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0ANALYSIS OF THE RESULTS OF SURGICAL TREATMENT
OF DUODENUM INJURIES
1Ruziboyev S.A., 1Amonov Kh.R., 2Mardonov V.N., 1Akhmedov Sh.Kh.
Samarkand State Medical University 2Samarkand branch of the Republican Scientific Center for Emergency Medical Care https://doi.org/10.5281/zenodo.14029000
Abstract. The paper presents the results of diagnostics and features of treatment of traumatic damage to the duodenum for 20 years. The analysis of the results of surgical treatment of 86 patients with closed injuries and wounds of the duodenum was carried out. In the early stages after trauma, the imposition of a duodenojejunostomy is, in our opinion, the best. Separation of duodenum from the digestive system (diverticulation) and operations on the drainage of the stomach, as well as duodenostomy were effective, when the disease was damaged more than half of the duodenum.
Keywords: damage to the duodenum, surgical treatment.
Introduction. According to the analysis of domestic and foreign literature, mechanical damage to the duodenum is an insufficiently studied problem. At the same time, the quality of diagnostics and the results of surgical treatment of victims with duodenal injury still remain at a fairly low level, which is explained by the lack of a unified approach to diagnostics and unified surgical tactics for various types of duodenal wall damage [1, 3, 9]. The most common and formidable complication in the early postoperative period is the failure of the duodenal wound sutures with the development of peritonitis or the formation of an external fistula [5, 7, 11]. In their scientific papers, the authors point to a large number of complications and high mortality in this category of patients. High postoperative mortality is mainly due to late hospitalization and diagnosis, amounting to 11.8 to 30.5% for isolated duodenal injuries, and from 46.6 to 80% for combined ones. With the development of retroperitoneal phlegmon, mortality can reach 100% [2, 6, 9].
It is known to everyone, damage to the duodenum (DU) is one of the difficult situations for a surgeon, determined primarily by the problem of choosing surgical tactics for treating such patients. Until now, there is no unified surgical tactics for patients with this pathology.
Objective of the research. To analyze the results of surgical treatment and determine the optimal volume of surgical care for patients with duodenal injuries.
Key words: duodenal injuries, archival data, gallbladder, duodenal diverticulization, duodenostomy, antrectomy, gastrojejunostomy, drainage of the common bile duct.
Material and methods of the reserarch. The treatment of 86 patients with combined and isolated duodenal injuries who underwent examination and treatment at Samarkand branch of the Republican Scientific Center for Emergency Medical Care for the period from 2000 to 2024 was analyzed. To conduct a retrospective analysis of the treatment results for patients with duodenal injuries, archival data on patients were used.
Definitely, the majority of the operated patients were young and middle-aged people - 65 (75.6%), there were 2 times more men than women. Among the injured, there were 71 men (82.5%), women - 15 (14.5%).
Traumatic injury to the duodenum in 3 (3.5%) cases was a result of a fall from a height (catatrauma); the vast majority of duodenal injuries were in 65 (75.6%) cases - road accidents; in 6 (7%) - industrial injuries, and suicide attempts - in 2 (2.4%) cases, iatrogenic injury occurred in 5 (5.8%) cases, beating - in 5 (5.8) patients.
The vast majority of cases, the time of delivery of the victim to the hospital was 45.3 + 14.5 minutes. However, 18 (20.9%) patients sought medical help more than 6 hours after receiving the injury. In most cases, these are patients with closed abdominal trauma. First of all, untimely treatment was associated with inadequate assessment of their condition. Combined and multiple injuries accounted for 41 (47.7%), which were more often detected with duodenal injuries, which affected the severity of this type of injury. Isolated injury was found in 45 (52.3%) cases. Duodenal injuries were combined with pancreatic injury in 15 (17.4%) cases, liver - 7 (8.1%), gallbladder - 4 (4.6%), large intestine - 7 (8.1%), small intestine - 3 (3.7%) and stomach - 3 (3.7%), portal vein - 2 (2.3%). Damage to the descending part of the duodenum was detected in 45 (52.3%) cases, the lower horizontal part -in 21 (24.4%) cases, and the upper horizontal part of the duodenum - in 18 (20.9%) cases.
Table 1.
Localization of damage Number of patients The number of patients
Abs %
Upper horizontal part 18 20,9%
Descending part 45 52,3%
Lower horizontal part 21 24,4%
Duodenal papilla 2 2,3%
Total 86 100%
The combination of damage to the duodenum with other organs and anatomical areas is presented in Table 2.
