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Management of duodenal trauma

A retrospective review from the Panamerican Trauma Society

Ferrada, Paula, MD; Wolfe, Luke, MS; Duchesne, Juan, MD; Fraga, Gustavo P., MD; Benjamin, Elizabeth, MD; Alvarez, Augustin, MD; Campbell, Andre, MD; Wybourn, Christopher, MD; Garcia, Alberto, MD; Morales, Carlos, MD; Correa, Julieta, MD; Pereira, Bruno M., MD; Ribeiro, Marcelo, MD; Quiodettis, Martha, MD; Peck, Gregory, DO; Salamea, Juan C., MD; Kruger, Victor F., MD; Ivatury, Rao R., MD; Scalea, Thomas, MD

Journal of Trauma and Acute Care Surgery: March 2019 - Volume 86 - Issue 3 - p 392–396
doi: 10.1097/TA.0000000000002157
AAST 2018 PODIUM PAPER
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INTRODUCTION The operative management of duodenal trauma remains controversial. Our hypothesis is that a simplified operative approach could lead to better outcomes.

METHODS We conducted an international multicenter study, involving 13 centers. We performed a retrospective review from January 2007 to December of 2016. Data on demographics, mechanism of trauma, blood loss, operative time, and associated injured organs were collected. Outcomes included postoperative intra-abdominal sepsis, leak, need for unplanned surgery, length of stay, renal failure, and mortality. We used the Research Electronic Data Capture tool to store the data. Poisson regression using a backward selection method was used to identify independent predictors of mortality.

RESULTS We collected data of 372 patients with duodenal injuries. Although the duodenal trauma was complex (median Injury Severity Score [ISS], 18 [interquartile range, 2–3]; Abbreviated Injury Scale, 3.5 [3–4]; American Association for the Surgery of Trauma grade, 3 [2–3]), primary repair alone was the most common type of operative management (80%, n = 299). Overall mortality was 24%. On univariate analysis, mortality was associated with male gender, lower admission systolic blood pressure, need for transfusion before operative repair, higher intraoperative blood loss, longer operative time, renal failure requiring renal replacement therapy, higher ISS, and associated pancreatic injury. Poisson regression showed higher ISS, associated pancreatic injury, postoperative renal failure requiring renal replacement therapy, the need for preoperative transfusion, and male gender remained significant predictors of mortality. Duodenal suture line leak was statistically significantly lower, and patients had primary repair over every American Association for the Surgery of Trauma grade of injury.

CONCLUSIONS The need for transfusion prior to the operating room, associated pancreatic injuries, and postoperative renal failure are predictors of mortality for patients with duodenal injuries. Primary repair alone is a common and safe operative repair even for complex injuries when feasible.

LEVEL OF EVIDENCE Therapeutic study, level IV.

From the Virginia Commonwealth University (P.F., L.W., R.I.), Richmond, Virginia; Tulane University (J.D.), New Orleans, Louisiana; University of Campinas (G.P.F., B.M.P.), Campinas, Brazil; Keck School of Medicine (E.B., A.A.), University of Southern California, Los Angeles, California; University of San Francisco (A.C., C.W.), San Francisco, California; Clinical Research Center (A.G.), Fundación Valle del Lili, Cali, Colombia; Universidad de Antioquia-Hospital Universitario San Vicente Fundación (C.M.J.C.), Medellin, Colombia; Hospital Geral Grajaú–Universidade Santo Amaro (M.R.), São Paulo, Brazil; Hospital Santo Tomas (M.Q.), Cuidada de Panamá, Panamá; Robert Wood Johnson Medical School (G.P.); Hospital Vicente Corral Moscoso–Universidad del Azuay (J.C.S.), Cuenca, Ecuador; and Shock Trauma Centre (T.S.), University of Maryland, College Park, Maryland.

Address for reprints: Paula Ferrada, MD, VCU Surgery Trauma, Critical Care and Emergency Surgery, PO Box 980454, Richmond, VA 23298; email: pferrada@mcvh-vcu.edu.

Presented as an oral presentation at the 77th American Association for the Surgery of Trauma annual meeting in San Diego, California, September 2018.

© 2019 Lippincott Williams & Wilkins, Inc.