复杂穿透性十二指肠损伤：少即是多。
Complex penetrating duodenal injuries: less is better.
机构信息
From the Departamento de Cirugía (L.F.P.) and Unidad de Cuidado Intensivo (C.O., A.G.), and Unidad de Investigaciones Clínicas (M.B., J.S.), Fundación Valle del Lili; Departamento de Cirugía (C.O., A.G., D.S., L.F.P., M.M., F.R., R.F.), Universidad del Valle, Cali, Colombia; Division of Trauma Critical Care (M.W.P.), Broward General Level I Trauma Center/Delray Provisional Level I Trauma Center, Delray Beach, Florida; and Department of Surgery (J.C.P.), University of Pittsburgh, Pittsburgh, Pennsylvania.
出版信息
J Trauma Acute Care Surg. 2014 May;76(5):1177-83. doi: 10.1097/TA.0000000000000214.
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.
背景
传统上，对于复杂穿透性十二指肠外伤（PDT）的处理方法是采用复杂的临时处理和复杂的程序，如幽门排除和十二指肠憩室化。我们试图确定是否简化 PDT 损伤的处理方法可以改善临床结果。
方法
对 2003 年至 2012 年期间所有连续的 PDT 进行回顾性分析。根据当地经验在区域一级创伤中心制定了简化手术算法，将患者分为三组。术后十二指肠漏通过传统的前引流或作为替代方案的后“腹膜后剖腹术”进行外部引流。
结果
连续有 44 例 PDT 患者，其中 41 例（93.2%）来自枪伤。由于与毁灭性创伤损伤相关的早期术中死亡，有 7 例患者被排除在外。在其余 36 例患者中，7 例（19.4%）采用一期单纯十二指肠修复和确定性腹壁筋膜闭合（PDR + NoDC 组）进行治疗。29 例患者采用损伤控制性剖腹术，其中 15 例（51.7%）行一期修复（PDR + DC 组），14 例（48.3%）行十二指肠缝合和连续性中断。在 15 例一期修复后和 13 例连续性中断后进行了十二指肠重建（DR + DC 组）。最常见的并发症是 36 例中的 12 例（33%）出现十二指肠瘘。这些漏通过传统的前引流处理了 9 例（75%），通过腹膜后剖腹术引流处理了 3 例（25%）。12 例中的 7 例（58.3%）的十二指肠瘘自行闭合。十二指肠相关死亡率为 2.8%，总死亡率为 11.1%。
结论
对 PDT 应用基本的损伤控制技术可提高生存率，并降低并发症发生率。
证据水平
治疗研究，IV 级。
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