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The use of pyloric exclusion in the management of severe duodenal injuries
The Use of Pyloric Exclusion in the Management of Severe Duodenal Injuries G. Dennis Vaughan, III, MD, Houston, Texas 0. H. Frazier, MD, Houston, Texas David Y. Graham, MD,’ Houston, Texas Kenneth L. Mattox, MD, Houston, Texas Frederick F. Petmecky, MD, Houston, Texas George L. Jordan, Jr, MD, Houston, Texas
That portion of the gastrointestinal tract extending from the pylorus of the stomach to the ligament of Treitz has many special features. From an anatomic standpoint, it is in juxtaposition to many organs and major vessels. It is adherent to the pancreas and shares its blood supply. The bile duct and pancreatic duct enter its second portion, and it is partly retroperitoneal. In addition to these anatomic features, it is filled with the most potent digestive juices in the body. Patients sustaining duodenal injuries, therefore, often present special problems in management. Many have multiple injuries which are immediately life-endangering. In others, the special anatomic features of the duodenum pose complex technical problems for repair. Lastly, fistula formation occurs more frequently after duodenal surgery than after surgery on the stomach or small intestine, and the digestive juices which leak constitute a hazard to life, as well as pose difficult problems in management in the patients who survive. The latter factor is of particular importance when a lateral duodenal fistula exists, with passage of all ingested food and upper gastrointestinal secretions past the fistulous opening. An end duodenal fistula is a less severe. problem, because nutrition can often be maintained in such patients by oral feedings without loss of nutrients from the fistula. Most duodenal wounds can be treated by simple repair and-drainage, but for the reasons stated above, many special technics have been described for management of selective complicated wounds [1--B]. These include the use of an anastomosis to the small From tha Ccva and Webb Mading Dapartment of Sugery and the Department of Medicine*, Baylor College of Medicine and the Ben Taub General Hospital, Houston, Texas. Reprint requests should be addressed to George L. Jordan, Jr, MD, 1200 Moursund Avenue, Houston, Texas 77030. Presented at the Twenty-Ninth Annual Meeting of the Southwestern Surgical Congress, Acapulco, Mexico, April 25-29, 1977.
Volume 134. December 1977
bowel or an onlay serosal or full thickness patch made from the jejunum to replace destroyed segments of the duodenal wall [5,6]. Resection with reanastomosis and Roux-en-Y loops has also been used in selected patients when stricture formation or fistula formation seems a likely complication. Some have recommended partial gastric resection with “diverticulization” of the duodenum [2,3]. 0 ne of us .(GLJ) devised a more simple method of “diverticulization” which eliminated the need for gastric resection and which created a temporary exclusion of the duodenum from the normal flow of gastrointestinal contents. It was believed that this would serve to protect the duodenum in the early postoperative period during the healing phase of the repair, while allowing the return of normal duodenal function in the late postoperative period. This procedure consists of repair of the duodenal wound by appropriate measures and repair of all other abdominal injuries. As the last stage in the operation, a gastrotomy incision is made on the greater curvature of the antrum of the stomach in a site selected for gastrojejunostomy. Through this opening the pylorus is closed with sutures of chromic catgut. Gastrojejuno&my, side-to-side, is then accomplished. (Figures 1 and 2.) This study constitutes a review of our experience with this technic and a comparison with other procedures which have been used. Clinical Material and Methods
From January 1969 to October 1976,175 patients with traumatic duodenal injuries were treated at the Ben Taub General Hospital. Seventy-five had severe injuries, and pyloric exclusion was used in conjunction with repair of the injury. Use of the procedure was predicated upon the judgment of the surgeon. Among the other 100 patients, 78 were treated by debridement, primary closure, and drainage, and
785
Vaughan et al
Fipre 1. hothal /nJuryand method of excluding the pylorus. (0 1977 Baylor College of MeQlclne. )
nine were treated by resection and reanastomosis. In four patients the injury involved the first portion of the duodenum and distal stomach and, therefore, distal gastric resection with closure of the stump and gastrojejunostomy was utilized. In three patients a serosal patch was used and in one a Roux-en-Y loop was used for reconstruction. Four patients with severe destruction of the head of the pancreas and
Figure 2. Completed pyloric exclusion and gastroJeJunostomy. ( 0 1977 Baylor College of Medlclne. )
