Duodenal injuries requiring surgical repair are rare. Higher-grade injuries are even more unusual. Hence, the best surgical treatment for complex duodenal injuries is controversial.1,2 Over the years, there have been many techniques described in the treatment of these injuries, especially when involving other organs.2–10 Primary repair is technically possible most of the time. More advanced procedures exist, largely to protect the suture line form dehiscence as leak from the duodenal repair, and can result in life-threatening complications such as septic shock and, in some cases, an increased mortality.2–10
Some of the techniques used to protect the suture line of the duodenum include duodenal diverticulization, pyloric exclusion with or without gastrojejunostomy, and primary repair with a retrograde duodenostomy tube and distal feeding tube.7,11–13 For more complex injuries with devascularization of the duodenum, other options such as resection with enteric anastomosis and the Whipple procedure have been described.7,16–21
We hypothesized that a primary repair alone can be used for duodenal injuries without increased complications such as intra-abdominal sepsis or increased mortality even in cases of high-grade duodenal injuries.
A retrospective multicenter trial was conducted including 11 Panamerican Trauma Society centers. An international chat created by the society, including surgeons from international centers, was used as a recruitment tool.
Each center obtained its own approval of its institutional review board (IRB). Virginia Commonwealth Center was the site for principal investigator and as such had an IRB approved for this purpose.
We included patients with duodenal injuries that required surgical management from January 2007 to December 2016. Data were collected using the REDCap (Research Electronic Data Capture) tool. We also included demographics, mechanism of injury, blood loss, operative time in minutes, and associated injuries. Outcomes included postoperative intra-abdominal sepsis, leak, need for unplanned surgery, length of stay, incidence of renal failure requiring dialysis, and mortality.
All analyses were performed using SAS 9.4 (Statistical Analysis System, North Carolina State University). All tests were two-tailed and assumed a significance level of 0.05. Continuous variables are reported as median with interquartile range and were compared using the Wilcoxon rank test or the Kruskal-Wallis test. Categorical variables were compared using the Fisher exact test. Poisson regression using a backward selection method was used to identify independent predictors of mortality. The center was used to model for intrafacility cluster effects.
Inclusion criteria included patients with duodenal trauma older than 18 years who needed surgical intervention. Exclusion criteria included pregnant patients, incarcerated patients, and patients who died in the first 24 hours.
We hypothesized that there would be far more primary repairs than other types of repairs and that a 20% difference in the rate of complications between primary repairs and other repairs would be significant. We therefore used a Fisher exact test of equal proportions assuming a significance level of 0.05, at two-tailed test, a 3:1 ratio of patients with a 20% difference in complication rates to calculate a power analysis of 73% with Group 1 as other repairs with a sample size of 60 and primary repairs alone with a sample size of 180.
During the study, 372 patients had duodenal injuries requiring surgical repair. Penetrating trauma was the most common mechanism (79%). The majority of these patients had associated intra-abdominal injuries (n = 253 [68%]). There were 128 colon injuries, 107 pancreas injuries, 90 gastric injuries, 44 kidney injuries, 34 inferior vena cava injuries, 24 liver injuries, 23 splenic injuries, 20 injuries to the common bile duct, 14 injuries to the diaphragm, and three aortic injuries. The overall injury burden and severity of duodenal trauma were high, with a median Injury Severity Score (ISS) of 18 (interquartile range, 2–3), median abdominal Abbreviated Injury Scale of 3.5 (3–4), and a median American Association for the Surgery of Trauma (AAST) duodenal injury grade of 3 (2–3). There were 181 Grade 3 injuries. However, of the 283 patients where the AAST grade was available, 217 (77%) were high grade (AAST grade >2).
Primary repair alone was the most common type of operative management (299 [80%]). In addition, 16 patients had pyloric exclusion with a gastrojejunostomy, 13 had pyloric exclusion without gastrojejunostomy, 37 had primary repair with retrograde decompressive duodenostomy with or without distal feeding tube, five had resection with primary anastomosis, and two had a Whipple procedure (Table 1).
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 (Table 2). Poisson regression showed higher ISS, associated pancreatic injury, renal failure requiring renal replacement therapy, the need for preoperative transfusion, and male gender remained significant predictors of mortality (Table 3). 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 (Table 4).
Injuries to the duodenum requiring surgical repair are relatively rare. However, the morbidity and mortality of these remain high. The location of the duodenum adjacent to important vascular and biliary structures, as well as the pancreas, makes isolated duodenal injuries relatively rare. This was certainly true in our data, as nearly 70% of patients had an associated intra-abdominal injury. Immediate mortality is usually not due to the duodenal injury, but instead due to hemorrhagic shock from associated injuries. As we wished to examine success of primary duodenal repair, we excluded early deaths.
