RESUMEN
INTRODUCTION: High-grade pancreaticoduodenal injuries are highly morbid and may require complex surgical management. Pancreaticoduodenectomy (Whipple procedure) is sometimes utilized in the management of these injuries, but guidelines on its use are lacking. This paper aims to present our 14-year experience in management of high-grade pancreaticoduodenal injuries at our busy, urban trauma center. METHODS: A retrospective review was performed on patients (ages >15 years) presenting with high-grade (AAST-OIS Grades IV and V) injuries to the pancreas or duodenum at our Southeastern Level 1 trauma center. Inclusion criteria included high-grade injury and requirement of Whipple procedure based on surgeon discretion. Patients were divided into two groups: (1) those who underwent Whipple procedures during the index operation and (2) Whipple candidates. Whipple candidates included patients who received Whipples in a staged fashion or who would have benefited from the procedure but either died or were salvaged to another procedure. Demographics, injury patterns, management, and outcomes were compared. Primary outcome was survival to discharge. RESULTS: Of 66,272 trauma patients in this study period, 666 had pancreatic or duodenal injuries, and 20 met inclusion criteria. Of these, 6 had Whipples on the index procedure and 14 were Whipple candidates (among whom 7 had staged Whipples, 6 died before completing a Whipple, and 1 was salvaged). Median (IQR) age was 28 (22.75-40) years. Patients were 85 % male, 70 % Black. GSWs comprised 95 % of injuries. All patients had at least one concomitant injury, most commonly major vascular injury (75 %), colonic injury (65 %), and hepatic injury (60 %). In-hospital mortality among Whipple patients was 15 %. CONCLUSIONS: Complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy are rare but life-threatening. In such patients, hemorrhage was the leading cause of death in the first 24 h. Approximately half underwent damage control surgery with staged Whipple Procedures. However, pancreaticoduodenectomy at the initial operation is feasible in highly selective patients, depending on the extent of injury, physiologic status, and resuscitation.
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Traumatismos Abdominales , Duodeno , Páncreas , Pancreaticoduodenectomía , Centros Traumatológicos , Humanos , Pancreaticoduodenectomía/métodos , Masculino , Duodeno/lesiones , Duodeno/cirugía , Estudios Retrospectivos , Femenino , Páncreas/lesiones , Páncreas/cirugía , Adulto , Resultado del Tratamiento , Traumatismos Abdominales/cirugía , Traumatismos Abdominales/mortalidad , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/mortalidad , Puntaje de Gravedad del Traumatismo , Persona de Mediana Edad , Adulto JovenRESUMEN
BACKGROUND The Over-the-Scope-Clip (OTSC) System is a class of endoscopic clips intended to provide improved strength and tissue capture compared to conventional through-the-scope clips. These clips are generally safe and effective in managing many gastrointestinal conditions, with a low overall adverse event rate. Although the OTSC has been used to treat gastrointestinal bleeding and bowel perforations for many years, it often is relegated to second-line therapy and has only recently become a first-line hemostatic therapy for gastrointestinal bleeding. CASE REPORT Here, we present a unique adverse event of the OTSC causing iatrogenic ligation of the gastroduodenal artery (GDA). A 71-year-old man presented with 6 months of epigastric abdominal pain and 2 weeks of hematemesis, and was ultimately diagnosed with a bleeding duodenal ulcer. He underwent multiple endoscopic interventions to attempt to control the duodenal ulcer bleeding, including placement of the OTSC on a visible vessel. Soon after OTSC placement, he became hypotensive with recurrent hematochezia, and Interventional Radiology was consulted for endovascular management of the bleeding. Angiography showed the OTSC had been deployed across the midportion of the GDA from the duodenal lumen, effectively ligating the GDA, causing bleeding due to direct vascular injury. This bleeding was ultimately controlled with coil embolization. However, this iatrogenic ligation of the midportion of the GDA by the OTSC significantly complicated endovascular intervention to control the bleeding. CONCLUSIONS As the OTSC device becomes more commonly used in the endoscopy suite, it is important to share potential pitfalls that may be encountered in the clinical setting that impact not only endoscopists and patients, but other specialties as well.
