RELAPAROTOMY IN TRAUMATIC INJURIES OF THE DUODENUM, CAUSES AND RISK FACTORS

Abstract

Objectives. Trauma to the duodenum represents 0.6-5% of the abdominal injuries. Unlike other injuries, patients with duodenal trauma are known to have a large number of evolutionary and postoperative complications that frequently require repeated surgical interventions – relaparotomy.

The aim of the study was the analysis of risk factors and causes of relaparotomy in traumatic duodenal injuries.

Material and methods. The paper presents a retrospective analysis of a group of 37 patients with traumatic injuries of the duodenum, subjected to repeated surgical operations in the Institute of Emergency Medicine, Chisinau and the "Floreasca" Emergency Clinical Hospital, Bucharest. The study lot included: 34 (91.9%) men and 3 (8.1%) women with a mean age of 39.17±14.25 years. The trauma mechanism was different: blunt trauma was found in 21 (56.7%) patients, penetrating trauma – in 16 (43.3%) patients. The injuries resulted from: road accidents – 11 (29.7%) cases, blunt force trauma – 10 (27.1%) cases, blunt physical aggression – 6 (16.2%) cases, gunshot trauma – 5 (13.5%) cases, fall down – 4 (10.8%) cases, sports injuries – 1 (2.7%) case. The applied diagnostic algorithm primarily depended on the hemodynamic stability of the victims.

Results. Isolated lesions of the duodenum were in n=7 (18.9%), multiple lesions of the intra-abdominal organs were in n=16 (43.2%), polytrauma was found in n=21 (37.9%) patients. All patients were diagnosed with lesions of more than two organs. In 16 (43.2%) cases, active intra-abdominal hemorrhages was found. The 21 polytrauma patients with relaparotomy also had associated trauma in multiple systems. Relaparotomy was performed more frequently for purulent complications: dehiscence of duodenal sutures and peritonitis – n=12 (32.4%), dehiscence of gastro-enteric anastomosis sutures with peritonitis n=1 (2.7%), severe pancreatitis with necrosis of the pancreas n=9 (24.4%), retroperitoneal phlegmon n=5 (13.5%). In n=8 (21.6%) reoperation was performed for intra-abdominal hemorrhages and in n=2 (5.4%) for early intestinal occlusion. N=17 patients underwent two repeated surgical interventions. The frequency of purulent complications prevailed: n=7 cases – progressive necrosis of the pancreas after trauma, n=6 – progressive secondary peritonitis and in n=4 – retroperitoneal phlegmon. In n=7 cases, several stage surgeries were performed. Mortality after the first reintervention was 24.3%, after two interventions – 47%, after serial relaparatomies – 57.1%.

Conclusions. The increased rate of complications requiring relaparotomy in patients with duodenal trauma is correlated with the complexity and severity of the trauma, the trauma-intervention time, the etiology and mechanism of the trauma, which are the main risk factors in duodenal trauma. The predominant etiological factors confirmed are: road accidents and stab wounds. Septic state and purulent complications are the prevalent causes of relaparotomy in duodenal trauma. Reducing the number of complications and mortality depends on complex and timely treatment. The strong point in this treatment is the quality and terms of the first surgical intervention.