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duodenum underwent pancreatoduodenectomy and one patient with an even more severe injury underwent total pancreatoduodenectomy. The majority of patients sustained penetrating injuries, fifty-nine by bullets and three by shotgun blasts, while two patients sustained stab wounds. There were eleven injuries secondary to blunt trauma, all sustained in automobile accidents. (Table I.) Male patients outnumbered females by approximately a 4 to 1 ratio. The average age was thirty-one years. The second portion of the duodenum was the part most frequently injured. Fifteen of the patients had multiple duodenal injuries. (Table II.) Of the seventy-five patients undergoing pyloric exclusion, fifty had three or more associated organ injuries, fourteen had two associated injuries, five had one associated injury, and only six patients had isolated injuries of the duodenum. There were 217 associated organs injured which included 30 pancreatic injuries and 26 inferior vena caval injuries. (Table III.) Once a need for the pyloric exclusion procedure was determined, the choice of technic for duodenal repair was selected. In the majority of patients debridement followed by a two-layer closure could be accomplished. Several patients with massive injury required resection with reanastomosis. The pyloric exclusion procedure was the last step in the operation. In the majority of patients the technic originally described was used, but in three patients nonabsorbable sutures were used and in three patients a
The American Journal of Surgery
Pyloric Exclusion after Duodenal
stapler was used as a rapid and simple method of obtaining exclusion. In all instances, the closure was accomplished so that antral mucosa would not be exposed to duodenal juices. In a few selected patients, gastrostomy and jejunostomy tubes were placed. Results
There were fourteen deaths (19 per cent) among the seventy-five patients. Thirteen deaths occurred in patients having three or more associated organ injuries and the fourteenth death occurred in a patient with two associated organ injuries. Eight deaths occurred in patients with injuries sustained by gunshot wounds, two occurred after shotgun wounds, one occurred after a stab wound, and three occurred in patients sustaining blunt trauma. (Table I.) Six deaths occurred as a result of shock within 36 hours after injury. Five deaths were from sepsis, one from a pulmonary embolus, one from renal and respiratory failure, and one from massive hemorrhage caused by a duodenoaortic fistula. (Table IV.) The most frequent complications were infections. Six patients had intraabdominal abscesses, all requiring operative drainage. Eight per cent of patients developed superficial wound infections. There were two cases of postoperative pseudomonas pneumonia. Other complications were related to associated organ injury and included nine pancreatic fistulas, two cases of pancreatitis, and one inferior vena caval thrombosis. There were six cases of postoperative small bowel obstruction, one of which required laparotomy and lysis of adhesions. There were four complications directly attributable to the duodenal injury. Three were duodenocutaneous fistulas. Two healed spontaneously, and only one required surgical correction. The other complication was the previously mentioned duodenoaortic fistula. Three complications were directly attributable to the pyloric exclusion and gastrojejunostomy. Two patients had postoperative bleeding from the gastrojejunostomy suture line and required reexploration for control. One patient developed gastric outlet obstruction at the site of anastomosis, but this responded to simple gastric decompression and resolved spontaneously after ten days of treatment.
TABLE I
Mortality Related to Mode of Injury in Patients Undergoing Pyloric Exclusion and Gastrojejunostomv Deaths/Cases
Type of Injury Penetrating Bullet Knife Shotgun Blunt trauma Total
TABLE II
11/64 6159 l/2 2/3 3/11 14/75
(17%) (13%) (50%) (67%) (27%) (19%)
Location of Injury in the Duodenum
Portion of Duodenum Injured
Penetrating
Blunt
Total
First portion Second portion Third portion Fourth portion Multiple injuries
2 33 11 4 14
2 5 1 2 1
4 36 12 6 15
TABLE Ill
Incidence Organs
of Associated
injuries of Other
Oman
Number
Pancreas Liver Inferior vena cava Transverse colon Small bowel Stomach Ascending colon Gallbladder Right kidney Aorta Right ureter Spleen Descending colon Right renal vein Superior mesenteric artery Superior mesenteric vein Inferior mesenteric artery Right renal artery Celiac axis
30 (40%) 30 (40%) 26 (35 % ) 22 (29%) 21 (28%) 19 (25%) 14 (19%) 13 (17%) 13 (17%) 7( 9%) 7( 9%) 7( 9%) 5( 7%) 5( 7%) 2( 3%) 2( 3%) 2( 3%) l( 1%) l( 1%)
TABLE IV
Cause of Death as Related to Number of Associated lnluries
Late Results
The pyloric exclusion procedure was evaluated in twenty-five patients by upper gastrointestinal studies performed after periods ranging from two months to three years postoperatively. All demonstrated a functioning pylorus with passage of contents into the duodenum.