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Duodeno , Enfermedad Iatrogénica , Humanos , Masculino , Anciano , Ligadura , Duodeno/lesiones , Duodeno/irrigación sanguínea , Instrumentos Quirúrgicos , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/terapia , Úlcera DuodenalRESUMEN
BACKGROUND: Duodenal injuries are relatively rare but remain a management challenge with a high incidence of postoperative complications. Guidelines from the World Society of Emergency Surgery and American Association for the Surgery of Trauma favour a primary repair for less-complex injuries, but the management of more complex duodenal trauma remains controversial with varying techniques supported, including pyloric exclusion, omental or jejunal patch closure, gastrojejunostomy and pancreatoduodenectomy. We describe the techniques used in one case of complex duodenal trauma. TECHNIQUE: The duodenum is approached via a standard laparotomy with Kocherisation. Primary repair of the duodenal perforations is performed using a 3/0 polydioxanone suture (PDS), followed by mobilisation of a loop of mid-jejunum against the area of duodenal trauma over the primary repair as a jejunal serosal patch. The antimesenteric jejunal serosal border is sutured to the serosa of the duodenum (serosa only) using a 3/0 PDS. Pyloric exclusion is then performed through an anterior gastrostomy, to control the volume of gastric juice entering the duodenum. The pylorus is sutured closed using an absorbable suture followed by closure of the anterior gastrostomy using a GIA stapling device.
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Duodeno , Yeyuno , Píloro , Humanos , Masculino , Duodeno/lesiones , Duodeno/cirugía , Perforación Intestinal/cirugía , Perforación Intestinal/etiología , Yeyuno/cirugía , Yeyuno/lesiones , Píloro/cirugía , Membrana Serosa/lesiones , Membrana Serosa/trasplante , Técnicas de Sutura , Persona de Mediana EdadRESUMEN
A 71-year-old woman underwent endoscopic submucosal dissection for early duodenal cancer at the second portion of the duodenum and developed acute peritonitis due to delayed duodenal perforation. Emergency laparotomy was performed. A huge perforation formed at the descending duodenum without ampulla involvement. Pancreas-sparing partial duodenectomy (PPD) with gastrojejunostomy was performed (250 min operative time) with 50 mL of intraoperative blood loss. She required intensive care for 3 days and was discharged on postoperative day 21 with no severe complications. Emergency treatment for a major duodenal injury or perforation remains challenging because of high morbidity and mortality. An appropriate treatment should be considered according to the nature of the defect. Although PPD is an acceptable procedure for patients with a duodenal neoplasm, its use in emergency surgery is rarely reported. PPD is more reliable than primary repair or anastomosis using a jejunal wall, and less invasive than pancreaticoduodenectomy, for emergency treatment. We performed PPD in this patient because the duodenal perforation was too large to reconstruct and did not involve the ampulla. PPD can be a safe and feasible alternative surgical procedure to pancreaticoduodenectomy for a major duodenal perforation, especially in patients with a duodenal perforation that does not involve the ampulla.
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Neoplasias Duodenales , Úlcera Duodenal , Femenino , Humanos , Anciano , Pancreaticoduodenectomía/métodos , Resultado del Tratamiento , Páncreas/cirugía , Duodeno/cirugía , Duodeno/lesiones , Neoplasias Duodenales/cirugía , Úlcera Duodenal/complicaciones , Úlcera Duodenal/cirugía , Anastomosis QuirúrgicaAsunto(s)
Duodeno , Humanos , Estudios Retrospectivos , Duodeno/cirugía , Duodeno/lesiones , Factores de RiesgoRESUMEN
Given its crucial location at the crossroads of the gastrointestinal tract, the hepatobiliary system and the splanchnic vessels, the duodenum can be affected by a wide spectrum of abnormalities. Computed tomography and magnetic resonance imaging, in conjunction with endoscopy, are often performed to evaluate these conditions, and several duodenal pathologies can be identified on fluoroscopic studies. Since many conditions affecting this organ are asymptomatic, the role of imaging cannot be overemphasized. In this article we will review the imaging features of many conditions affecting the duodenum, focusing on cross-sectional imaging studies, including congenital malformations, such as annular pancreas and intestinal malrotation; vascular pathologies, such as superior mesenteric artery syndrome; inflammatory and infectious conditions; trauma; neoplasms and iatrogenic complications. Because of the complexity of the duodenum, familiarity with the duodenal anatomy and physiology as well as the imaging features of the plethora of conditions affecting this organ is crucial to differentiate those conditions that could be managed medically from the ones that require intervention.
