创伤性十二指肠损伤的诊断和治疗

目的 研究十二指肠损伤因素,提高其诊断和治疗水平。方法 回顾性总结1968－1998年收治的十二指肠损伤19例,对受伤因素、诊断和治疗进行分析。结果 闭合型损伤占83％,开放型损伤17％;受伤部位以第二段为多占44％,第三段次之占28％;合并伤84％;手术后并发症发生率为28％,死亡率为6％,治愈率94％。结论 十二指肠损伤在我国以闭合性损伤多见。重视术前、术中探查及选择恰当术式,加强术后管理,可减少死亡和并发症的发生。     

闭合性十二指肠损伤的诊断与治疗对策

目的探讨闭合性十二指肠损伤的早期诊断方法及治疗效果。方法回顾性分析经手术证实的22例闭合性十二指肠损伤的临床资料。结果术前早期确诊7例(31.8%),受伤部位主要为十二指肠第二段,共10例,占45.5%。全组死亡4例(18.2%),共发生各种并发症11例次。结论详细的病史询问、细致全面的体格检查、有针对性的辅助检查和仔细全面的术中探查可提高早期诊断率;早期诊断、及时正确的手术治疗、充分的十二指肠减压和腹腔引流、全身营养支持治疗是降低并发症和提高生存率的关键。     

Traumatic duodenal rupture

Traumatic duodenal perforation has an incidence of 1%-17% (blunt injury) or 1.7%-5% (penetrating injury). Its prognosis correlates to the kind of injury, associated injuries, size of perforation and delayed diagnosis. Mortality in cases of delayed repair is 65% compared with 5% mortality in early repaired perforation. In cases of delayed diagnosis, we recommend drainage of the perforation, naso-duodenal suction tube, parenteral alimentation. 5 patients where diagnosis was delayed for 8 days or longer were treated in this way and the duodenal wound healed completely without any complications within 22-44 days.     

闭合性十二指肠损伤的治疗

目的 进一步提高闭合性十二指肠损伤的早期诊断及其相应手术方式的选择。方法 总结1989年3月至1999年12月收治的10例闭合性十二指肠损伤病例的临床资料。均行手术治疗。其中行十二指肠浆膜切开血肿清除术2例，十二指肠修补术2例，损伤肠段切除吻合术2例，十二指肠空肠Roux-Y吻合术2例，十二指肠憩室化1例，十二指肠造口减压术1例。结果 全部治愈，无死亡及明显并发症发生。结论 早诊断、早手术是闭合性十二指肠损伤治疗的关键，同时选择适宜的手术方式对降低病死率和提高远期生活质量很重要。     

十二指肠损伤12例诊治体会

目的探讨十二指肠损伤的诊断、伤情评估和治疗方法。方法对我院1996年1月～2006年12月收治的十二指肠损伤12例的临床资料进行回顾性分析。结果本组治愈11例,死亡1例。并发创伤性十二指肠瘘2例,腹腔出血1例,腹腔感染1例,经保守治疗后治愈。结论尽早诊断、及时手术、有效减压和引流及视不同伤情采取相应的治疗策略对十二指肠损伤的成功治疗有重要作用。     

Surgical management of duodenal injuries in children

BACKGROUND: The goal of this study was to review current injury characteristics, severity, intervention, and outcome of duodenal injuries from a single, pediatric trauma facility. METHODS: A retrospective review was performed of duodenal injuries in children less than 16 years of age from 1990 to 2000. RESULTS: Twelve children had duodenal injuries as a result of blunt abdominal trauma. Six injuries were the result of motor vehicle crashes. Nonaccidental trauma (2) and contact injury (4) provided the remaining cases. Diagnosis was achieved by abdominal computed tomography. Severity of duodenal injury included grade I (1), II (8), and III (3). Seven patients had associated visceral or neurologic injuries. Average Injury Severity Score was 18. Duodenal repair was required in 9 of the 10 patients explored. Treatment included observation (3); primary repair, alone, (2) or with proximal decompression (4); and pyloric exclusion with gastrojejunostomy (3). Exclusion techniques had fewer complications (0% vs 57%) and fewer hospital days (19 vs 23). CONCLUSIONS: Blunt abdominal trauma remains the most prevalent mechanism for pediatric duodenal injuries. Patients undergoing pyloric exclusion for severe duodenal trauma had a lesser morbidity and a shorter hospital stay in this small series. Pyloric exclusion remains an alternative for the treatment of severe duodenal injuries in selected children.     