Vdume 1.94,December 1977
injury
Cause of Death Hemorrhage and shock Sepsis Pulmonary embolus Adult respiratory distress syndrome Hemorrhage secondary to aortoduodenal fistula
Number 6 5 1 1 1
Number of Associated Injuries 2 3 4+ 1
5
113 1 1 1
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Vaughan et al
TABLE V
Reported Mortalities and Incidence of Fistula Formation after Duodenal Trauma Author
Mclnnis et al [ 61 Donovan and Hagen [ 81 Lucas and Ledgerwood [ 121 Webb et al [ 791 Berne et al [ 31 Smith et al [ 731 Stone and Garoni [ 141 Corley, Norcross, and Shoemaker Morton and Jordan [ 761 Present series Total series Pyloric exclusion procedure
No. of Cases
No. of Deaths
No. of Fistulas
22 29 36 50 50 53 70 98 131
3 (14%) 4 (14%) 7 (19%) 14 (28%) 8 (16%) 15 (28%) 16 (23%) 23 (24%) 28(21%)
2( 9%) 3 (10%) 3( 8%) 3( 6%) 7 (14%) 3( 6%) 6( 9%) 10 (10%) 8( 6%)
175 75
24 (14%) 14 (19%)
[ 771
Ten patients were readmitted to the hospital for additional follow-up studies pertaining to the effects of this procedure on gastric physiology and functional gastrointestinal anatomy. All patients had determinations of hematologic values, serum electrolyte concentrations, and hepatic function tests. No abnormal tests were found on these studies. All patients underwent gastric analysis and serum gastrin determinations. All of the serum gastrin concentrations were within normal range, except for one patient in whom the concentration was lower than normal. One hour basal and stimulated gastric acid determinations were made on each of these ten patients. The acid secretory rates were within the normal range of 1 to 3 mEq/hr in eight patients. Two patients, however, had acid secretory rates ranging from 6 to 7 mEq/hr. Fiberoptic endoscopy in these ten patients confirmed the roentgenographic findings of a patent pylorus. No significant pyloric abnormality was noted, except for some mild mucosal erythema in one patient. No patient had evidence of reflux gastritis or significant duodenal obstruction. One significant finding among these patients was the development of three marginal ulcers at periods of four months to two years postoperatively. One of the patients had had a history of a previous duodenal ulcer, despite normal gastric acid levels. The patient was treated conservatively and the ulcer healed spontaneously. The other two patients were those who had marked gastric hypersecretion and both were treated surgically. One was treated simply by take-down of the gastrojejunostomy, while the other was treated by vagotomy and gastric resection. Comments
The anatomic location of the duodenum deep within the abdomen has both beneficial aspects as well as detrimental ones. It is well protected from external injury by surrounding abdominal muscu-
788
4( 4(
2%) 5%)
lature and soft tissue. However, because of its juxtaposition to the rigid vertebral column and its potential for being a closed, hollow viscus, it is subject to potential devastating blowouts secondary to blunt trauma. With the advent of the seat belt and continued high speed transportation, vehicular accidents have led to an increase in the number of patients seen with duodenal blowout injuries. Because of its contiguous position to so many other vital structures, injuries to this organ are usually accompanied by numerous associated injuries, some of which are more devastating than the reported organ injury. Mortality rates after duodenal injury have been consistently high throughout the reported literature. In the early nineteenth century, they approached 100 per cent and have shown a gradual decline, with reported series showing 89 per cent in the early 19OOs, including World War I, with a decline to 57 per cent in World War II [9,20]. In 1974, Corley, Norcross, and Shoemaker [II] reported a mortality of 23.5 per cent in a series of ninety-eight patients. Several other series report similar mortality rates in the approximate range of 14 to 28 per cent [3,6,12-141. (Table V.) Previous reports from this institution have described an overall mortality of 21 per cent [15,16]. If one considers only the severe injuries among the seventy-five patients constituting the primary subject of the present study, the mortality of 18.6 per cent in this group is still lower than that in most reported series. This is particularly significant in view of the fact that all of the patients in this group who died had three or more organs injured, including the duodenum, and our experience, as well as that of others, indicates that there is a high mortality in patients with multiple organ injuries, regardless of which organs are injured. The mortality was 10 per cent among the other 100 patients, thus making an overall mortality rate of 14 per cent in 175 consecutive duodenal injuries. This is one of the lowest
The American Journal of Surgery
Pyloric Exclusion after Duodenal Injury
mortalities appearing in the literature and significantly lower than the previous mortality rate reported from this institution. (Table VI.) Of particular significance is the fact that out of the entire 175 patients, the patient who developed the duodenoaortic fistula was the only patient who died as a direct result of a complication of the duodenal wound itself. In most reported series, duodenal fistula was the most dreaded and devastating complication of the duodenal injury itself, and most of the methods of treatment described in the literature have been devised with the objective of diminishing the incidence of this complication or decreasing its catastrophic consequences. Methods of decompression of the duodenum by simply diverting the gastric secretion through a gastrojejunostomy, gastrostomy and jejunostomy or gastric resection have been reported by others [2,3,8,11]. Corley, Norcross, and Shoemaker [ll] reported on fourteen patients with primary repair, external drainage, gastrostomy, and afferent and efferent jejunostomy with a zero mortality and zero rate of fistula formation. However, in their series of ninetyeight patients, treatment ranged from simple repair with or without external drainage to the decompressive procedures already mentioned, and the overall rate of fistula formation was 10 per cent. Of these ten patients, four died as a direct result of the fistula. In the reports by Berne and co-workers [2,3] and Donovan and Hagen [B] of duodenal diverticulization by antrectomy, gastrojejunostomy, and tube duodenostomy, duodenal fistula formed in 14 per cent of the fifty patients so treated. All of these, however, closed