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Neoplasias , Enfermedades Pancreáticas , Humanos , Duodeno/diagnóstico por imagen , Duodeno/lesiones , Tomografía Computarizada por Rayos X/métodos , Imagen por Resonancia Magnética/métodos , Neoplasias/patologíaRESUMEN
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.
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Traumatismos Abdominales , Enfermedades Duodenales , Heridas no Penetrantes , Humanos , Masculino , Adulto , Femenino , Estudios Retrospectivos , Duodeno/cirugía , Duodeno/lesiones , Traumatismos Abdominales/diagnóstico , Traumatismos Abdominales/cirugía , Heridas no Penetrantes/cirugía , HematomaRESUMEN
Traumatic duodenal injuries are rare and often challenging to diagnose and treat. Management of these injuries remains controversial and continues to evolve. Here, we performed a review of the literature and guidelines for the diagnosis and management of traumatic duodenal injuries.A common recommendation in more recent literature is primary, tension-free repair of duodenal injuries when possible if surgical repair is necessary. Conversely, if duodenal injuries are unamenable to primary repair, more complex procedures such as Roux-en-Y duodenojejunostomy or pancreaticoduodenectomy may be necessary. Regardless of injury grade or type of surgical repair, the literature continues to support wide extraluminal drainage. Over time, the management of complex duodenal injuries has evolved to favor simple primary repair whenever possible. According to recent studies, more complex procedures are associated with higher rates of post-operative complications and should be reserved for severe injuries when primary repair is not possible.
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Traumatismos Abdominales , Heridas Penetrantes , Humanos , Estudios Retrospectivos , Duodeno/cirugía , Duodeno/lesiones , Pancreaticoduodenectomía , Heridas Penetrantes/cirugía , Anastomosis Quirúrgica/métodos , Traumatismos Abdominales/diagnóstico , Traumatismos Abdominales/cirugíaRESUMEN
Introduction: Iatrogenic duodenal injuries represent a condition associated with high morbidity and even mortality. Management is still controversial with a lack of consensus among experts regarding the optimal treatment. The purpose of the present study was to test and assess the results of a certain reconstruction technique. Material and Methods: Four patients (2 males and 2 females) of a mean age of 83 years with iatrogenic duodenal injuries underwent surgical repair of the duodenal perforation, with a two-layer duodenojejunostomy and a Roux-en-Y jejunal loop. Results: Three out of four patients (75%) had a rapid and uncomplicated recovery (13 days mean postoperative length of hospital stay), while the fourth patient died in the ICU due to ARDS three weeks later, without however evidence of anastomotic leak. Conclusion: A variety of surgical repair techniques have been proposed to date; however, with controversial results. A repair using an isolated jejunal Roux-en-Y loop seems to fulfill all the optimal prerequisites for a successful anastomotic outcome and proved efficient in its certain form for the given patient sample.
