Duodenal injury following blunt or penetrating abdominal trauma remains one of the most diallenging problems confronting the surgeon.
Duodenal injury caused by abdominal trauma represented lower incidences among gastrointestinal injuries but the rate of complication and mortality was higher than that of other organic injuries.
When early diagnosis and treatment are carefully made by analizing the prognostic factors influencing duodenal injuries, the rate of complication and mortality can be decreased.
This study constitutes a retrospective review of 34 patients having duodenal injury among 336 patients of gastrointestinal injuries who were diagnosed by operation and roentgenologic findings from January, 1964 to May, 1983 at the Department of Surgery, College of Medicine, Yonsei University.
The results are summarized briefly as follows:
1) The age of these 34 patients ranged from 1 month to 55 years and their average age was 26 years and 76.5% ocurred between the 1st and 4th decade. The male-female ratio was 4.7:1.
2) The incidence of duodenal injuries was 7.9% among 63 cases of gastrointestinal injuries in the first 10 years(1964. 1. 1~1973. 12. 31) and 10.6% among 273 cases of gastrointestinal injuries in the following nine years and 5 months(1974. 1. 1~1983. 5. 31). Among the 34 cases of duodenal injuries, 5 cases occurred in the first 10 years and 29 cases occurred in the following nine years and five months. Duodenal injuries were more frequent in the second period than in the first.
3) The cause of injuries: Only 8.8% were penetrating injuries. 41.2% were traffic accident, and blow or kick and fall, in the order named.
4) Type of duodenal injury and results: The types of injuries were classified into perforation and non perforation. In 9 cases of non perforation, there was no complication or mortality. Among 25 cases of perforation, 12 cases involved less than 20% of the lumenal circumference. This was the highest frequency.
But disruption involving more than 70% of the lumenal circumference showed the highest rate of complication and mortality, 71.7% and 57.1% respectively.
5) Site of injury and results: The majority of injuries occurred in the second and third portion of the duodenum, representing 73.5% of the duodenal injuries. Particulary it the second portion, one complication occurred in one case of duodenal injury alone. Among 11 cases with associated injuries, 63.5% of complications and 36.3% mortality occurred in this portion. So the second portion showed the highest incidence of complication and mortality.
6) Results according to time interval from injury to operation: In 4 cases with surgery performed within 6 hours after injury, there was no complication or mortality. Among 28 cases of operation performed longer than 6 hours after injury, the rates of complication and mortality were 39.3% and 17.9% respectively. The critical time was 6 hours post injury.
7) Results according to duodenal injury with or without associated injury: Among 10 cases of duodenal injury alone, there was one case of complication and no mortality. Among 24 cases of associated injuries, the rates of complicatino and mortality were 41.7% and 25% respectively.
Particulary in pancreatic associated injury, there was a 57.4% complication rate and a 42.1 % mortality rate. In pancreatic and common bile duct associated injury, the rates for complication and mortality were both 50%.
In other associated injuries, the complication rate was 26.7% and mortality 13.3%. So the rates for complication and mortality were increased in associated injuries, particuiary in case with pancreas and common bile duct injuries.
8) Results according to preoperative state: The rates of complication and mortality were 58.1% and 42.5% respectively in patients in a preoperative shock state, but 25.9% and 11.1% respectively in patients without preoperative shock.
9) Results according to operative procedures: The operative procedures were classified into primary closure, primary closure with decompression, and miscellaneous (Whipples operation, Roux-en.Y procedures, Du.odenojejina1 anastomosis). The rates of complication and mortality were higher in cases receiving more aggressive operative procedures, but this was because of more serious injury. Therefore, the rate of complication and mortality is not determined by operative procedure.
10) In 34 cases of duodenal injury, the overall rates of complication and mortality were 47% and 17.6% respectively.
According to analysis of the above results, the prognostic factors influencing cuodcnal injuries are thought to be as follows:
(1) Site of injury.
(2) Type of injury.
(3) Associated injury, Particulary pancreas and common bile duct.
(4) Time interval from injury to operation.
(5) Preoperative shock state.
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