spontaneously with patient survival. In other reported series, the rate of lateral duodenal fistula formation ranges between 6 and 14 per cent in all patients regardless of the type of closure. (Table V.) In our total series of 175 patients, the incidence of duodenal fistula was significantly lower than that reported by others. Remarkably, there were no duodenal fistulas among the 100 patients treated without the pyloric exclusion procedure and only 5 per cent among the patients treated by pyloric exclusion. Therefore, in the 175 patients, the overall incidence of duodenal fistula, either internal or external, was only 2 per cent. During the period of this study there have in actuality been three identifiable groups of patients. The first group, with limited duodenal injury and a lesser number of associated organ injuries, was treated satisfactorily without use of complicated procedures while still obtaining a lower mortality. The group in which pyloric exclusion was employed were those
Vohme 134, December 1977
TABLE VI
Mortality Related to Mode of Injury in 175 Consecutive Cases of Duodenal Trauma
Type of Injury
Deaths/Cases
Penetrating Bullet Knife Shotgun Blunt trauma Total
18/152 (12%) 13/124(11%) 2/18(11%) 3110 (30%) 6/23 (26%) 241175 (14%)
with severe injuries but in whom there was not so much destruction of tissue that repair was not possible. In this group, however, are included many patients who might have been treated by resection in other centers [4]. It is our belief that preservation of normal tissue is desirable in these patients insofar as possible. The third, and very small, group constitutes those in whom destruction of the duodenum and adjacent head of the pancreas was so severe that salvage of tissue for reconstruction seemed impossible. These were the five patients treated by pancreatoduodenectomy, and we believe that this procedure should be reserved for selected patients [13,17,18]. These data support the concept that temporary pyloric exclusion, gastrojejunostomy, and primary repair does not significantly alter gastric physiology and allows protection of the duodenal closure during the early postoperative period with resumption of duodenal function within a few weeks. A point of specific interest among those who have discussed this procedure has been the desirability of utilizing vagotomy in such patients to prevent marginal ulcer. Excluding the patient who had a previous history of ulcer and who was treated conservatively, only two patients developed marginal ulcers, although follow-up data are not complete on all patients. The incidence of 5 per cent among those surviving operation is less than the recurrent ulcer rate accepted by those utilizing vagotomy-pyloroplasty or vagotomy-jejunostomy electively in the treatment of duodenal ulcer. Thus, it seems to be an acceptable rate in exchange for the avoidance of postvagotomy complications which would occur among a group of patients so treated. A more important consideration in our opinion, however, is the fact that all the patients treated by pyloric exclusion have life-endangering injuries and the procedures used should be designed to save life. To add vagotomy as an additional procedure for prophylactic purposes in patients in whom shock is present and in whom difficult technical maneuvers have been required to repair multiple organ injuries seems unjustified.
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Summary
Repair of severe duodenal injuries often constitutes a technical challenge, and a variety of special technics have been described. For the past seven years we have utilized temporary pyloric exclusion and gastrojejunostomy to produce “diverticulization” of the duodenum. This procedure was utilized in seventy-five patients selected from 175 consecutive patients presenting with duodenal trauma. The mortality was 19 per cent and the rate of fistula formation was 5 per cent in this series and 14 per cent and 2 per cent, respectively, in the overall series. Follow-up studies of gastric physiology and functional anatomy show no evidence of alteration of these parameters. We thus believe that patients presenting with severe duodenal trauma and often multiple devastating associated organ injuries can be adequately treated with this procedure with a significant decrease in mortality and with marked improvement of postoperative morbidity. References 1. Berg AA: Duodenal flstula: Its treatment by gastrojejunostomy and pylorlc occlusion. Ann Surg 45: 721, 1907. 2. Berne CJ, Donovan AJ, Hagen WE: Comblned duodenal pancreatlc trauma. Arch S&g 98: 712, 1988. 3. Berne CJ, Donovan AJ, White EF, Yellln AE: Duodenal “dlvertlcullzatlon” for duodenal and pancreatic Injury. Am J Surg
790
127: 503, 1974. 4. Halgrlmson DG, Trlmble C, Gale S, Waddell WR: Pancreatlcoduodenectomy for traumatic lesions. Am J Surg 118: 877, 1989. 5. Kobold EE, Thal AP: A simple method for the management of experlmental wounds of the duodenum. Surg Gyneco/ Ofxsfef 118: 340, 1983. 8. Mclnnis WD, Aust JB, Cruz AB, Root HD: Traumatic Injuries of the duodenum: a comparison of prlmary closure and the jejunal patch. J Trauma 15: 847, 1975. 7. Summers JR Jr: The treatment of posterior perforation of the final portions of the duodenum. Ann Surg 38: 727, 1904. 8. Donovan AJ, Hagen WE: Traumatic perforations of the duodenum. Am J Surg 111: 341, 1988. 9. Cave WH: Duodenal injuries. Am J Surg 72: 28, 1948. 10. Miller RT: Retroperltoneal rupture of the duodenum by blunt force. Ann Surg 84: 550, 1918. 11. Corley RD, Norcross WJ, Shoemaker WC: Traumatic injuries to the duodenum. Ann Surg 181: 92, 1975. 12. Lucas CD, Ledgerwood AM: Factors influencing outcome after blunt duodenal injury. J Trauma 15: 839, 1975. 13. Smith AD Jr, Woolverton WC, Weichert RF Ill, Drapanas T: Operative management of pancreatic and duodenal In/uries. J Trauma 11: 570, 1971. 14. Stone HH, Garoni WJ: Experience in the management of duodenal wounds. South Med J 59: 884, 1988. 15. BurrusOR,Howell JF, Jordan GLJr: Traumatic duodenal lnjurles: an analysis of 88 cases. J Trauma 1: 98, 1981. 18. Morton JR, Jordan GL Jr: Traumatlc duodenal inJuries.J Traums 8: 127, 1988. 17. Werschky LR, Jordan GL: Surgical management of traumatlc lnjurles of the pancreas. Ati J Surg 1i8: 788, 1988. 18. Yellln AE. Rosoff L Sr: Pancreatoduodenectomv for combined pancreatoduodenal InjurIes. Arch Surg 118: 1177, 1975. 19. Webb HW, Howard JM, Jordan GL Jr, Vowles KDJ: Surgical experience In the treatment of duodenal Injuries. Surg GynecolObstet 108: 105, 1958.
