Shilyansky J, Pearl R H, Kreller M, Sena L M, Babyn P S
Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
J Pediatr Surg. 1997 Jun;32(6):880-6. doi: 10.1016/s0022-3468(97)90642-4.
Traumatic duodenal perforations in children pose a diagnostic and therapeutic challenge. To identify specific diagnostic criteria and define an optimal therapeutic protocol, we reviewed all duodenal injuries treated at our institution in the past 10 years. There were 14 hematomas and 13 perforations. The diagnosis was confirmed by computed tomography (CT), ultrasound scan (US), upper gastrointestinal contrast studies (UGI), or at laparotomy. The clinical findings and CT findings of the two groups were compared. Children with suspected duodenal hematomas were treated expectantly, and children with duodenal perforations were treated surgically. Twenty-five associated injuries (10 pancreatic) occurred in 19 children. Children with perforations had higher injury severity scores (ISS) (25 v 9), but the two groups could not be differentiated based on presenting signs, symptoms, or laboratory findings. CT findings of retroperitoneal air or contrast were seen in 9 of 9 perforations and in 0 of 10 hematomas. CT findings of intraabdominal or retroperitoneal fluid, mesenteric enhancement, and thickened duodenal wall did not differentiate the two groups. Duodenojejunostomy was performed in one patient, and primary repair was performed in 11 children who had perforation. In five children, duodenostomy tube drainage with feeding jejunostomy or gastrojejunostomy were added. Complications occurred in three of four children in the first 5 years of the study and in two of nine children in the last 5 years. The decreased morbidity rate correlated with reduced time to definitive therapy (28 v 7.8 hours). Duodenal fistulae resulted in three of seven children treated without duodenostomy tube drainage and zero of five treated with drainage. Enteral feeds resumed faster (average, 12 v 27 days) if repair of perforation was combined with feeding jejunostomy or pyloric exclusion and gastrojejunostomy. Children with duodenal hematoma resumed eating an average of 16 days after injury. Only one child required surgery for persistent obstruction. The findings of retroperitoneal air and contrast extravasation on CT accurately distinguish duodenal perforation from hematoma. Conservative management of hematoma is safe and effective. Primary repair of perforation with duodenal drainage results in fewer postoperative complications, and gastrojejunostomy or feeding jejunostomy shorten the time to resumption of feeds.
儿童创伤性十二指肠穿孔带来了诊断和治疗方面的挑战。为了确定具体的诊断标准并制定最佳治疗方案，我们回顾了过去10年在我们机构治疗的所有十二指肠损伤病例。其中有14例血肿和13例穿孔。诊断通过计算机断层扫描（CT）、超声扫描（US）、上消化道造影检查（UGI）或剖腹手术得以证实。对两组的临床发现和CT表现进行了比较。怀疑有十二指肠血肿的儿童采用保守治疗，而十二指肠穿孔的儿童则接受手术治疗。19名儿童出现了25处合并伤（10处胰腺损伤）。穿孔患儿的损伤严重程度评分（ISS）更高（25比9），但两组在临床表现、症状或实验室检查结果方面无法区分。9例穿孔患儿中有9例CT显示腹膜后积气或造影剂外渗，而10例血肿患儿中无此表现。CT显示腹腔内或腹膜后积液、肠系膜强化以及十二指肠壁增厚并不能区分两组。1例患者接受了十二指肠空肠吻合术，11例穿孔患儿进行了一期修复。5例患儿在一期修复基础上增加了十二指肠造瘘管引流并联合空肠造瘘或胃空肠吻合术。在研究的前5年，4例患儿中有3例出现并发症，后5年9例患儿中有2例出现并发症。发病率的降低与确定性治疗时间的缩短相关（28小时比7.8小时）。7例未行十二指肠造瘘管引流治疗的患儿中有3例发生十二指肠瘘，而行引流治疗的5例患儿中无1例发生。如果穿孔修复联合空肠造瘘或幽门旷置及胃空肠吻合术，肠内喂养恢复得更快（平均12天比27天）。十二指肠血肿患儿受伤后平均16天恢复进食。只有1例患儿因持续性梗阻需要手术治疗。CT上腹膜后积气和造影剂外渗的表现可准确区分十二指肠穿孔和血肿。对血肿进行保守治疗是安全有效的。十二指肠穿孔一期修复并引流术后并发症较少，胃空肠吻合术或空肠造瘘术可缩短喂养恢复时间。