Morbidity and late mortality in duodenal injuries are usually related to sepsis and/or other intra-abdominal complications, particularly duodenal suture line dehiscence. However, determining the safest way to repair the injured duodenum to prevent duodenal suture line leak has been difficult. For years, trauma surgeons assumed that more complex duodenal injuries were better served by more complicated methods of repair. A number of rules were generated with a paucity of data to support any of these. For instance, common dogma was that any duodenal injury greater than 50% of the circumference required some manner of duodenal diversion.
A number of procedures became popular. Stone and Fabian14 described a method of triple-tube diversion. Patients with duodenal injury had a primary repair and then were diverted with a gastrostomy, a retrograde duodenostomy, and a feeding jejunostomy. In their series of 237 patients, only one patient developed suture line leak when using this technique. However, eight of the 44 patients not treated with decompression developed duodenal leak.
Duodenal diverticularization was first described by Berne et al.15 to treat a severe duodenal injury. The duodenal injury was repaired. An antrectomy with end-to-side gastrojejunostomy was then performed with a tube duodenostomy for duodenal decompression. The magnitude of this operative procedure required some degree of hemodynamic stability. It also altered normal anatomy, interfered with normal eating, and could be ulcerogenic. Finally, pyloric exclusion was described in the late 1970s. This consists of opening the stomach and suturing the pylorus closed with an absorbable suture. This was originally done with a gastrojejunostomy to drain the stomach. Later, surgeons began eliminating the gastrojejunostomy and drained the stomach with either a nasogastric tube or a gastrostomy. This protected the duodenal repair, at least temporarily. Over some weeks, the pyloric closure reopened, restoring normal anatomy.
In our series, primary repair alone was the most common method used to repair duodenal injuries. Primary repair alone was used in 80% of patients. This was true even in high-grade duodenal injuries. In the 20% treated with other techniques, a variety of operative procedures were used. The most common procedure used was primary repair supplemented with retrograde decompression. Only seven patients, approximately 2.5%, had injuries where primary repair was not possible. Five had resection with anastomosis, and two had a Whipple procedure.
Overall mortality was approximately 25%. Perhaps not surprisingly, mortality was related to physiology at the time of presentation, intraoperative factors such as blood loss, injury severity, renal failure, and associated pancreatic injury. This was true, for the most part, on both univariate analysis and logistic regression. The choice of the method used for duodenal repair did not predict morbidity or mortality. In fact, complications such as duodenal leak, sepsis, and need for unplanned reoperation were statistically significantly lower when primary repair was used. This was true over every AAST grade of injury.
Death is a consequence of blood loss. This seems to be the case, even when early deaths (within 24 hours) are excluded. There are major adjacent vascular and structures such as the inferior vena cava in the aorta. Approximately 12% of our patients had injury to these structures. In addition, an additional 70 patients had solid organ injury, to the kidney, liver, or spleen. Any of these injuries could have produced a substantial blood loss. Admission blood pressure, need for preoperative transfusion, and intraoperative blood loss all predicted mortality on univariate analysis.
Common complications included sepsis, duodenal leak, and the need for unplanned reoperation. Associated pancreatic injury is a known risk factor for these complications. Even with good external and/or internal drainage, pancreatic enzyme leak can weaken gastrointestinal suture lines producing leak. It is not a surprise that associated pancreatic injury was associated with mortality on both univariate analysis and logistic regression.
We retrospectively reviewed data from 11 Panamerican Trauma Society centers over 10 years. Despite the fact that most of these are high-volume centers, seeing a large amount of penetrating injury, in fact each center saw a mean of 3.5 duodenal injuries per year. Given the number of surgeons taking call, each individual surgeon performed a relatively small number of duodenal repairs. This may have affected results. Additionally, the number of procedures performed other than primary repair is fairly small. This also could potentially have affected the data. The resources between the various hospitals may have varied. It is not possible to know whether this affected the choice of duodenal repair and/or the outcomes.
Primary repair is a safe and efficacious manner of treating duodenal injury. The vast majority, 98% of patients in this series, had duodenal injuries amenable to primary repair. While more complex options do exist, it is unclear that they are any better than primary repair alone. Primary repair is the treatment of choice. Adding pyloric exclusion and/or additional decompression should be reserved for special cases.
P.F. developed the hypothesis, recruited centers, and collected the data. L.W. analyzed the data. All other authors contributed with data as well as revisions of the manuscript. T.S. performed a critical revision of the manuscript.
Jinfeng Han was the main site study coordinator in charge of managing the data and IRB procedures and site coordination. Salem Rustom assisted with the statistical analyses.
The authors declare no conflicts of interest.
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Gregory J. “Jerry” Jurkovich, M.D. (Sacramento, California): Good afternoon, members and guests, President-Elect Croce, Dr. Winchell. Thank you for the honor of discussing this important paper.