Injuries to the duodenum and pancreas in 42 operated cases

42 consecutive patients who sustained injuries to the duodenum or/and pancreas were admitted to our hospital. Over a twenty year period 32 blunt injuries and 10 penetrating injuries were encountered. Penetrating injuries were always suspected and treated by time: following blunt injury diagnostic delay was encountered in 14 patients and insufficient surgical procedure because of intra-operative misinterpretation in 2 patients. Most of the patients had associated intra-abdominal organ injuries. Adjusts to diagnosis such as abdominal roentgenograms, serum amylase levels and gastroduodenography was not helpful. CT scan and ultrasound allowed to confirm the suspected diagnosis in 3 cases only. Intraoperative diagnosis was also challenging. Complete mobilization of the strictures surrounding the duodenum and the pancreas to provide entire exposure was necessary in 12 patients treated first in a peripheral hospital, diagnosis of the injury have been missed at first laparotomy and reoperation was necessary in all of them. Suture closure of the duodenum and drainage of the pancreatic region wee the most common reparative techniques used. More complicated procedures with pancreatic and/or duodenal resection were performed in 12 patients. Overall mortality in patients surviving more than 24 hours was 14%. Suture live dehiscence after delayed operation (4) and 2 deaths due to brain injury.     

Blunt duodenal injuries in children

BACKGROUND: Duodenal injury secondary to blunt trauma continues to pose a diagnostic challenge. The purpose of this study is to evaluate the cause, radiologic findings, and management of duodenal injuries from a Level I pediatric trauma center. METHODS: A retrospective review of our trauma registry from 1990 to 2000 identified 24 children with blunt duodenal injuries. Clinical and radiographic findings and management strategies were assessed and compared in children with duodenal hematomas and perforations. RESULTS: The majority of injuries were secondary to motor vehicle collisions. Pancreatic (42%) injuries were most commonly associated with duodenal trauma. With the exception of hematocrit level, initial clinical and laboratory findings were similar between groups. Of the 19 (79%) with duodenal hematomas, computed tomographic (CT) scan alone identified 15 and the remaining 4 were confirmed by duodenography. Incision and drainage of a hematoma was performed in two children. Duodenal perforation was identified in five (21%) children. Extraluminal air by CT scan was present in three of five children with perforation; however, none had extravasation of contrast. Four (80%) children with perforations underwent primary repair and one (20%) required segmental resection. CONCLUSION: CT scanning remains a valuable tool in the diagnosis of blunt duodenal injuries in children. Although extravasation of oral contrast was not beneficial, the presence of extraluminal air was highly suggestive of perforation. The vast majority of hematomas were successfully managed nonoperatively, and duodenorrhaphy was safe and effective therapy for perforations.     

Management of duodenal injuries in children

Background/purpose

The natural history and management of pediatric duodenal injuries are incompletely described. This study sought to review injury mechanism, surgical management, and outcomes from a collected series of pediatric duodenal injuries.

Methods

A retrospective chart review was conducted for a 10-year period of all children less than 18 years old treated for duodenal injuries at 2 pediatric trauma centers.

Results

Forty-two children were treated for duodenal injuries. There were 33 blunt and 9 penetrating injuries. Injuries were classified using the Organ Injury Scale for the Duodenum. Twenty-four patients underwent operative management by primary repair (18), duodenal resection and gastrojejunostomy (4), or pyloric exclusion (2). Duodenal hematomas were treated nonoperatively in 94% of cases. The average ISS for operative versus nonoperative cases was 23 and 10, respectively. Delay in diagnosis or operative intervention (>24 hours) was associated with increased complication rate (43% v 29%) and hospitalization (32 v 20 days). Nine children requiring surgery experienced delays and were most highly associated with foreign body, child abuse, and bicycle injuries. There were no deaths caused by duodenal injuries.