The Amorlcm Journal of &gory
That portion of the gastrointestinal tract extending from the pylorus of the stomach to the ligament of Treitz has many special features. From an anatomic standpoint, it is in juxtaposition to many organs and major vessels. It is adherent to the pancreas and shares its blood supply. The bile duct and pancreatic duct enter its second portion, and it is partly retroperitoneal. In addition to these anatomic features, it is filled with the most potent digestive juices in the body. Patients sustaining duodenal injuries, therefore, often present special problems in management. Many have multiple injuries which are immediately life-endangering. In others, the special anatomic features of the duodenum pose complex technical problems for repair. Lastly, fistula formation occurs more frequently after duodenal surgery than after surgery on the stomach or small intestine, and the digestive juices which leak constitute a hazard to life, as well as pose difficult problems in management in the patients who survive. The latter factor is of particular importance when a lateral duodenal fistula exists, with passage of all ingested food and upper gastrointestinal secretions past the fistulous opening. An end duodenal fistula is a less severe. problem, because nutrition can often be maintained in such patients by oral feedings without loss of nutrients from the fistula. Most duodenal wounds can be treated by simple repair and-drainage, but for the reasons stated above, many special technics have been described for management of selective complicated wounds [1--B]. These include the use of an anastomosis to the small From tha Ccva and Webb Mading Dapartment of Sugery and the Department of Medicine*, Baylor College of Medicine and the Ben Taub General Hospital, Houston, Texas. Reprint requests should be addressed to George L. Jordan, Jr, MD, 1200 Moursund Avenue, Houston, Texas 77030. Presented at the Twenty-Ninth Annual Meeting of the Southwestern Surgical Congress, Acapulco, Mexico, April 25-29, 1977.
Volume 134. December 1977
bowel or an onlay serosal or full thickness patch made from the jejunum to replace destroyed segments of the duodenal wall [5,6]. Resection with reanastomosis and Roux-en-Y loops has also been used in selected patients when stricture formation or fistula formation seems a likely complication. Some have recommended partial gastric resection with “diverticulization” of the duodenum [2,3]. 0 ne of us .(GLJ) devised a more simple method of “diverticulization” which eliminated the need for gastric resection and which created a temporary exclusion of the duodenum from the normal flow of gastrointestinal contents. It was believed that this would serve to protect the duodenum in the early postoperative period during the healing phase of the repair, while allowing the return of normal duodenal function in the late postoperative period. This procedure consists of repair of the duodenal wound by appropriate measures and repair of all other abdominal injuries. As the last stage in the operation, a gastrotomy incision is made on the greater curvature of the antrum of the stomach in a site selected for gastrojejunostomy. Through this opening the pylorus is closed with sutures of chromic catgut. Gastrojejuno&my, side-to-side, is then accomplished. (Figures 1 and 2.) This study constitutes a review of our experience with this technic and a comparison with other procedures which have been used. Clinical Material and Methods
From January 1969 to October 1976,175 patients with traumatic duodenal injuries were treated at the Ben Taub General Hospital. Seventy-five had severe injuries, and pyloric exclusion was used in conjunction with repair of the injury. Use of the procedure was predicated upon the judgment of the surgeon. Among the other 100 patients, 78 were treated by debridement, primary closure, and drainage, and
785
Vaughan et al
Fipre 1. hothal /nJuryand method of excluding the pylorus. (0 1977 Baylor College of MeQlclne. )
nine were treated by resection and reanastomosis. In four patients the injury involved the first portion of the duodenum and distal stomach and, therefore, distal gastric resection with closure of the stump and gastrojejunostomy was utilized. In three patients a serosal patch was used and in one a Roux-en-Y loop was used for reconstruction. Four patients with severe destruction of the head of the pancreas and
Figure 2. Completed pyloric exclusion and gastroJeJunostomy. ( 0 1977 Baylor College of Medlclne. )
786
duodenum underwent pancreatoduodenectomy and one patient with an even more severe injury underwent total pancreatoduodenectomy. The majority of patients sustained penetrating injuries, fifty-nine by bullets and three by shotgun blasts, while two patients sustained stab wounds. There were eleven injuries secondary to blunt trauma, all sustained in automobile accidents. (Table I.) Male patients outnumbered females by approximately a 4 to 1 ratio. The average age was thirty-one years. The second portion of the duodenum was the part most frequently injured. Fifteen of the patients had multiple duodenal injuries. (Table II.) Of the seventy-five patients undergoing pyloric exclusion, fifty had three or more associated organ injuries, fourteen had two associated injuries, five had one associated injury, and only six patients had isolated injuries of the duodenum. There were 217 associated organs injured which included 30 pancreatic injuries and 26 inferior vena caval injuries. (Table III.) Once a need for the pyloric exclusion procedure was determined, the choice of technic for duodenal repair was selected. In the majority of patients debridement followed by a two-layer closure could be accomplished. Several patients with massive injury required resection with reanastomosis. The pyloric exclusion procedure was the last step in the operation. In the majority of patients the technic originally described was used, but in three patients nonabsorbable sutures were used and in three patients a