Table 2.
Organ damage Number of patients
Abs %
Pancreas 15 17,4%
Liver 7 8,1%
Portal vein 2 2,3%
Gall bladder 4 4,6%
Stomach 3 3,7%
Small intestine 3 3,7%
Large intestine 7 8,1%
Total 41 47,7%
Taking into account that in the stated goal and objectives of the study, all the patients studied were divided into two groups.
Group I (retrospective) consisted of 41 (47.7%) patients who were treated with a traditional method of treatment, according to the protocol developed in the clinic, designed to apply a primary suture to the damage to the duodenum with drainage of the abdominal cavity.
Group II (prospective) consisted of 45 (52.3%) patients whose primary suture of the duodenal wound was supplemented with nasogastric decompression and insertion of a feeding
tube; in case of damage of more than 1/2 of the duodenal circumference, the primary suture was supplemented with a stomach drainage operation, duodenal diverticulization, duodenostomy, antrectomy, gastrojejunostomy, and drainage of the common bile duct due to well-coordinated organizational treatment and diagnostic measures and equipping with modern equipment and qualified personnel, which has dramatically expanded diagnostic capabilities and reduced the time of examination of patients admitted for emergency indications with closed injuries and abdominal wounds and acute surgical pathology. In the vast majority of patients with abdominal injuries and wounds, diagnostic examinations were performed directly in the operating room against the background of anti-shock measures.
The results of the study. Mostly, upon admission, patients complained of abdominal pain. The pain was usually non-localized. In 21 (24.4%) cases, pain was noted in the lumbar region.
For determining a more optimized treatment and diagnostic program and continuity in the provision of surgical care, the classification of duodenal injuries by E. Moore et al (1990) was used for patients:
Grade I injury - hematoma - isolated involvement of one section. Ruptures - superficial tears and partial tears that do not penetrate the lumen. P degree of damage - hematoma -involvement of two or more sections. Ruptures of the intestinal wall, occupying less than 1/2 of its circumference.
III degree of damage - Ruptures - within 50-70% of the circumference of the II section of the duodenum with concomitant damage to the pancreas and the presence of retroperitoneal phlegmon.
IV degree of damage - rupture of more than 75% of the intestinal circumference, damage to the ampulla and the distal part of the common bile duct.
V degree of damage - Ruptures - massive damage to the entire pancreatoduodenal complex. Damage to blood vessels - devascularization of the duodenum.
A particularly important moment of the operation for duodenal damage is nasointestinal decompression of the duodenum. In the retrospective group, nasogastroduodenal decompression was rarely performed for duodenal damage. In the prospective group of patients, absolutely all observations ended with nasogastroduodenal decompression and insertion of an intestinal feeding tube through the Treitz ligament.
In case of isolated hematomas and superficial tears - (I degree of damage) duodenal hematoma in the retrospective group, they were limited to evacuation of the hematoma with subsequent drainage of the retroperitoneal tissue. In the prospective group - removal of the hematoma with subsequent drainage of the retroperitoneal tissue was supplemented by cholecystostomy - in 11 (24.4%) observations. In all cases, hematomas were revised to exclude the damage penetrating into the intestinal lumen. Retroperitoneal hematomas in the duodenum were revised after mobilization according to Kocher. Revision of the hematoma in two patients allowed to establish a rupture of the intestinal wall.
Ruptures of the intestinal wall occupying less than 1/2 of its circumference - II degree of damage in closed abdominal trauma was detected in 14 (31.1%) victims. In case of damage to the duodenum after excision of the wound edges, a primary suture was applied, supplemented by cholecystostomy, drainage of the omental bursa and retroperitoneal tissue and nasogastric decompression and insertion of an intestinal feeding tube for Treitz ligament.
Fig. 1. Damage to the lower horizontal part of the duodenum up to 50% of the circumference.
Definitely, ruptures - within 50-70% of the circumference of the second part of the duodenum with concomitant damage to the pancreas and the presence of retroperitoneal phlegmon were detected in 9 (20%) victims. In 7 patients of this group, single damage to the duodenal wall within 50% of the circumference was detected, complicated by focal pancreatic necrosis and infected hematoma of the retroperitoneal space. In almost the majority of cases, patients were admitted in the first 12 hours from the moment of injury with clinical picture of peritonitis. All patients underwent exclusion of the duodenum from the digestive tract with drainage operations of the stomach.