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Anastomosis en-Y de Roux , Duodeno , Anciano de 80 o más Años , Duodeno/lesiones , Duodeno/cirugía , Femenino , Humanos , Enfermedad Iatrogénica , Yeyuno/cirugía , Masculino , Resultado del TratamientoRESUMEN
Background and Objectives: Traumatic duodenal injury is a rare disease with limited evidence. We aimed to evaluate the risk factors for postoperative leakage and outcomes of pyloric exclusion after duodenal grade 2 and 3 injury. Materials and Methods: We reviewed a prospectively collected trauma database for the period January 2004-December 2020. Patients with grade 2 and 3 traumatic duodenal injury were included. To identify the risk factors for postoperative leakage, we used a stepwise multivariable logistic regression model and a least absolute shrinkage and selection operator (LASSO) logistic model. We constructed a receiver operator characteristic (ROC) curve to predict risk factors for postoperative leakage. Results: During the 17-year period, 179,887 trauma patients were admitted to a regional trauma center in Korea. Of these patients, 74 (0.04%) had duodenal injuries. A total of 49 consecutive patients had grade 2 and 3 traumatic duodenal injuries and underwent laparotomy. The incidence of postoperative leakage was 32.6% (16/49). Overall mortality was 18.4% (9/49). A stepwise multivariable logistic regression and LASSO logistic regression model showed that time from injury to initial operation was the sole statistically significant risk factor. The ROC curve at the optimal threshold of 15.77 h showed the following: area under ROC curve, 0.782; sensitivity, 68.8%; specificity, 87.9%; positive predictive value, 73.3%; and negative predictive value, 85.3%. There was no significant difference in outcomes between primary repair alone and pyloric exclusion. Conclusions: Time from injury to initial operation may be the sole significant risk factor for postoperative duodenal leakage. Pyloric exclusion may not be able to prevent postoperative leakage.
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Duodeno , Centros Traumatológicos , Duodeno/lesiones , Duodeno/cirugía , Humanos , Periodo Posoperatorio , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Duodenal injuries are rare due to their preserved retroperitoneal location. They are mostly observed after deep penetration or high-impact blunt trauma. They are difficult to diagnose and treat. Our purpose was to report a case of duodenal injury after blunt trauma with the review of the literature. A 20-year male patient was brought to Emergency Department with abdominal pain after an accident, in which he was stuck between a reversing truck and a pole. Rigidity in all abdominal quadrants was detected. Free pelvic fluid was observed in computed tomography (CT). There was a grade II laceration at the fourth part of the duodenum. The laceration was primarily sutured, and a naso-jejunal tube was placed. The patient was discharged on postoperative day-8 with uneventful recovery. In suspicion of duodenal trauma, a meticulous anamnesis, careful physical examination, proper imaging technique at appropriate timing, and surgical exploration are important to reduce morbidity and mortality. Imaging findings of retroperitoneal organ injuries can be non-specific. We suggest that surgical exploration should be the first choice of treatment in cases with acute abdomen findings. Key Words: Blunt trauma, Acute abdomen, Duodenum, Retroperitoneum.
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Traumatismos Abdominales , Heridas no Penetrantes , Traumatismos Abdominales/complicaciones , Traumatismos Abdominales/diagnóstico por imagen , Dolor Abdominal , Duodeno/lesiones , Humanos , Masculino , Tomografía Computarizada por Rayos X , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/cirugíaAsunto(s)
Dolor Abdominal/diagnóstico por imagen , Duodeno/diagnóstico por imagen , Duodeno/lesiones , Migración de Cuerpo Extraño/diagnóstico por imagen , Perforación Intestinal/diagnóstico por imagen , Stents/efectos adversos , Dolor Abdominal/cirugía , Anciano de 80 o más Años , Diagnóstico Diferencial , Duodeno/cirugía , Femenino , Migración de Cuerpo Extraño/cirugía , Humanos , Perforación Intestinal/cirugía , Pruebas en el Punto de Atención , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
Resumen Introducción: La perforación duodenal secundaria a la colangiopancreatografía retrógrada endoscópica (CPRE) es una complicación infrecuente y más aún cuando su mecanismo lesional es por barotrauma. La inyección de aire a alta presión produce un neumoretroperitoneo, cuya extensión y evolución lesional es incierta. Caso Clínico: Se comunica el caso de un hombre joven que sufrió una perforación duodenal durante una CPRE, su manejo quirúrgico y evolución. Discusión: El diagnóstico clínico-imagenológico suele ser precoz y claro si se detecta la lesión durante el procedimiento. El manejo terapéutico conservador o quirúrgico de esta entidad depende de varios factores que se analizan en el presente estudio.