The American Journal of Surgery
Pyloric Exclusion after Duodenal
stapler was used as a rapid and simple method of obtaining exclusion. In all instances, the closure was accomplished so that antral mucosa would not be exposed to duodenal juices. In a few selected patients, gastrostomy and jejunostomy tubes were placed. Results
There were fourteen deaths (19 per cent) among the seventy-five patients. Thirteen deaths occurred in patients having three or more associated organ injuries and the fourteenth death occurred in a patient with two associated organ injuries. Eight deaths occurred in patients with injuries sustained by gunshot wounds, two occurred after shotgun wounds, one occurred after a stab wound, and three occurred in patients sustaining blunt trauma. (Table I.) Six deaths occurred as a result of shock within 36 hours after injury. Five deaths were from sepsis, one from a pulmonary embolus, one from renal and respiratory failure, and one from massive hemorrhage caused by a duodenoaortic fistula. (Table IV.) The most frequent complications were infections. Six patients had intraabdominal abscesses, all requiring operative drainage. Eight per cent of patients developed superficial wound infections. There were two cases of postoperative pseudomonas pneumonia. Other complications were related to associated organ injury and included nine pancreatic fistulas, two cases of pancreatitis, and one inferior vena caval thrombosis. There were six cases of postoperative small bowel obstruction, one of which required laparotomy and lysis of adhesions. There were four complications directly attributable to the duodenal injury. Three were duodenocutaneous fistulas. Two healed spontaneously, and only one required surgical correction. The other complication was the previously mentioned duodenoaortic fistula. Three complications were directly attributable to the pyloric exclusion and gastrojejunostomy. Two patients had postoperative bleeding from the gastrojejunostomy suture line and required reexploration for control. One patient developed gastric outlet obstruction at the site of anastomosis, but this responded to simple gastric decompression and resolved spontaneously after ten days of treatment.
TABLE I
Mortality Related to Mode of Injury in Patients Undergoing Pyloric Exclusion and Gastrojejunostomv Deaths/Cases
Type of Injury Penetrating Bullet Knife Shotgun Blunt trauma Total
TABLE II
11/64 6159 l/2 2/3 3/11 14/75
(17%) (13%) (50%) (67%) (27%) (19%)
Location of Injury in the Duodenum
Portion of Duodenum Injured
Penetrating
Blunt
Total
First portion Second portion Third portion Fourth portion Multiple injuries
2 33 11 4 14
2 5 1 2 1
4 36 12 6 15
TABLE Ill
Incidence Organs
of Associated
injuries of Other
Oman
Number
Pancreas Liver Inferior vena cava Transverse colon Small bowel Stomach Ascending colon Gallbladder Right kidney Aorta Right ureter Spleen Descending colon Right renal vein Superior mesenteric artery Superior mesenteric vein Inferior mesenteric artery Right renal artery Celiac axis
30 (40%) 30 (40%) 26 (35 % ) 22 (29%) 21 (28%) 19 (25%) 14 (19%) 13 (17%) 13 (17%) 7( 9%) 7( 9%) 7( 9%) 5( 7%) 5( 7%) 2( 3%) 2( 3%) 2( 3%) l( 1%) l( 1%)
TABLE IV
Cause of Death as Related to Number of Associated lnluries
Late Results
The pyloric exclusion procedure was evaluated in twenty-five patients by upper gastrointestinal studies performed after periods ranging from two months to three years postoperatively. All demonstrated a functioning pylorus with passage of contents into the duodenum.
Vdume 1.94,December 1977
injury
Cause of Death Hemorrhage and shock Sepsis Pulmonary embolus Adult respiratory distress syndrome Hemorrhage secondary to aortoduodenal fistula
Number 6 5 1 1 1
Number of Associated Injuries 2 3 4+ 1
5
113 1 1 1
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TABLE V
Reported Mortalities and Incidence of Fistula Formation after Duodenal Trauma Author
Mclnnis et al [ 61 Donovan and Hagen [ 81 Lucas and Ledgerwood [ 121 Webb et al [ 791 Berne et al [ 31 Smith et al [ 731 Stone and Garoni [ 141 Corley, Norcross, and Shoemaker Morton and Jordan [ 761 Present series Total series Pyloric exclusion procedure
No. of Cases
No. of Deaths
No. of Fistulas
22 29 36 50 50 53 70 98 131
3 (14%) 4 (14%) 7 (19%) 14 (28%) 8 (16%) 15 (28%) 16 (23%) 23 (24%) 28(21%)
2( 9%) 3 (10%) 3( 8%) 3( 6%) 7 (14%) 3( 6%) 6( 9%) 10 (10%) 8( 6%)
175 75
24 (14%) 14 (19%)
[ 771
Ten patients were readmitted to the hospital for additional follow-up studies pertaining to the effects of this procedure on gastric physiology and functional gastrointestinal anatomy. All patients had determinations of hematologic values, serum electrolyte concentrations, and hepatic function tests. No abnormal tests were found on these studies. All patients underwent gastric analysis and serum gastrin determinations. All of the serum gastrin concentrations were within normal range, except for one patient in whom the concentration was lower than normal. One hour basal and stimulated gastric acid determinations were made on each of these ten patients. The acid secretory rates were within the normal range of 1 to 3 mEq/hr in eight patients. Two patients, however, had acid secretory rates ranging from 6 to 7 mEq/hr. Fiberoptic endoscopy in these ten patients confirmed the roentgenographic findings of a patent pylorus. No significant pyloric abnormality was noted, except for some mild mucosal erythema in one patient. No patient had evidence of reflux gastritis or significant duodenal obstruction. One significant finding among these patients was the development of three marginal ulcers at periods of four months to two years postoperatively. One of the patients had had a history of a previous duodenal ulcer, despite normal gastric acid levels. The patient was treated conservatively and the ulcer healed spontaneously. The other two patients were those who had marked gastric hypersecretion and both were treated surgically. One was treated simply by take-down of the gastrojejunostomy, while the other was treated by vagotomy and gastric resection. Comments
