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.

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Simple repair is sufficient for most injuries to the duodenum - a case series of 23 patients

Annals of King Edward Medical University ◽

10.21649/akemu.v12i1.831 ◽

2016 ◽

Vol 12 (1) ◽

Author(s):

Munir Ahmad Rathore ◽

Syed Muzahir Najfi ◽

Muhammad Farooq Afzal ◽

Abdul Majeed Chaudhry

Keyword(s):

Injury Severity ◽

Primary Repair ◽

Time Lag ◽

Case Series ◽

Operation Time ◽

Associated Injuries ◽

Hollow Viscus ◽

Senior Registrar ◽

Duodenal Injuries ◽

Simple Repair

Background: Duodenal injury is the most important hollow viscus injury in the abdomen. The study analysed the outcome of duodenal injuries at the unit. Patients & Methods: Prospectively collected data on a case series involving 23 patients over 3 years. It involved demographic details, part of duodenum injured, injury severity according to the AAST, injury-operation time lag, mode of repair, and the extent of significant associated injuries. Results: M:F ratio was 4.75:1. Mean age 33yrs. Patients with non-perforating injury were excluded. All were operated by a senior registrar or senior. 7/23 were blunt, 13/23 firearm & 3/23 stab injuries. D2 was involved in 87%. Injury severity was graded according to AAST (American Association for Surgery of Trauma). 17/23 were Grade II/III, 3 Grade IV & 3 Grade V injuries. Four had injury-operation lag of >18hrs. Two injuries were missed. All injuries up to Grade IV had simple repair. Two of them had T-tube duodenostomy. None had pyloric exclusion. Complex repairs wer e required for 3/23 patients. Five patients died, as a result of associated insults. One delayed repair developed duodenal fistula. Intra-abdominal abscess, septicaemia and wound dehiscence were seen in two patients each. Duodenum-related mortality was zero. Adverse prognostic factors towards morbidity were injury severity >GIII and injury-operation lag >18hrs. The mortality was related to associated injuries. Conclusion: Primary repair is sufficient for most non-resectional duodenal injuries.

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Predictors of Morbidity and Mortality in Patients with Traumatic Duodenal Injuries

The American Surgeon ◽

10.1177/000313480507100914 ◽

2005 ◽

Vol 71 (9) ◽

pp. 763-767 ◽

Cited By ~ 12

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.

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

ISRN Pediatrics ◽

10.5402/2012/298753 ◽

2012 ◽

Vol 2012 ◽

pp. 1-4 ◽

Cited By ~ 1

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.

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Uždari dvylikapirštės žarnos sužalojimai: Klaipėdos ligoninės patirtis

Lietuvos chirurgija ◽

10.15388/lietchirur.2005.2.2319 ◽

2005 ◽

Vol 3 (2) ◽

pp. 0-0

Author(s):

Algirdas Šlepavičius ◽

Feliksas Grigalauskas ◽

Vaidotas Turskis

Keyword(s):