Introduction: Duodenal perforation during endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication and even more if the mechanism of injury is secondary to barotrauma. The injection of high-pressure-air produces a pneumo-retroperitoneum, the extent and lesional evolution of which is uncertain. Clinical Case: We report the case of a young man who suffered a duodenal perforation during an ERCP, his surgical management and evolution. Discussion: The clinical-imaging diagnosis is usually early and clear if the lesion is detected during the procedure. Its conservative or surgical management will depends on several factors that are analyzed in the present study.
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Humanos , Masculino , Persona de Mediana Edad , Barotrauma/complicaciones , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Duodeno/lesiones , Barotrauma/diagnóstico , Colangiopancreatografia Retrógrada Endoscópica/métodos , Duodeno/cirugíaRESUMEN
Background: Small bowel injuries are infrequent after blunt trauma and typically affect fixed segment. Untimely management of such injuries, results in high-output entero-cutaneous fistula which increases morbidity and mortality. Treatment of duodeno-jejunal flexure transection has been traditionally done by pyloric exclusion with gastrojejunostomy, but more recent evidence suggests that end-to-end anastomosis or primary closure may be equally effective in which duodeno-jejunal anastomosis is protected via an external tube duodenostomy. Objective: The objective of the study is to provide a modification to the technique of management of duodeno-jejunal flexure injury, avoiding external tube duodenostomy. Material and Methods: Patients admitted from July 1, 2015 to June 1, 2018 were identified and examined for duodeno-jejunal flexure transection. Non-accidental injury cases were excluded. Results: In the study period, a total of 10 patients were admitted with duodeno-jejunal flexure transection. All cases were admitted 24 hours after the injury and presented with shock. After fluid resuscitation and investigations, they were taken for urgent laparotomy. The whole of duodenum was mobilised, the transected ends were debrided and end-to-end duodenojejunal anastomosis was performed in two-layer fashion. An 18-French Nasojejunal (NJ) tube was placed beyond the anastomosis, and an 18-French nasogastric (NG) tube was placed in the stomach for gastric decompression. A feeding jejunostomy was performed in all cases. Both NG and NJ tubes were removed after bowel movements started and FJ was removed on first follow up. There was no incidence of duodenum related complications, and all were doing well on follow up. Discussion and conclusion: Placing the nasojejunal and nasogastric tube eliminates the need for duodenostomy and gastrostomy, respectively. This method protects the duodeno-jejunal anastomosis and decreases the incidence of duodenum-related complications.
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Derivación Gástrica , Heridas no Penetrantes , Duodenostomía , Duodeno/lesiones , Duodeno/cirugía , Humanos , Resultado del Tratamiento , Heridas no Penetrantes/cirugíaRESUMEN
The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of "Less is Better". Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.
El trauma de duodeno comúnmente se produce por un trauma penetrante que puede asociarse a lesiones vasculares y de órganos adyacentes. En el manejo quirúrgico se recomienda realizar un reparo primario o el empleo de técnicas quirúrgicas simples. Sin embargo, el abordaje de lesiones severas del duodeno es un tema controversial. Anteriormente, se han descrito técnicas como la exclusión pilórica o la pancreatoduodenectomía con resultados no concluyentes. El presente artículo presenta una propuesta del manejo de control de daños del trauma penetrante de duodeno, a través, de un algoritmo de cinco pasos. Este algoritmo plantea una solución para el cirujano cuando no es posible realizar el reparo primario. El control de daños del duodeno y su reconstrucción depende de una toma de decisiones respecto a la porción del duodeno lesionada y el compromiso sobre el complejo pancreatoduodenal. Se recomiendan medidas rápidas para contener el daño y se proponen vías de reconstrucción duodenal diferente a las clásicamente descritas. Igualmente, la probabilidad de complicaciones como fistula duodenales es considerable, por lo que proponemos, que el manejo de este tipo de fistulas de alto gasto se aborde por medio de una laparostomía retroperitoneal (lumbotomía). El abordaje del trauma penetrante de duodeno se puede realizar a través del principio "menos es mejor".
