title: Management of full-thickness duodenal laceration in the damage control era: evolution to primary repair without diversion or decompression.
abstract: The management of duodenal laceration (DL) is controversial. We sought to determine the influence of damage control (DC) on the use of decompression/diversion/exclusion (DDE) techniques and the risk of duodenal-related complications (DRC). We conducted a retrospective review of all patients with full-thickness DL surviving more than 72 hours in the years 1989 to 2009. Forty-one patients with a median duodenal organ injury scale of 3 and a mean abdominal trauma index (ATI) of 45 ± 24 underwent laparotomy. Twenty-five patients (61%) were treated with DC and 16 (39%) with fascial closure (FC). Although the ATI of the patients treated with DC was greater than the ATI of the patients treated with FC (56 ± 23 vs 28 ± 17, P < 0.001), DRCs were equivalent (two vs three, nonsignificant). Twenty-one patients were treated in the first decade and 20 in the second decade. Between the first and second decades, there were trends toward an increased use of DC (52 to 70%, nonsignificant) and a decreased use of DDE (52 to 35%, nonsignificant) with a significant reduction in DRC (5 vs 0, P = 0.04). Among the 18 patients (44%) who underwent DDE procedures there were 2 DRCs (11%) related to DDE. Among the 23 patients who did not have DDE, there were three DRCs (13%), including two obstructions, one partial and one complete. When DC is used after DL, DDE may be unnecessary. Diversion is recommended, however, when the duodenum is at risk for obstruction after primary repair.
authors.affiliation: Division of Trauma, Critical Care, & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA. mayberrj@ohsu.edu
authors.forename: John
authors.initials: J
authors.lastname: Mayberry
authors.forename: Loic
authors.initials: L
authors.lastname: Fabricant
authors.forename: Amy
authors.initials: A
authors.lastname: Anton
authors.forename: Bruce
authors.initials: B
authors.lastname: Ham
authors.forename: Martin
authors.initials: M
authors.lastname: Schreiber
authors.forename: Richard
authors.initials: R
authors.lastname: Mullins
mesh_terms: D000328:Adult; D003646:Debridement; D019299:Decompression, Surgical; D013505:Digestive System Surgical Procedures / Q000379:methods*; D004386:Duodenum / Q000293:injuries*; D000071938:Fasciotomy; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D022125:Lacerations / Q000601:surgery*; D007813:Laparotomy / Q000379:methods; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014948:Wounds, Gunshot / Q000601:surgery; D014949:Wounds, Nonpenetrating / Q000601:surgery; D014950:Wounds, Penetrating / Q000601:surgery*; D014951:Wounds, Stab / Q000601:surgery