Duodenal perforation: a diagnostic pitfall in non-accidental injury

Complicated duodenal perforation in children: Role of T-tube

BACKGROUND

Diagnosis of duodenal perforation (DP) in children is often delayed. This worsens the clinical condition and complicates simple closure.

OBJECTIVES

To explore the advantages of using T-tube in surgeries for DP in children.

PATIENTS AND METHODS

A retrospective study was conducted on all patients of DP managed in the Department of Paediatric surgery at a tertiary centre from January 2016 to December 2020. Clinical, operative and post-operative data were collected. Patients, with closure over a T-tube to ensure tension-free healing, were critically analysed.

RESULTS

A total of nine DP patients with ages ranging from 2 years to 9 years were managed. Five (55.6%) patients had blunt abdominal trauma; a 2-year-old male had perforation following accidental ingestion of lollypop-stick while a 3-year-old male had DP during endoscopic evaluation (iatrogenic) of bleeding duodenal ulcers; cause could not be found in other 2 (22.2%) patients. Of the five patients with blunt abdominal trauma, 4 (80%) had large perforation with oedematous bowel, necessitating repair over T-tube. Both patients with unknown causes had uneventful outcomes following primary repair with Graham's patch. Patients with lollypop-stick ingestion and iatrogenic perforation did well with repair over T-tube. The only trauma patient with primary repair leaked but subsequently had successful repair over a T-tube. One patient with complete transection of the third part of the duodenum and pancreatic injury who had repair over T-tube died due to secondary haemorrhage on the 10^th post-operative day.

CONCLUSION

Closure over a T-tube in DP, presenting late with oedematous bowel, ensures low pressure at the perforation site, forms a controlled fistula and promotes healing, thereby lessening post-operative complications.

Isolated duodenal perforation in children: Importance of high index of suspicion following blunt trauma abdomen

Introduction

Isolated duodenal perforation (IDP) is rare and only isolated cases are reported in the literature. Due to its rarity and subtle presentation, the diagnosis of IDP is often delayed. Delay in the diagnosis and surgical intervention result in increased morbidity and mortality. The aim of this article is to highlight the importance of a high index of suspicion of IDP following blunt abdominal trauma and safety of primary repair without diversion in such cases.

Material and methods

Children with isolated duodenal injuries following blunt abdominal trauma were included; mode of trauma, clinical presentation, diagnosis, operative intervention and outcome were studied.

Results

Nine patients with isolated duodenal perforations were identified and operated on. Most had minimal clinical findings on arrival and were haemodynamically stable. Abdominal radiography and ultrasonography were unremarkable. However, pain remained persistent and worsening of vomiting was seen over time. Contrast-enhanced computed tomography (CECT) of the abdomen with oral and intravenous contrast was done to identify the injuries. Primary repair of perforation was performed in all cases. The most common cause was road traffic accident. There were three Grade 2 injuries, five Grade 3 and one Grade 4 injuries. Eight patients healed well with uneventful recovery – one patient died from sepsis after presenting 24 h after injury with frank peritonitis.

Conclusion

Isolated duodenal perforation presents without specific signs and symptoms and a high index of suspicion is necessary for early diagnosis. Contrast-enhanced computed tomography of the abdomen with oral contrast should be ordered early if symptoms persist or worsened over time.

Diagnosis and treatment of traumatic duodenal rupture in children

Background

The purpose of this study was to investigate the diagnosis and treatment experience of traumatic duodenal ruptures in children.

Methods

Clinical data were collected from four children suffering from a traumatic duodenal rupture who were admitted to and treated by our hospital from January 2012 to December 2020. The early diagnosis and treatment, surgical plan, postoperative management, complications, and prognosis of each child were analyzed. The key points and difficulties of the diagnosis and treatment for this type of injury are summarized.

Results

One child had an extreme infection caused by drug-resistant bacteria, which resulted in severe complications, including wound infection, dehiscence, and an intestinal fistula. One child developed an anastomotic stenosis after the duodenostomy, which improved following an endoscopic balloon dilatation. The other two children had no relevant complications after their operations. All four patients were cured and discharged from hospital. The average hospital stay was 48.25 ± 26.89 days. The follow-up period was 0.5 to 1 year. No other complications occurred, and all children had a positive prognosis.

Conclusions

The early identification of a duodenal rupture is essential, and surgical exploration should be carried out proactively. The principles of damage-control surgery should be followed as much as possible during the operation. Multidisciplinary cooperation and management are both important to reduce the occurrence of postoperative complications and improve cure rates.

An isolated duodenal perforation in pediatric blunt abdominal trauma: a rare but distinct possibility

Isolated duodenal perforation (IDP) in pediatric trauma is rarely reported. Since most of the children with blunt trauma are managed expectantly, timely diagnosis is imperative to avoid morbidity and mortality. We report a case of IDP and emphasize on certain specific clinical features indicating possibility of duodenal injury. We also stress upon the role of early contrast-enhanced computerized tomography (CECT) in such cases.

The importance of surgeon involvement in the evaluation of non-accidental trauma patients

INTRODUCTION

Non-Accidental Trauma (NAT) is a significant cause of childhood morbidity and mortality, causing 50% of trauma-related deaths at our institution. Our purpose was to evaluate the necessity of primary surgical evaluation and admission to the trauma service for children presenting with NAT.

METHODS

We reviewed all NAT patients from 2007-2011. Injury types, demographic data, and hospitalization information were collected. Comparisons to accidental trauma (AT) patients were made using Wilcoxon rank sum and Student's t tests.