Conclusions

Duodenal injuries in children were predominantly blunt and had a low mortality rate. When surgery was required, primary repair was usually feasible.     

闭合性十二指肠损伤的早期诊断

目的 探讨闭合性十二指肠损伤的早期诊断原则：方法 回顾分析了本院自1962年至今29例闭合性十二指肠损伤的诊断过程,包括腹部X线、腹腔穿刺、腹腔灌洗、超声和CT检查。受伤后24小时以内获诊治25例,24小时后获诊治4例。结果 术前正确诊断5例,其余均为对闭合性十二指肠合并伤行剖腹探查时获诊。24小时内诊断并手术25例,死亡2例,死亡率8％,而24小时后再行诊治4例中3例死亡,死亡率75％。结论 早期诊断对闭合性十二指肠损伤有重要意义：高度警惕是早期诊断的前提,仔细探查是早期诊断的关键。联合运用多种辅助诊断方法,必要时重复使用,有助于早期正确诊断。     

Operative blunt duodenal injury in children: a multi-institutional review

Background/AimOperative blunt duodenal injury in children is rare. The purpose of this analysis is to describe the clinical presentation, current management, and outcome of children with operative blunt duodenal injury.MethodsThe American Pediatric Surgical Association Trauma Committee solicited data from its members on children with blunt intestinal injuries identified at autopsy or operation from January 2002 through August 2006.ResultsFifty-four children from 16 hospitals with operative blunt duodenal injuries were identified: 0.67 patients per hospital per year. The most common mechanisms of injury were motor vehicle crashes (35%), bicycle crashes (22%), and nonaccidental trauma (20%). Forty-nine patients (90%) had positive physical examination findings on initial presentation, including peritonitis in 18 patients (33%). Twenty-five computed tomographic (CT) scans performed demonstrated free fluid, and 13 (52%), free air. Eleven CT scans used enteral contrast, and only 2 (18%) showed extravasation. Fifty-two patients (96%) survived to operation. The overall complication rate was 42%.ConclusionOperative blunt duodenal injury occurs less than once per year in the typical pediatric trauma center. Most of the patients have pertinent physical examination findings on arrival. Computed tomographic scans with enteral contrast do not seem to be helpful in diagnosis of duodenal injuries. Postoperative complications are frequent, but most children survive.     

Diagnosis and treatment of traumatic injuries of the duodenum and pancreas: 21 cases

Twenty one consecutive patients who sustained injuries to the duodenum or/and pancreas were admitted to our hospital over a ten year period. Sixteen blunt injuries and 5 penetrating injuries were encountered. Penetrating injuries were always suspected and treated by time; following blunt injury diagnostic delay was encountered in 7 patients and insufficient surgical procedure because of intraoperative misinterpretation in 2 patients. Most of the patients had associated intra-abdominal organ injuries. Adjuncts to diagnosis such as abdominal roentgenograms, serum amylase levels and gastroduodenography were not helpful. CT-Scan and ultrasound allowed to confirm the suspected diagnosis in 3 cases only. Intraoperative diagnosis was also challenging. Complete mobilization of the structures surrounding the duodenum and the pancreas to provide entire exposure was necessary. In 6 patients treated first in a peripheral hospital, diagnosis of the injury have been missed at first laparotomy and reoperation was necessary in all of them. Suture closure of the duodenum and drainage of the pancreatic region were the most common reparative technique used. More complicated procedures with pancreatic and/or duodenal resection were performed in 6 patients. Overall mortality in patients surviving more than 24 hours was 14% (suture line dehiscence after delayed operation and one death due to brain injury).     