The presentation was based, as you heard, on a multi-center review from North, Central and South American trauma hospitals. It represents an effort from the Panamerican Trauma Society, and this collaboration is representative of this landmark meeting of the AAST and the World Trauma Congress, so well done.
Dr. Ferrada and her colleagues have emphasized the great variability that exists in the management of duodenal injuries.
Over the decade of this retrospective review, the 13 trauma centers who compiled the data managed a large number – 372 patients – with duodenal injuries. It is not a common entity, but also not so rare that every surgeon will eventually have to face this management dilemma.
I have a few observations about this cohort of duodenal trauma patients that are worth noting, and along with that will be my questions.
Number one, 80 percent of this population suffered penetrating trauma. Are the factors that influence the outcome any different between penetrating and blunt trauma mechanisms?
Secondly, associated injuries are highly common, and I presume that hemorrhage control and control of contamination remain the highest priorities of initial trauma care.
To that end, mortality was high, at 24 percent, and while many of these deaths are likely due to acute blood loss, the authors did not provide us with data on the timeline nor the cause of mortality, so what was the time of death and the cause of death in these 24 percent of patients?
And fourth, four of the study centers were from North America, but the remainder were from Central or South America. Are there any differences in management style and outcome noted based on the geography of the trauma centers?
And finally, I would like to emphasize the operative techniques utilized. Primary repair alone was performed in 80 percent of the patients, as we heard.
Are any of the adjuncts to simple primary repair or resection in primary anastomosis really necessary or beneficial in the management of duodenal trauma?
I believe that's the crux of the dilemma of judgment that faces the trauma surgeon in the middle of the night in trying to decide how to manage these patients.
Perhaps for the very rare circumstance of significant loss of duodenal tissue, a resection and primary anastomosis will be required – that was five patients in this series –, or if tension exists, a roux-en-Y limb of intestine will need to be sutured to the proximal duodenum to establish continuity – none in this series – or even rarer, a pancreatic-duodenectomy and Whipple reconstruction will be needed for a complete destruction of the duodenum and pancreatic head – and there were two in this series.
But the role of pyloric exclusion, duodenostomy tube, prograde or retrograde duodenal lumen decompression, buttressing of the duodenal repairs, et cetera, their role remains unanswered. And I wonder what the authors could suggest as a way to help resolve some of these uncommon intra-operative questions about management.
Finally, my sincere congratulations on this accomplishment, as this is the first multi-center trial study from the PanAmerican Trauma Society.
Sheldon H. Tepperman (Bronx, New York): Dr. Ferrada, I, too, offer my congratulations. Awesome.
So, Dr. Ron Gross is sitting here in the audience on his computer, and he is about to update the definitive textbook on this question, which would be the Advanced Trauma Operative Management course. And so there is a chapter on duodenal injury.
And as we are teaching this course, it's confusing for our young surgeons. So is it time to turn to Dr. Gross and offer the advice of, let's down-regulate all of these tubes and things and just tell people to do a primary repair?
Omar Bekdache, M.D., F.R.C.S., F.A.C.S. (Montreal, Canada): My question is, how was the assessment of the associated pancreatic injury done intra-operatively, and how did this impact your management protocol intra-operatively for the primary type of repair? Thank you.
Marc A. de Moya, (Milwaukee, Wisconsin): Thank you, Dr. Ferrada, always great presentations, and my question actually has to do with the leaks.
You had a significant number of patients in this cohort, and so it would be nice to kind of drill down into the type of leak, and whether or not, if you separated those that had a leak versus those who didn't have a leak, rather than look at the mortality.
Was there any difference at all among the groups, in terms of the technique of closure, and then also the management, because not all leaks are the same, right? So, if you could just shed some light on that, perhaps.
Ari K. Leppaniemi, M.D., Ph.D. (Helsinki, Finland): Nice work, Paula. Congratulations. As Marc was saying, the key to duodenal injuries is really the leak. And I saw you showed some data on that, but I would be interested if you could elaborate a little bit more how you managed the leaks, and how much the leaks actually contributed to the outcomes in terms of not just mortality, but complications, length of stay, and so on.
Paula Ferrada, M.D.(Glen Allen, Virginia): Thank you everybody for the wonderful comments and support.
We excluded the deaths within the first 24 hours, because we wanted to hone in on the deaths secondary to intra-abdominal sepsis.
Regarding how many patients had a leak, those that underwent primary repair leaked less however no repair showed a decreased mortality.
To answer the question about if there was a difference between North America and Latin America, the large majority of the patients underwent primary repair, and surgeons in Latin America almost exclusively used primary repair.
I agree with the statement that perhaps it's time to at the very least attempt primary repair, if there is adequate blood supply, and no other injuries that can prevent this repair. It is more likely the patients would heal one anastomosis than several other enterotomies that can cause further morbidity for our patients.
Thank you so much for the opportunity to present this paper. It is an honor for the Panamerican Trauma Society to present our fist multicenter trial in this forum.