RESULTS

We identified 267 NAT patients presenting with 473 acute injuries. Injuries in NAT patients were more severe than in AT patients, and Injury Severity Scores, ICU admission rates, and mortality were all significantly (p<0.001) higher. The majority suffered from polytrauma. Multiple areas of injury were seen in patients with closed head injuries (72%), extremity fractures (51%), rib fractures (82%), and abdominal/thoracic trauma (80%). Despite these complex injury patterns, only 56% received surgical consults, resulting in potential delays in diagnosis, as 24% of abdominal CT scans were obtained >12 hours after hospitalization.

CONCLUSION

Given the high incidence of polytrauma in NAT patients, prompt surgical evaluation is necessary to determine the scope of injury. Admission to the trauma service and a thorough tertiary survey should be considered for all patients.

Operative blunt duodenal injury in children: a multi-institutional review

BACKGROUND/AIM

Operative blunt duodenal injury in children is rare. The purpose of this analysis is to describe the clinical presentation, current management, and outcome of children with operative blunt duodenal injury.

METHODS

The American Pediatric Surgical Association Trauma Committee solicited data from its members on children with blunt intestinal injuries identified at autopsy or operation from January 2002 through August 2006.

RESULTS

Fifty-four children from 16 hospitals with operative blunt duodenal injuries were identified: 0.67 patients per hospital per year. The most common mechanisms of injury were motor vehicle crashes (35%), bicycle crashes (22%), and nonaccidental trauma (20%). Forty-nine patients (90%) had positive physical examination findings on initial presentation, including peritonitis in 18 patients (33%). Twenty-five computed tomographic (CT) scans performed demonstrated free fluid, and 13 (52%), free air. Eleven CT scans used enteral contrast, and only 2 (18%) showed extravasation. Fifty-two patients (96%) survived to operation. The overall complication rate was 42%.

CONCLUSION

Operative blunt duodenal injury occurs less than once per year in the typical pediatric trauma center. Most of the patients have pertinent physical examination findings on arrival. Computed tomographic scans with enteral contrast do not seem to be helpful in diagnosis of duodenal injuries. Postoperative complications are frequent, but most children survive.

Duodenal perforation: an interesting case report

We describe a young child presenting with vomiting and altered neurological status. An incidental finding of pneumoperitoneum on abdominal X-ray led to laparotomy and the discovery of a duodenal perforation. We describe the difficulties in making the diagnosis of duodenal perforation in children and some of the factors that led to the delay in diagnosis in this case.

[War, traffic and iatrogenic injuries of D3 duodenal segment]

BACKGROUND

Injuries of the duodenum at the level of aortomesenteric clamp (segment D3) are with a high incidence of death due to the development of fistula and peritonitis. In three successfully managed cases, we applied the biliary surgery method.

CASE REPORTS

All three cases were with the injuries of D3 duodenal segment. The first patient suffered from the blast perforation of duodenum at the level of the aortomesenteric clamp which occurred at the 7th day after the injury. The second patient suffered from the duodenal injury caused in a traffic accident. The third patient suffered from an iatrogenic injury at the beginning of D3 duodenal segment inflicted during ureterolithotomy. The described surgical procedure included basically the suture to narrow the site of the injury, then lateroterminal anastomosis with the Roux-en-Y jejunal flexure and, finally, the placement of a silicone prosthesis starting from the duodenum through the site of injury and the Roux-en-Y out. Octreotide and the total parenteral nutrition were administered to the patients postoperatively.

CONCLUSION

The use of the releasing silicone prosthesis in all three patients provided the repair of the site of the injury with anastomosed Reux-en-Y jejunum.

Duodenal injuries in children: beware of child abuse

PURPOSE

It is frequently overlooked that child abuse may result in significant intraabdominal injury, particularly to the duodenum. The authors hypothesized that a significant number of duodenal injuries in young children would be the result of nonaccidental trauma.

METHODS

An 8-year (1995 through 2002) retrospective review of a pediatric level I trauma center database was performed after Institutional Review Board approval was obtained, and information regarding patients with duodenal injury was abstracted. Demographic variables, injury severity, length of stay, mortality rate, and mechanism of injury were examined. Statistical analysis was performed using descriptive statistics and Student's t test. Statistical significance was defined as P less than.05.

RESULTS

Over the 8-year study period, 8,968 patients were admitted, 2,179 (24%) were less than 3 years of age. Thirty children (0.3%) suffered injury to the duodenum, with 20 hematomas and 10 perforations. Patients were overwhelmingly boys (80%), with an average age of 7.6 +/- 4.4 years and Injury Severity Score (ISS) of 14 +/- 10. No patients died. Children were injured by a variety of mechanisms, including collisions involving motor vehicles (n = 9), bicycles (n = 4), and ATVs (n = 2). However, all children less than 4 years of age (n = 8) were victims of nonaccidental trauma, 2.8% of all child abuse admissions. Three of these children suffered perforations of the duodenum. Among the entire population, those children who suffered perforations had a significantly higher ISS (23.7 +/- 7.2 v 9.6 +/- 7.3; P <.0003) and longer length of stay (27.1 +/- 15.3 v 12.6 +/- 11.7; P <.007) than those with hematomas

CONCLUSIONS

Injury to the duodenum is unusual in the pediatric trauma patient but does result in significant injury severity and prolonged hospitalization. In the young child, one must maintain a high index of suspicion regarding the etiology of the injury, because a large percentage is potentially the result of child abuse.