Fig. 2. Damage to the lower horizontal part of the duodenum with more than 50% of the circumference and retroperitoneal phlegmon.
Ruptures of more than 75% of the intestinal circumference - grade IV of duodenal injury was observed in 8 (17.8%) victims. In 5 cases, duodenal diverticulization with unloading jejunostomy was performed (the duodenal wall was sutured with a double-row suture, then the duodenum was excluded with subsequent peritonization with a row of interrupted sutures). The operations were completed with GEA.
In case of damage to the upper horizontal part of the duodenum in combination with the stomach, in 3 cases, resection of 2/3 of the stomach was performed according to Bilroth-P in the modification of Hofmeister-Finsterer with cholecystostomy, bypass GEA with Braun's anastomosis. The duodenal wall defect was sutured with double-row interrupted sutures.
However, all patients underwent nasogastric active aspiration, installation of an intestinal feeding tube, and drainage of retroperitoneal tissue. In all cases, the operation was supplemented by duodenostomy and cholecystostomy.
Definitely, massive damage to the entire pancreatoduodenal complex - grade V of damage to the duodenum was diagnosed in 3 (6.7%) victims. One patient underwent pancreatoduodenal resection with unloading jejunostomy. Two patients died during surgery due to profuse bleeding. The main causes of death in the acute period were most often acute massive blood loss - 5 (5.8%) cases, and in the late period - sepsis and MODS - 11 (12.8%) cases, only in 2 (2.3%) cases of the deceased, complications such as fistulas and cachexia determined the fatal outcome.
Abdominal trauma -> duodenal trauma EG DFS-^u Itra s o u n d -> La pa rosco py-^-La pa roto my
Hematoma grade I
Suturi ngthe tear, followed by drai nage of the subhepatic and ret ro p erito ne al space
Suturi rig of duodenal defects with a double-row suture with additi onal drai nage of the bi I i ary tract and
with m andatory subsequent drai nage of
the subhepati c and retro peri tone al space
Suturi ng of duodenal defects, duodenoanast om osi s, exclusion of the duodenum from the di gesti ve system., application of HE A, followed by drai nage of the subhepatic and
ret ro p e ri t oneal
space, nasoi ntesti nal probe i ntubation
Suturi ng of duodenal defects, duodenoanas
torn osi s, excl usi on of
the duodenum from the di gesti ve system., appl i cati on of
GEA, chol edochoen teroanastomo si s with subsequent drainage of
the subhepati c and ret roperi tone
al space, nasoi ntestinal
Duodenosto my on a FoI ey catheter with re i nf o rc e m e n t by a strand of the greater
omentum, excl usi on of
ga stro e nte ro
loop, drai nage of
the s u b h e p ati c and retro peri to ne
ai space, nasoi nte sti n a I tube i ntubati on
Certainly, postoperative mortality in patients with duodenal injuries who underwent surgery over the past 10 years was 5 (11.1%) compared to 13 (31.7%) over the previous 10 years. The main factors influencing the mortality rate were the size of the wound defect of the duodenum, the severity of associated injuries, the possibility of rapid and accurate diagnosis, and the adequacy of surgical intervention. It should be noted that the frequency of complications after various disconnection operations is much lower than with preservation of passage through the duodenum.
In the treatment of patients with duodenal injuries, as a result of using various surgical tactics, a comparative analysis of the treatment results showed that:
In most patients in the retrospective group, a duodenal rupture was not diagnosed against the background of peritonitis, or sutures were applied within 24 hours or more at a later date, which led to suture failure and repeated operations.
1. Another aspect of negative consequences in patients of the retrospective study group in the regions is that in most patients with damage of more than 1/2 of the duodenal circumference and grade III-IV, the exclusion of the duodenum from the digestive system with drainage operations of the stomach was not performed.
2. In both groups, the main causes of duodenal fistulas were previously undiagnosed ruptures of the duodenum or sutures were applied for 24 hours or more at a later date, suppuration of intramural hematomas of the duodenum, retroperitoneal hematoma, complicated pancreatic necrosis.
Based on the results of the study, a tactical algorithm for diagnosis and selection of the optimal volume of surgical care for patients with damage to the duodenum was formed.
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