To Observe the Treatment Outcomes of Duodenal Injury in Penetrating and Blunt Trauma Patients

Aim: To study about the management of duodenal injury in two clinical aspects, blunt and penetrating injury, along with its complications. Study design: Observational case series. Place and duration of study: Accident & Emergency and General Surgery Departments at M. Islam Teaching Hospital, Gujranwala from March 2019 to March 2020. Methodology: One hundred patients presenting in Accident & Emergency and General Surgical Department of with penetrating chest trauma as diagnosed clinically were included. Routine investigations like complete blood tests, X-rays and special investigations i.e. ultrasound, CT scan were done only in cases where patients were stable. Each hemithorax was divided into medial and lateral hemithorax by an imaginary line drawn longitudinally from clavicle down to the costal margin passing through the nipple. All patients were observed for the type of treatment they were getting i.e. thoracotomy or tube thoracostomy. Patients who were initially treated with tube thoracostomy were cautiously observed for any developing indications for thoracotomy. If such indications arose thoracotomy would be arranged at the earliest possible. Results: A total of 100 patients, 85 (85%) were males and 15 (15%) were females. Male to female ratio was 5.66:1. The mean age of patient was 35.65±9.75 years. There were 38 (38%) had road traffic accidents, 10 (10%) were fall, 7 (7%) injured with fight, 41 (41%) victims of firearm injury and only 4 (4%) victims of stab. The mean blood pressure was 82.15±7.97mmHg. Eighty five (85%) patients were stay in the hospital for 2 weeks and while 15 (15%) were hospital stay >2 weeks. The mean values of hospital stay was 12.45±4.16 days. Conclusion: It is concluded that penetrating thoracic trauma is a major cause of morbidity and mortality. The overall complications rate for blunt trauma injuries after adequate treatment is 18% and mortality rate is 8%. Keywords: Blunt trauma, Thorocotomy, Tube thoracostomy, Pneumothorax

A NEW SURGICAL TECHNIQUE FOR PREVENTION OF LEAKAGE AFTER DUODENAL REPAIRS

Background: Duodenal injuries, due to their retroperitoneal location, are a diagnostic challenge to the surgeon; for this reason, they are identified in a late stage, and thus associated with increased morbidity and mortality. The diagnosis of duodenal injury requires a high level of suspicion. Delayed diagnosis and management of these injuries results in increased morbidity and mortality rates. It must be remembered that the retroperitoneal location of the duodenum usually precludes early detection of injury by physical examination, which is characterised by minimal findings. Signs of defence, abdominal rigidity and absence of bowel sounds indicate intra-abdominal injury and lead to a surgical procedure. There are many different surgical procedures based on injury complexity, one of which is the tube duodenostomy technique. Despite the advances in surgical technique, duodenal lesions are still associated with high morbidity and mortality rates. Purpose: The purpose of this presentation is to describe a new surgical technique in the management of duodenal injuries. Surgical Technique: The technique was performed on a patient, presented with Crohn’s disease together with intestinal tuberculosis, in the management of duodenal injury secondary to duodenocolic fistula and abscess during the postoperative follow-up. The patient was operated on due to invagination, intra-abdominal abscess and general condition deterioration. The second operation was performed because of contrast extravasation from the duodenum. Especially the third part of the technique, application of negative pressure through a tube enterostomy in order to prevent the accumulation of secretions and pressure increase in the duodenum, minimized the intra-duodenal pressure and decreased the risk of anastomotic dehiscence and fistula formation (Figure 1). For this purpose, continuous negative aspiration was performed with an aspiration cannula extended through the enterostomy tube during the first 14 days. The patient was recovered without any complications. Conclusion: The authors concluded that this new technique of “pyloric exclusion, the repair of the mucosal layer of the primary wound in the duodenum with a stapler and of serosa with vicryl, minimizing intra-duodenal pressure by applying negative pressure with the enterostomy tube” can be considered to be an alternative solution for duodenal injuries.

Iatrogenic injury of duodenum: malady of a therapeutic misadventure

Endoscopic procedures are the front-runner of the management of bleeding duodenal ulcer. Rarely, surgical intervention is sought for acute bleeding, not amenable to endoscopic procedures. Oversewing of the gastroduodenal artery at ulcer crater by transduodenal approach is the most acceptable and recommended method of treatment. We describe a case of an intraoperative duodenal injury that occurred during an attempt to oversew the gastroduodenal artery after a duodenotomy, leading to an unsatisfactory and meagre duodenal stump. This case will highlight the intraoperative turmoil, postoperative complications and management of a series of anticipated but unfortunate events that have rendered us wiser in terms of surgical management of a bleeding duodenal ulcer.

A case of traumatic isolated duodenal perforation due to blunt abdominal trauma

Isolated duodenal injury following blunt abdominal trauma is a rare clinical entity and is often unnoticed leading to delay in management thereby increasing morbidity and mortality. We report a case of isolated duodenal perforation following blunt abdominal trauma and highlight the challenges and decision-making dilemmas associated with its management. The present patient had two perforations, one on the anterior and the other on the posterior wall of the duodenum. Complete duodenal mobilization during laparotomy and a decision of performing pyloric exclusion aided momentously in the management.

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.