The anatomic location of the duodenum deep within the abdomen has both beneficial aspects as well as detrimental ones. It is well protected from external injury by surrounding abdominal muscu-
788
4( 4(
2%) 5%)
lature and soft tissue. However, because of its juxtaposition to the rigid vertebral column and its potential for being a closed, hollow viscus, it is subject to potential devastating blowouts secondary to blunt trauma. With the advent of the seat belt and continued high speed transportation, vehicular accidents have led to an increase in the number of patients seen with duodenal blowout injuries. Because of its contiguous position to so many other vital structures, injuries to this organ are usually accompanied by numerous associated injuries, some of which are more devastating than the reported organ injury. Mortality rates after duodenal injury have been consistently high throughout the reported literature. In the early nineteenth century, they approached 100 per cent and have shown a gradual decline, with reported series showing 89 per cent in the early 19OOs, including World War I, with a decline to 57 per cent in World War II [9,20]. In 1974, Corley, Norcross, and Shoemaker [II] reported a mortality of 23.5 per cent in a series of ninety-eight patients. Several other series report similar mortality rates in the approximate range of 14 to 28 per cent [3,6,12-141. (Table V.) Previous reports from this institution have described an overall mortality of 21 per cent [15,16]. If one considers only the severe injuries among the seventy-five patients constituting the primary subject of the present study, the mortality of 18.6 per cent in this group is still lower than that in most reported series. This is particularly significant in view of the fact that all of the patients in this group who died had three or more organs injured, including the duodenum, and our experience, as well as that of others, indicates that there is a high mortality in patients with multiple organ injuries, regardless of which organs are injured. The mortality was 10 per cent among the other 100 patients, thus making an overall mortality rate of 14 per cent in 175 consecutive duodenal injuries. This is one of the lowest
The American Journal of Surgery
Pyloric Exclusion after Duodenal Injury
mortalities appearing in the literature and significantly lower than the previous mortality rate reported from this institution. (Table VI.) Of particular significance is the fact that out of the entire 175 patients, the patient who developed the duodenoaortic fistula was the only patient who died as a direct result of a complication of the duodenal wound itself. In most reported series, duodenal fistula was the most dreaded and devastating complication of the duodenal injury itself, and most of the methods of treatment described in the literature have been devised with the objective of diminishing the incidence of this complication or decreasing its catastrophic consequences. Methods of decompression of the duodenum by simply diverting the gastric secretion through a gastrojejunostomy, gastrostomy and jejunostomy or gastric resection have been reported by others [2,3,8,11]. Corley, Norcross, and Shoemaker [ll] reported on fourteen patients with primary repair, external drainage, gastrostomy, and afferent and efferent jejunostomy with a zero mortality and zero rate of fistula formation. However, in their series of ninetyeight patients, treatment ranged from simple repair with or without external drainage to the decompressive procedures already mentioned, and the overall rate of fistula formation was 10 per cent. Of these ten patients, four died as a direct result of the fistula. In the reports by Berne and co-workers [2,3] and Donovan and Hagen [B] of duodenal diverticulization by antrectomy, gastrojejunostomy, and tube duodenostomy, duodenal fistula formed in 14 per cent of the fifty patients so treated. All of these, however, closed spontaneously with patient survival. In other reported series, the rate of lateral duodenal fistula formation ranges between 6 and 14 per cent in all patients regardless of the type of closure. (Table V.) In our total series of 175 patients, the incidence of duodenal fistula was significantly lower than that reported by others. Remarkably, there were no duodenal fistulas among the 100 patients treated without the pyloric exclusion procedure and only 5 per cent among the patients treated by pyloric exclusion. Therefore, in the 175 patients, the overall incidence of duodenal fistula, either internal or external, was only 2 per cent. During the period of this study there have in actuality been three identifiable groups of patients. The first group, with limited duodenal injury and a lesser number of associated organ injuries, was treated satisfactorily without use of complicated procedures while still obtaining a lower mortality. The group in which pyloric exclusion was employed were those