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Algoritmos , Duodeno/lesiones , Heridas Penetrantes/cirugía , Hemorragia/terapia , Humanos , Ilustración Médica , Heridas Penetrantes/clasificación , Heridas Penetrantes/complicaciones , Heridas Penetrantes/diagnósticoRESUMEN
RATIONALE: Pediatric sports injuries, including those from baseball, most often are musculoskeletal injuries and rarely include blunt abdominal injuries. Duodenal injury is rare and often associated with other organ injuries. Because it has a relatively high mortality, early recognition and timely treatment are needed. Here, we report a case of successful treatment of a pediatric patient with duodenal injury incurred in the context of school baseball. PATIENT CONCERNS: A 13-year-old boy suffered blunt abdominal trauma and a right-hand injury caused by beating his abdomen strongly with his own right knuckle after he performed a diving catch during a baseball game. On the following day, the abdominal pain had worsened. DIAGNOSES: Computed tomography led to a suspicion of injury to the horizontal part of the duodenum. INTERVENTIONS: The duodenal injuries were repaired by simple closure. On the 10th post-operative day, an abscess formed in the retroperitoneal cavity because of an occult pancreatic injury. Ultrasound-guided percutaneous drainage of the cavity was performed. OUTCOMES: The post-operative course of the abscess drainage was uneventful. The patient was discharged from our hospital on day 72 after admission and was in good health at the 9-month follow-up. LESSONS: Regardless of the type of injury, we must assess the life-threatening conditions that can be expected based on the mechanism of the injury. In duodenal injuries, it is critical to perform surgical procedures and post-operative management based on the assumption of injuries to other organs.
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Traumatismos Abdominales/cirugía , Béisbol/lesiones , Duodeno/lesiones , Heridas no Penetrantes/cirugía , Traumatismos Abdominales/etiología , Adolescente , Duodeno/cirugía , Humanos , Masculino , Heridas no Penetrantes/etiologíaRESUMEN
BACKGROUND: Traumatic duodenal injuries in children are rare, and few studies have documented duodenal injuries in children, especially in Australasia. This study assessed the mechanism, investigations, management and outcomes of children (aged <16 years) with duodenal injuries. METHODS: Retrospective review was conducted over a 16-year period from a single paediatric trauma centre. RESULTS: Sixteen cases of duodenal injuries were identified: 15 cases of blunt duodenal injury and only one case of penetrating injury. Motor vehicular accidents were the most common cause of injury, followed by auto-pedestrian injuries and handlebar injuries. Only grade I and II injuries were identified. Computed tomography aided diagnosis in all cases of blunt duodenal injuries, especially given the variable nature of symptoms. Eight patients underwent laparotomy, of whom five required duodenal repair. Three patients underwent primary repair with omental patch, one patient underwent primary repair with gastrostomy and one patient underwent two-layered repair with t-tube duodenostomy. There were no delays in operative management within 24 h and no complications identified. CONCLUSION: In comparison to other paediatric trauma centres worldwide, the majority of duodenal injuries were low grade and attributed to blunt trauma. Computed tomography aided diagnosis in all cases of blunt duodenal injury. Primary repair of duodenal injuries was possible in the majority of cases requiring operative repair.
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Traumatismos Abdominales , Heridas no Penetrantes , Traumatismos Abdominales/diagnóstico por imagen , Traumatismos Abdominales/cirugía , Anciano , Australasia , Niño , Duodeno/diagnóstico por imagen , Duodeno/lesiones , Duodeno/cirugía , Humanos , Estudios Retrospectivos , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/cirugíaRESUMEN
ABSTRACT: Cases of foreign body ingestion in the forensic literature are mainly described in children or psychiatric patients. Postmortem imaging can detect most foreign bodies, but its sensitivity depends, among other things, on the type of item and its location. In some cases, the ingestion of foreign bodies can remain unnoticed and have serious consequences for the patient. We describe the case of a patient who died in a psychiatric seclusion room with no obvious cause and for whom a forensic autopsy was requested. Further investigations showed the existence of a subdural hematoma associated with a midline shift, secondary to a skull fracture that was considered to be the cause of death. Toxicological analyses identified in blood several drugs, including diazepam (24 ng/mL) and its major metabolite nordazepam (24 ng/mL), propranolol (57 ng/mL), paliperidone (9 ng/mL), and loxapine (620 ng/mL). The forensic autopsy revealed the existence of a gastrointestinal perforation after the ingestion of a plastic teaspoon, which the postmortem CT scan had failed to detect. Although technological advances continue to assist the forensic pathologist in his diagnosis, autopsy still has a leading role in forensic investigations and does not yet seem to be replaceable by imaging techniques alone.
