Complex penetrating duodenal injuries: less is better.

BACKGROUND The traditional management of complex penetrating duodenal trauma (PDT) has been the use of elaborate temporizing and complex procedures such as the pyloric exclusion and duodenal diverticulization. We sought to determine whether a simplified surgical approach to the management of complex PDT injuries improves clinical outcome. METHODS A retrospective review of all consecutive PDT from 2003 to 2012 was conducted. Patients were divided into three groups according to a simplified surgical algorithm devised following the local experience at a regional Level I trauma center. Postoperative duodenal leaks were drained externally either via traditional anterior drainage or via posterior "retroperitoneal laparostomy" as an alternate option. RESULTS There were 44 consecutive patients with PDT, and 41 of them (93.2%) were from gunshot wounds. Seven patients were excluded owing to early intraoperative death secondary to associated devastating traumatic injuries. Of the remaining 36 patients, 7 (19.4%) were managed with single-stage primary duodenal repair with definitive abdominal wall fascial closure (PDR + NoDC group). Damage-control laparotomy was performed in 29 patients, (80.5%) in which primary repair was performed in 15 (51.7%) (PDR + DC group), and the duodenum was over sewn and left in discontinuity in 14 (48.3%). Duodenal reconstruction was performed after primary repair in 2 of 15 cases and after left in discontinuity in 13 of 14 cases (DR + DC group). The most common complication was the development of a duodenal fistula in 12 (33%) of 36 cases. These leaks were managed by traditional anterior drainage in 9 (75%) of 12 cases and posterior drainage by retroperitoneal laparostomy in 3 (25%) of 12 cases. The duodenal fistula closed spontaneously in 7 (58.3%) of 12 cases. The duodenum-related mortality rate was 2.8%, and the overall mortality rate was 11.1%. CONCLUSION An application of basic damage-control techniques for PDT leads to improved survival and an acceptable incidence of complications. LEVEL OF EVIDENCE Therapeutic study, level IV.