Retroperitoneal Space ◽

Suture Repair ◽

Significant Morbidity ◽

Results Of Treatment ◽

Pyloric Exclusion ◽

Hospital Patients ◽

Additional Procedure ◽

Duodenal Injuries ◽

Simple Repair ◽

Repair Group

Algirdas Šlepavičius, Feliksas Grigalauskas, Vaidotas TurskisKlaipėdos ligoninė,Liepojos g. 41, LT-5808 KlaipėdaEl paštas: [email protected] Įvadas Uždari dvylikapirštės žarnos sužalojimai yra reti. Diagnozė dažniausiai nustatoma tik operacijos metu. Šio darbo tikslas – išanalizuoti Klaipėdos ligoninės 20 metų (1985–2005 m.) patirtį, susijusią su uždarų dvylikapirštės žarnos plyšimų diagnozavimu ir gydymu. Pacientai ir metodai Nekomplikuoti dvylikapirštės žarnos plyšimai be aiškių retroperitoninio tarpo infekcijos požymių buvo gydomi dvylikapirštės žarnos sienos užsiuvimu ir retroperitoninio tarpo drenavimu. Prievarčio izoliavimas buvo taikomas, kai sužalojimai sunkesni, operacija uždelsta ir esama retroperitoninio tarpo flegmonos reiškinių. Rezultatai Operuota 14 ligonių. Aštuoniems iš jų dvylikapirštės žarnos žaizda užsiūta, o šešiems – žaizdos užsiuvimas papildytas prievarčio izoliavimu. Pooperacinių komplikacijų buvo 8 ligoniams. Keturi ligoniai mirė. Išvados Nekomplikuoti dvylikapirštės žarnos plyšimai gali būti gydomi užsiuvant žarnos defektą. Susidarius retroperitoninio tarpo pūlynui, žarnos sienos užsiuvimą reikėtų derinti su prievarčio izoliavimu. Reikšminiai žodžiai: uždara dvylikapirštės žarnos trauma, chirurginis gydymas, komplikacijos, mirštamumas Blunt duodenal trauma: experience of the Klaipėda Hospital Algirdas Šlepavičius, Feliksas Grigalauskas, Vaidotas TurskisKlaipėda Hospital,Liepojos str. 41, LT-5808 Klaipėda, LithuaniaE-mail: [email protected] Background / objective Blunt duodenal injuries are relatively rare. The diagnosis is usually delayed, resulting in a significant morbidity and mortality. The purpose of this study was to examine the results of treatment of patients with blunt duodenal injuries at our hospital. Patients and methods This is a retrospective study of patients who sustained blunt duodenal injuries and were admitted to Klaipėda Hospital in 1985 through 2005. During the study period, the managment of duodenal injuries at our institution depended on the severity of injuries, timing of diagnosis and presence of retroperitoneal infection. Uncomplicated wounds of the duodenum with no obvious retroperitoneal infection were treated by simple duodenum repair and drainage of the retroperitoneal space. Pyloric exclusion was performed in cases of difficult duodenal repair and in the presence of retroperitoneal infection. Results Fourteen patients were entered into the study. All of them were operated on: eight underwent a simple repair with drainage of retroperitoneal space, and six underwent a simple repair of duodenal wounds combined with pyloric exclusion. Nine patients developed complications. Three patients had duodenal fistulas: two in the simple repair group and one in the pyloric exclusion group. Four patients died. Conclusions The diagnosis of blunt duodenal injuries before surgery is difficult. Uncomplicated duodenal wounds should be treated by simple suture repair. Pyloric exclusion is a useful additional procedure in patients with complicated duodenal injuries and in the presence of retroperitoneal infection. Keywords: blunt duodenal trauma, surgical treatment, postoperative complications, mortality

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

The American Surgeon ◽

10.1177/000313480807401009 ◽

2008 ◽

Vol 74 (10) ◽

pp. 925-929 ◽

Cited By ~ 23

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.

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Emergency trauma laparotomy and/or thoracotomy in the emergency department: risks and benefits

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2018-000269 ◽

2019 ◽

Vol 4 (1) ◽

pp. e000269 ◽

Cited By ~ 2

Author(s):

Kaori Ito ◽

Kahoko Nakazawa ◽

Tsuyoshi Nagao ◽

Hiroto Chiba ◽

Yasufumi Miyake ◽

...

Keyword(s):