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Duodeno/lesiones , Cuerpos Extraños/patología , Perforación Intestinal/etiología , Estómago/lesiones , Autopsia , Duodeno/patología , Femenino , Humanos , Perforación Intestinal/patología , Absceso Hepático/etiología , Absceso Hepático/patología , Plásticos , Estómago/patología , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
BACKGROUND Duodenal trauma usually consists of retroperitoneal lesions. Its management can be complicated by the location of the injury and difficulty in making an early diagnosis. Duodenal injuries are divided into blunt and penetrating trauma, and the possible results are hematoma, laceration, and devascularization. Duodenal lesions due to blunt trauma are usually accompanied by lesions of nearby organs. We present a rare case of a single duodenal laceration due to blunt abdominal trauma caused by a horse kick, along with a literature review. CASE REPORT A 13-year-old boy presented to our emergency department after being kicked by a horse in his abdomen. He was stable and complained of abdominal pain without any other specifications. Computed tomography imaging revealed a retropneumoperitoneum and free fluid in the abdominal cavity. The patient was taken for an emergency laparotomy, which showed a single duodenal laceration of the second and third portions of the duodenum. The laceration was repaired with a double-layer closure using monofilament 3-0 polypropylene suture. The patient recovered from his injuries and was well at his last follow-up. CONCLUSIONS This case highlights the possible outcomes of an innocent blunt trauma and the importance of early diagnosis for the best outcome of a duodenal laceration. It also identifies the dissociation between the patient's clinical presentation and his significant intra-abdominal injury.
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Traumatismos Abdominales , Laceraciones , Heridas no Penetrantes , Animales , Duodeno/lesiones , Duodeno/cirugía , Caballos , Humanos , Laceraciones/etiología , Laceraciones/cirugía , Laparotomía , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/cirugíaRESUMEN
OBJECTIVE: To evaluate the outcome of primary repair in penetrating duodenal injuries. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Adana City Training and Research Hospital, Adana, Turkey, between March 2011 and September 2018 Methodology: Patients with penetrating duodenal injury, who underwent primary repai, were reviewed retrospectively. The patients who had early death, grade 1 duodenum injuries and operative procedures except primary repair, were excluded from the study. Age, gender, mechanism of penetrating injury, grade of the duodenal injury, associated intra-abdominal injuries, length of intensive care unit and hospital stay, duodenum-related mortality and morbidity were analysed. Fisher's exact test was used to compare the outcomes between survivor and non-survivor groups. RESULTS: Data of 26 patients with primary repair (5 females, 21 males) were reviewed. The mean age was 33.11 ±12.07 years; and gunshot (n=19, 73.1%) was the most common cause of the duodenal injury. Twenty-five had a total of 103 (3.9 injuries per patient) associated intra-abdominal organ injuries. 20 (76.9%) patients had grade 2 duodenal injuries; and the most injured portion of the duodenum was segment IV (n: 9, 34.6%). Three (11.5%) patients had duodenal leakage and postoperative complication rate was 53.8%. Duodenum-related mortality (DRM) was 3.8% (n:1) and overall mortality was 19.2% (n:5). The anatomic localisation of duodenal injury and associated vascular trauma were significantly different between survivor and non-survivor groups (p: 0.038, and p: 0.034, respectively). CONCLUSION: Associated intra-abdominal organ and vascular injuries were predictive factors of overall mortality in duodenal injuries. Duodenum-related mortality was low, for this reason minimally invasive procedures such as primary repair will be more accurate in surgical management of penetrating duodenal injuries. Key Words: Duodenal injury, Primary repair, Surgical management.