Focus on Pancreatic and Duodenal Injuries

Incidence and Management of Duodenal Trauma in a War Setting: Insights From a Military Hospital in Yemen

Background Duodenal injuries are rare but pose significant challenges in war trauma settings because of their complexity and associated complications. This study evaluated the incidence, anatomical distribution, surgical approaches, postoperative complications, and factors influencing the outcomes of duodenal injury management in a conflict setting in Yemen. Methods A retrospective analysis was conducted on 520 exploratory laparotomy cases from June 2019 to December 2023 at a military hospital in Yemen. Twenty-seven patients with confirmed duodenal injuries were included. Data on demographic characteristics, injury characteristics, surgical management, and outcomes were collected and analyzed. Results Among the 520 exploratory laparotomy cases reviewed, 27 (5.2%) patients had confirmed duodenal injuries. The study population was predominantly young males (n = 26, 96.3%) with a mean age of 21.93 ± 4.08 years. Penetrating trauma was the leading cause of injury (n = 26, 95.7%), and the second portion of the duodenum (D2) was the most frequently affected segment (n = 12, 44.4%). Most injuries were classified as the American Association for the Surgery of Trauma (AAST) grade II (n = 26, 96.3%). Surgical management primarily involved exploratory laparotomy (n = 22, 81.5%) and primary repair (n = 18, 66.7%). Postoperative complications occurred in 70.4% (n = 19), with sepsis (n = 10, 52.6%) and chest-related complications (n = 9, 47.4%) being the most common. The short-term success rate was 81.5% (n = 22), while the mortality rate was 11.1% (n = 3). Shrapnel injuries (80% vs. 13%, p = 0.009), higher injury severity scores (27.20 ± 9.34 vs. 19.14 ± 7.80, p = 0.05), and damage control surgery (60.0% vs. 9.1%, p = 0.008) were key factors associated with poorer outcomes. Conclusion Duodenal injuries after war trauma are associated with high rates of complications and mortality. Early diagnosis, appropriate surgical approaches, and vigilant postoperative care are critical for improved outcomes. These findings highlight the importance of tailored management strategies in conflict settings and the need for further research to optimize care protocols in resource-limited environments.

Damage control in penetrating duodenal trauma: less is better - the sequel

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.

Complex penetrating duodenal injuries: less is better

BACKGROUND

The traditional management of complex penetrating duodenal trauma (PDT) has been the use of elaborate temporizing and complex procedures such as the pyloric exclusion and duodenal diverticulization. We sought to determine whether a simplified surgical approach to the management of complex PDT injuries improves clinical outcome.

METHODS

A retrospective review of all consecutive PDT from 2003 to 2012 was conducted. Patients were divided into three groups according to a simplified surgical algorithm devised following the local experience at a regional Level I trauma center. Postoperative duodenal leaks were drained externally either via traditional anterior drainage or via posterior "retroperitoneal laparostomy" as an alternate option.

RESULTS

There were 44 consecutive patients with PDT, and 41 of them (93.2%) were from gunshot wounds. Seven patients were excluded owing to early intraoperative death secondary to associated devastating traumatic injuries. Of the remaining 36 patients, 7 (19.4%) were managed with single-stage primary duodenal repair with definitive abdominal wall fascial closure (PDR + NoDC group). Damage-control laparotomy was performed in 29 patients, (80.5%) in which primary repair was performed in 15 (51.7%) (PDR + DC group), and the duodenum was over sewn and left in discontinuity in 14 (48.3%). Duodenal reconstruction was performed after primary repair in 2 of 15 cases and after left in discontinuity in 13 of 14 cases (DR + DC group). The most common complication was the development of a duodenal fistula in 12 (33%) of 36 cases. These leaks were managed by traditional anterior drainage in 9 (75%) of 12 cases and posterior drainage by retroperitoneal laparostomy in 3 (25%) of 12 cases. The duodenal fistula closed spontaneously in 7 (58.3%) of 12 cases. The duodenum-related mortality rate was 2.8%, and the overall mortality rate was 11.1%.

CONCLUSION

An application of basic damage-control techniques for PDT leads to improved survival and an acceptable incidence of complications.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Management of isolated duodenal rupture due to blunt abdominal trauma: case series and literature review

INTRODUCTION

Duodenal injuries are uncommon and are associated with significant morbidity and mortality due to delayed diagnosis (in the case of blunt trauma) or associated major vascular injuries (in the case of penetrating trauma). Isolated blunt injuries may have a subtle clinical presentation, and are particularly difficult to diagnose when the perforation is located in the retroperitoneal part of the duodenum.

MATERIALS AND METHODS

This paper presents in company with three cases of successfully treated isolated duodenal injuries due to blunt trauma, focusing on with their preoperative diagnosis, surgical management and final out comes.

CONCLUSIONS

Early diagnosis and successful surgical planning require experience and clinical suspicion on the part of the surgeon, as well as meticulous laparotomy results.