Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial
Recommended Citation
Choron RL, Teichman AL, Bargoud CG, Sciarretta JD, Smith RN, Hanos DS, Afif IN, Beard JH, Dhillon NK, Zhang A, Ghneim M, Devasahayam RJ, Gunter OL, Smith AA, Sun BL, Cao CS, Reynolds JK, Hilt LA, Holena DN, Chang G, Jonikas M, Echeverria K, Fung NS, Anderson A, Fitzgerald CA, Dumas RP, Levin JH, Trankiem CT, Yoon JJ, Blank J, Hazelton J, McLaughlin CJ, Al-Aref R, Kirsch JM, Howard DS, Scantling DR, Dellonte K, Vella M, Hopkins B, Shell CH, Udekwu PO, Wong EG, Joseph BA, Lieberman H, Ramsey W, Stewart C, Alvarez C, Berne JD, Nahmias J, Puente I, Patton JH, Jr., Rakitin I, Perea LL, Pulido OR, Ahmed H, Keating J, Kodadek LM, Wade J, Henry R, Schreiber MA, Benjamin AJ, Khan A, Mann LK, Mentzer CJ, Mousafeiris V, Mulita F, Reid-Gruner S, Sais E, Marks J, Foote C, Palacio CH, Argandykov D, Kaafarani H, Coyle S, Macor M, Manderski MTB, Narayan M, and Seamon MJ. Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial. J Trauma Acute Care Surg 2023; 95(1):151-159.
Document Type
Article
Publication Date
7-1-2023
Publication Title
J Trauma Acute Care Surg
Abstract
BACKGROUND: Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur.
METHODS: A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy).
RESULTS: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA.
CONCLUSION: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible.
LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
Medical Subject Headings
Male; Humans; Retrospective Studies; Postoperative Complications; Wounds, Penetrating; Abdominal Injuries; Anastomosis, Surgical
PubMed ID
37072889
Volume
95
Issue
1
First Page
151
Last Page
159