Vohme 134, December 1977
TABLE VI
Mortality Related to Mode of Injury in 175 Consecutive Cases of Duodenal Trauma
Type of Injury
Deaths/Cases
Penetrating Bullet Knife Shotgun Blunt trauma Total
18/152 (12%) 13/124(11%) 2/18(11%) 3110 (30%) 6/23 (26%) 241175 (14%)
with severe injuries but in whom there was not so much destruction of tissue that repair was not possible. In this group, however, are included many patients who might have been treated by resection in other centers [4]. It is our belief that preservation of normal tissue is desirable in these patients insofar as possible. The third, and very small, group constitutes those in whom destruction of the duodenum and adjacent head of the pancreas was so severe that salvage of tissue for reconstruction seemed impossible. These were the five patients treated by pancreatoduodenectomy, and we believe that this procedure should be reserved for selected patients [13,17,18]. These data support the concept that temporary pyloric exclusion, gastrojejunostomy, and primary repair does not significantly alter gastric physiology and allows protection of the duodenal closure during the early postoperative period with resumption of duodenal function within a few weeks. A point of specific interest among those who have discussed this procedure has been the desirability of utilizing vagotomy in such patients to prevent marginal ulcer. Excluding the patient who had a previous history of ulcer and who was treated conservatively, only two patients developed marginal ulcers, although follow-up data are not complete on all patients. The incidence of 5 per cent among those surviving operation is less than the recurrent ulcer rate accepted by those utilizing vagotomy-pyloroplasty or vagotomy-jejunostomy electively in the treatment of duodenal ulcer. Thus, it seems to be an acceptable rate in exchange for the avoidance of postvagotomy complications which would occur among a group of patients so treated. A more important consideration in our opinion, however, is the fact that all the patients treated by pyloric exclusion have life-endangering injuries and the procedures used should be designed to save life. To add vagotomy as an additional procedure for prophylactic purposes in patients in whom shock is present and in whom difficult technical maneuvers have been required to repair multiple organ injuries seems unjustified.
789
Vaughan et al
Summary
Repair of severe duodenal injuries often constitutes a technical challenge, and a variety of special technics have been described. For the past seven years we have utilized temporary pyloric exclusion and gastrojejunostomy to produce “diverticulization” of the duodenum. This procedure was utilized in seventy-five patients selected from 175 consecutive patients presenting with duodenal trauma. The mortality was 19 per cent and the rate of fistula formation was 5 per cent in this series and 14 per cent and 2 per cent, respectively, in the overall series. Follow-up studies of gastric physiology and functional anatomy show no evidence of alteration of these parameters. We thus believe that patients presenting with severe duodenal trauma and often multiple devastating associated organ injuries can be adequately treated with this procedure with a significant decrease in mortality and with marked improvement of postoperative morbidity. References 1. Berg AA: Duodenal flstula: Its treatment by gastrojejunostomy and pylorlc occlusion. Ann Surg 45: 721, 1907. 2. Berne CJ, Donovan AJ, Hagen WE: Comblned duodenal pancreatlc trauma. Arch S&g 98: 712, 1988. 3. Berne CJ, Donovan AJ, White EF, Yellln AE: Duodenal “dlvertlcullzatlon” for duodenal and pancreatic Injury. Am J Surg
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127: 503, 1974. 4. Halgrlmson DG, Trlmble C, Gale S, Waddell WR: Pancreatlcoduodenectomy for traumatic lesions. Am J Surg 118: 877, 1989. 5. Kobold EE, Thal AP: A simple method for the management of experlmental wounds of the duodenum. Surg Gyneco/ Ofxsfef 118: 340, 1983. 8. Mclnnis WD, Aust JB, Cruz AB, Root HD: Traumatic Injuries of the duodenum: a comparison of prlmary closure and the jejunal patch. J Trauma 15: 847, 1975. 7. Summers JR Jr: The treatment of posterior perforation of the final portions of the duodenum. Ann Surg 38: 727, 1904. 8. Donovan AJ, Hagen WE: Traumatic perforations of the duodenum. Am J Surg 111: 341, 1988. 9. Cave WH: Duodenal injuries. Am J Surg 72: 28, 1948. 10. Miller RT: Retroperltoneal rupture of the duodenum by blunt force. Ann Surg 84: 550, 1918. 11. Corley RD, Norcross WJ, Shoemaker WC: Traumatic injuries to the duodenum. Ann Surg 181: 92, 1975. 12. Lucas CD, Ledgerwood AM: Factors influencing outcome after blunt duodenal injury. J Trauma 15: 839, 1975. 13. Smith AD Jr, Woolverton WC, Weichert RF Ill, Drapanas T: Operative management of pancreatic and duodenal In/uries. J Trauma 11: 570, 1971. 14. Stone HH, Garoni WJ: Experience in the management of duodenal wounds. South Med J 59: 884, 1988. 15. BurrusOR,Howell JF, Jordan GLJr: Traumatic duodenal lnjurles: an analysis of 88 cases. J Trauma 1: 98, 1981. 18. Morton JR, Jordan GL Jr: Traumatlc duodenal inJuries.J Traums 8: 127, 1988. 17. Werschky LR, Jordan GL: Surgical management of traumatlc lnjurles of the pancreas. Ati J Surg 1i8: 788, 1988. 18. Yellln AE. Rosoff L Sr: Pancreatoduodenectomv for combined pancreatoduodenal InjurIes. Arch Surg 118: 1177, 1975. 19. Webb HW, Howard JM, Jordan GL Jr, Vowles KDJ: Surgical experience In the treatment of duodenal Injuries. Surg GynecolObstet 108: 105, 1958.
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