Emergency Department ◽

Injury Severity ◽

Balloon Occlusion ◽

Red Blood Cell Transfusion ◽

Acute Care Surgery ◽

Perioperative Outcomes ◽

Emergency Laparotomy ◽

Level Of Evidence ◽

Anesthetic Care ◽

Care Surgery

BackgroundIt is not mandatory for Japanese trauma centers to have an operating room (OR) and OR team available 24 hours a day/7 days a week. Therefore, emergency laparotomy/thoracotomy is performed in the emergency department (ED). The present study was conducted to assess the safety of this practice.MethodsThe data were reviewed from 88 patients who underwent emergency trauma laparotomy and/or thoracotomy performed by our acute care surgery group during the period from April 2013 to December 2017. Operation was performed in the ED for 43 of 88 patients (51%, ED group), and in the OR for 45 of 88 patients (49%, OR group). The perioperative outcomes of the two groups were compared.ResultsCompared with the OR group, the ED group had a higher Injury Severity Score (30±15 vs. 13±10, p<0.01), greater incidence of blunt trauma (74% (32/43) vs. 36% (16/45), p<0.01), larger volume of red blood cell transfusion (18±18 units vs. 5±10 units, p<0.01), higher incidence of new-onset shock after sedation among patients who received sedation in the ED (59% (17/29) vs. 25% (6/24), p<0.01), and higher in-hospital mortality rate (49% (21/43) vs. 0, p<0.01). All five patients who underwent laparotomy followed by thoracotomy died in the ED; none of these patients underwent preoperative placement of resuscitative endovascular balloon occlusion of the aorta (REBOA). Of the 21 patients in the ED group who died, 17 (81%) died immediately postoperatively; furthermore, 12 of the 22 patients who survived (55%) were not in shock prior to operation.DiscussionEmergency trauma laparotomy and/or thoracotomy outcomes were related to injury severity. The resources for trauma operations in the ED seemed suboptimal. The outcome of trauma operations may be improved by reviewing the protocols for anesthetic care, and by the usage of REBOA rather than aortic cross-clamping.Level of evidenceIV

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Rapid Detection of Significant Traumatic Brain Injury Requiring Emergency Intervention

The American Surgeon ◽

10.1177/0003134820973355 ◽

2020 ◽

pp. 000313482097335

Author(s):

Isaac W. Howley ◽

Jonathan D. Bennett ◽

Deborah M. Stein

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Brain Injuries ◽

Trauma Team ◽

Altered Mental Status ◽

Acute Care Surgery ◽

Ct Scanner ◽

Mickey Mouse ◽

Clinically Significant ◽

Care Surgery

Moderate and severe traumatic brain injuries (TBI) are a major cause of severe morbidity and mortality; rapid diagnosis and management allow secondary injury to be minimized. Traumatic brain injury is only one of many potential causes of altered mental status; head computed tomography (HCT) is used to definitively diagnose TBI. Despite its widespread use and obvious importance, interpretation of HCT images is rarely covered by formal didactics during general surgery or even acute care surgery training. The schema illustrated here may be applied in a rapid and reliable fashion to HCT images, expediting the diagnosis of clinically significant traumatic brain injury that warrants emergent medical and surgical therapies to reduce intracranial pressure. It consists of 7 normal anatomic structures (cerebrospinal fluid around the brain stem, open fourth ventricle, “baby’s butt,” “Mickey Mouse ears,” absence of midline shift, sulci and gyri, and gray-white differentiation). These 7 features can be seen even as the CT scanner obtains images, allowing the trauma team to expedite medical management of intracranial hypertension and pursue neurosurgical consultation prior to radiologic interpretation if the features are abnormal.

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Acute Care Surgery Billing, Coding and Documentation Series Part 3: Coding of Additional Select Procedures; Modifiers; Telemedicine Coding; Robotic Surgery

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000587 ◽

2020 ◽

Vol 5 (1) ◽

pp. e000587

Author(s):

Thomas Esposito ◽

Robert Reed ◽

Raeanna C Adams ◽

Samir Fakhry ◽

Dolores Carey ◽

...

Keyword(s):

Complex System ◽

Robotic Surgery ◽

Acute Care ◽

Acute Care Surgery ◽

Formal Training ◽

Experienced Surgeon ◽

Care Surgery

This series of reviews has been produced to assist both the experienced surgeon and coder, as well as those just starting practice that may have little formal training in this area. Understanding this complex system will allow the provider to work “smarter, not harder” and garner the maximum compensation for their work. We hope we have been successful in achieving and that goal that this series will provide useful information and be worth the time invested in reading it by bringing tangible benefits to the efficiency of practice and its reimbursement. This third section deals with coding of additional select procedures, modifiers, telemedicine coding, and robotic surgery.

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