The use of pyloric exclusion for treating duodenal trauma
case series
Keywords:
Duodenum, Wounds and injuries, Sutures, Morbidity, Pancreatitis, GastroenterostomyAbstract
CONTEXT AND OBJECTIVES: Signifi cant controversy exists regarding the best surgical treatment for complex duodenal injuries. The aims of this study were to report on a series of eight cases of duodenal repairs using pyloric exclusion and to describe reported complications or improvements in clinical outcomes among patients with complex duodenal trauma. DESIGN AND SETTING: Cross-sectional study followed by a case series in a university hospital. METHODS: Data on eight patients with duodenal trauma who underwent pyloric exclusion over a 17.5 year period were collected and analyzed. RESULTS: The causes of the injuries included penetrating gunshot wounds (GSW) in fi ve patients and motor vehicle accidents (blunt trauma) in three patients. The time elapsed until surgery was longer in the blunt trauma group, while in one patient, the gunshot injury was initially missed and thus the procedure was carried out 36 hours after the original injury. The injuries were grade III (50%) or IV (50%) and the morbidity rate was 87.5%. Four patients (50%) died during the postoperative period from complications, including hypovolemic shock (one patient), sepsis (peritonitis following the missed injury) and pancreatitis with an anastomotic fi stula (two patients). CONCLUSIONS: Pyloric exclusion was associated with multiple complications and a high mortality rate. This surgical technique is indicated for rare cases of complex injury to the duodenum and the surgeon should be aware that treatment with a minimalistic approach, with only primary repair, may be ideal.
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References
Weigelt JA. Duodenal injuries. Surg Clin North Am. 1990;70(3):529-39.
Asensio JA, Feliciano DV, Britt LD, Kerstein MD. Management of duodenal injuries. Curr Probl Surg. 1993;30(11):1023-93.
Fraga GP, Biazotto G, Villaça MP, Andreollo NA, Mantovani M. Trauma de duodeno: análise de fatores relacionados à morbimor- talidade. [Duodenal trauma: factors related to morbimortality]. Rev Col Bras Cir. 2008;35(2):94-102.
Carrillo EH, Richardson JD, Miller FB. Evolution in the man- agement of duodenal injuries. J Trauma. 1996;40(6):1037-45; discussion 1045-6.
Berg AA. Duodenal fistula: its treatment by gastrojejunostomy and pyloric occlusion. Ann Surg. 1907;45(5):721-9.
Vaughan GD 3rd, Frazier OH, Graham DY, Mattox KL, Petmecky FF, Jordan GL Jr. The use of pyloric exclusion in the management of severe duodenal injuries. Am J Surg. 1977;134(6):785-90.
Seamon MJ, Pieri PG, Fisher CA, et al. A ten-year retrospective review: does pyloric exclusion improve clinical outcome after penetrating duodenal and combined pancreaticoduodenal injuries? J Trauma. 2007;62(4):829-33.
Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma. 1989;29(5):623-9.
Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury sever- ity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187- 96.
Borlase BC, Moore EE, Moore FA. The abdominal trauma index--a critical reassessment and validation. J Trauma. 1990;30(11):1340-4.
Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma. 1990;30(11):1427-9.
Pierro AC, Mantovani M, Reis NS, Morandin RC, Fraga GP. Tratamento do trauma duodenal complexo: comparacão entre sutura simples e sutura associada à exclusão pilórica e gastrojejunostomia em cães. [Treatment of complex duodenal lesions: comparison between simple repair and repair associated to pyloric exclusion and gastrojejunostomy in dogs]. Acta Cir Bras. 2005;20(1):28-38.
Cogbill TH, Moore EE, Feliciano DV, et al. Conservative management of duodenal trauma: a multicenter perspective. J Trauma. 1990;30(12):1469-75.
Timaran CH, Martinez O, Ospina JA. Prognostic factors and management of civilian penetrating duodenal trauma. J Trauma. 1999;47(2):330-5.
Snyder WH 3rd, Weigelt JA, Watkins WL, Bietz DS. The surgical management of duodenal trauma. Precepts based on a review of 247 cases. Arch Surg. 1980;115(4):422-9.
Martin TD, Feliciano DV, Mattox KL, Jordan GL Jr. Severe duodenal injuries. Treatment with pyloric exclusion and gas- trojejunostomy. Arch Surg. 1983;118(5):631-5.
Buck JR, Sorensen VJ, Fath JJ, Horst HM, Obeid FN. Severe pancreatico-duodenal injuries: the effectiveness of pyloric exclu- sion with vagotomy. Am Surg. 1992;58(9):557-60; discussion 561.
Degiannis E, Krawczykowski D, Velmahos GC, Levy RD, Souter I, Saadia R. Pyloric exclusion in severe penetrating injuries of the duodenum. World J Surg. 1993;17(6):751-4.
Ginzburg E, Carrillo EH, Sosa JL, Hertz J, Nir I, Martin LC. Pyloric exclusion in the management of duodenal trauma: is concomitant gastrojejunostomy necessary? Am Surg. 1997;63(11):964-6.
Velmahos GC, Kamel E, Chan LS, et al. Complex re- pair for the management of duodenal injuries. Am Surg. 1999;65(10):972-5.
César JMS, Petroianu A, Gouvêa AP, Alvin DR. Reabertura do piloro gastroduodenal após sua cerclagem, em ratos. [Re- opening of pylorus after its closure, in rats]. Rev Col Bras Cir. 2005;32(6):328-31.
Kashuk JL, Moore EE. Should pyloric exclusion for duodenal and pancreatico-duodenal injuries be abandoned? J Trauma. 2007;63(2):452-3.
