solid tumors. Efti is an MHC class II agonist which activates antigen-presenting cells followed by CD8 T-cell activation. Combination with PD-1/PD-L1 blockade aims at enhanced efficacy. Methods: This IIT platform trial consists of 5 strata: intratumoral (A) or intraperitoneal efti (B); s.c. efti with SOC (C) or with PD-L1 inhibition (D). Strat E is currently under development and starts soon with a new efti combination. This abstract focuses on preliminary data of Strat D. Patients (pts) received 800mg avelumab i.v. q2w along with s.c. efti: 6mg in cohort 1 (coh 1, 6 pts), 30mg in cohort 2 (coh 2, 6 pts). Primary endpoint: safety. Results: Recruitment has been completed with 12 pts (coh 1: gastric, gallbladder, colon cancer, pleural mesothelioma; coh 2: gastric, gastroesophageal, anal, rectum, cervix uteri). No dose limiting toxicities (DLTs) occurred. 10 serious adverse events (SAEs) were reported, none of them considered causally related (4 in 3 pts of coh 1 [1 acute renal insufficiency grade 5 in 1 pt, 2 preileus grade 3 in 1 pt, hearing impaired grade 4 in 1 pt] and 6 in 4 pts of coh 2 [1 anal hemorrhage and 1 gallbladder obstruction in 1 pt, 1 eye pain and 1 surgery to replace the feeding tube in 1 pt, each grade 3, 1 skin infection grade 2, 1 diffuse myocardial fibrosis grade 5]. 1 AE of special interest (AESI) possibly related with avelumab (sarcoidosis grade 1) occurred in coh 1. 2 pts completed max treatment duration with 24 cycles. In coh 1, 47 adverse events (AEs; grade 1-2, 29; grade 3, 14; grade 4, 3; grade 5, 1) occurred in 5 pts. Most common grade 1-2 AEs were nausea, pain in 33%, 33% of the pts. Most common grade 3 AEs were ileus, vomiting in 33%, 33% of the pts. 2 AEs grade 4 (hearing impaired, sepsis) and 1 AE grade 5 (acute renal insufficiency) were reported. All AEs grade 3-5 were considered causally unrelated. In coh 2, 51 adverse events (AEs; grade 1-2, 29; grade 3, 19; grade 4, 2; grade 5, 1) occurred in 5 pts. The most common grade 1-2 AE was hypothyroidism in 33% of the pts. 1 AE grade 5 (diffuse myocardial fibrosis) was reported. Only 1 AE grade 3-5 was considered causally related (urinary tract infection grade 3 related with avelumab). 5 pts showed partial response as best response (2 coh 1: colon, pleural mesothelioma; 3 coh 2: gastric, anal, cervical), 1 stable disease with clinical progression (coh 2) (all but one of these pts still alive), 5 disease progressions acc. to RECIST 1.1 (3 coh 1, 2 coh 2), 1 clinical progression (coh 1). Signals of activity were also observed in pre-treated MSS/PD-L1low pts. Conclusions: Combined treatment with avelumab 800mg and efti 6mg (coh 1) or 30 mg efti (coh 2) seems feasible and safe. No unexpected AEs occurred. Signals of efficacy with CPI combination were seen (DCR 50%). Clinical trial information: NCT03252938.

Congenital diaphragmatic hernia: Impact of contemporary management strategies on perinatal outcomes

2018 ◽  
Vol 38 (13) ◽  
pp. 1004-1012 ◽  
Author(s):  
Han‐Shin Lee ◽  
Jan E. Dickinson ◽  
Jason KG Tan ◽  
Wendy Nembhard ◽  
Carol Bower
Keyword(s):  
Congenital Diaphragmatic Hernia ◽  
Diaphragmatic Hernia ◽  
Management Strategies ◽  
Perinatal Outcomes ◽  
Contemporary Management

scholarly journals Use of Integra dermal substitute to prevent implantable device extrusion in an Olympic athlete

2018 ◽  
pp. bcr-2018-226181
Author(s):  
Felicity Page ◽  
Krupali Patel ◽  
Wayne Jaffe
Keyword(s):  
Management Strategies ◽  
Spastic Paraparesis ◽  
Operative Management ◽  
Soft Tissue Coverage ◽  
Dermal Substitute ◽  
Quick Recovery ◽  
Hereditary Spastic Paraparesis ◽  
First Case ◽  
Olympic Athlete ◽  
Intrathecal Medication

We present a challenging case of imminent metallic implant extrusion in a Paralympic athlete managed with a single-stage procedure using ‘Integra’ dermal substitute. The patient had hereditary spastic paraparesis, for which a baclofen pump delivering intrathecal medication was vital in the management of his condition. The device had been most recently implanted into the thigh after previous complications. Integra provided robust soft-tissue coverage over the implanted baclofen pump in the thigh. Different operative management strategies were considered but the use of Integra was felt to offer the least morbidity and a quick recovery. The patient was able to successfully compete in a Paralympic canoeing qualifying event the week following surgery and achieve medal success. To the authors’ knowledge, this is first case in which Integra has been used in such circumstances.

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