外伤性十二指肠损伤漏诊的临床分析

目的：探讨如何避免十二指肠损伤的漏诊。方法：回顾性分析我院450例腹部外伤中漏诊的8例十二指肠损伤病人处理和临床特点。结果：致伤原因以车祸伤为主(6例)，复合伤6例，术前无一例正确诊断为十二指肠伤，所有病例均行手术治疗，6例治愈，死亡2例，死亡原因为严重感染及多器官功能衰竭。漏诊的主要原因为认识不足并缺乏相应的特殊检查。结论：对有严重上腹外伤史者，应高度警惕十二指肠损伤，反复的物理检查，动态的辅助检查尤其是CT检查，及时剖腹探查等可减少十二指肠损伤的漏、误诊率。     

Duodenal injuries

BACKGROUND: The worldwide increase in road traffic accidents and use of firearms has increased the incidence of duodenal trauma. METHODS: The English language literature on duodenal trauma over the period 1970-1999 was reviewed. RESULTS AND CONCLUSION: Upper gastrointestinal radiological studies and computed tomography may lead to the diagnosis of blunt duodenal trauma. Exploratory laparotomy remains the ultimate diagnostic test if a high suspicion of duodenal injury continues in the face of absent or equivocal radiographic signs. The majority of duodenal injuries may be managed by simple repair. More complicated injuries require more sophisticated techniques. High-risk duodenal injuries are followed by a high incidence of suture line dehiscence and they should be treated by duodenal diversion. Pancreaticoduodenectomy should be considered only if no alternative is available. 'Damage control' should precede definitive reconstruction.     

DUODENAL TRAUMA

Fifteen cases of duodenal trauma that presented to westmead hospital between 1979 and july 1986 are reviewed. There were 12 blunt injuries, nine caused by motor vehicle accidents. Three patients sustained penetrating injuries, two due to stab wounds. Repair for blunt laceration or incised wound was by primary closure or serosal patch repair, most often with decompressive t-tube duodenostomy. No leak from the duodenal repair occurred in any patient. Two patients died. This was not due to complications of the duodenal injury. Pyloric exclusion, duodenal diverticulization or pancreaticoduodenectomy was not considered necessary in any patient. Morbidity of duodenal haematoma in the form of continuing abdominal pain may be avoided by intra-operative drainage.     

Duodenal trauma

Fifteen cases of duodenal trauma that presented to Westmead Hospital between 1979 and July 1986 are reviewed. There were 12 blunt injuries, nine caused by motor vehicle accidents. Three patients sustained penetrating injuries, two due to stab wounds. Repair for blunt laceration or incised wound was by primary closure or serosal patch repair, most often with decompressive t-tube duodenostomy. No leak from the duodenal repair occurred in any patient. Two patients died. This was not due to complications of the duodenal injury. Pyloric exclusion, duodenal diverticulization or pancreaticoduodenectomy was not considered necessary in any patient. Morbidity of duodenal haematoma in the form of continuing abdominal pain may be avoided by intra-operative drainage.     

Risk factors of delayed diagnosis of pancreatic trauma.

OBJECTIVE: To identify risk factors associated with delayed diagnosis of pancreatic injuries. DESIGN: Retrospective study. SETTING: University hospital, Finland. PATIENTS: 31 patients treated for pancreatic injuries from January 1986 to April 1998. INTERVENTIONS: Clinical, laboratory, and radiological assessment. Initial management operative (n = 22) and non-operative (n = 9). MAIN OUTCOME MEASURES: Timely or delayed (>12 hours after injury) recognition of pancreatic trauma. RESULTS: Blunt trauma (7/17 timely and 12/14 delayed diagnosis, p = 0.03), intoxication on admission (4/10 compared with 5/5 patients studied, p < 0.05), low New Injury Severity Score (median, interquartile 34, 11.5-41 compared with 14.5, 10-25, p = 0.02), low Abdominal Trauma Index (38, 20-54 compared with 16.5 15-24, p = 0.01), absence of associated abdominal organ injuries (1/17 compared with 8/14, p = 0.004), and initial nonoperative management (2/17 compared with 7/14, p = 0.04) were significant risk factors of delayed diagnosis of pancreatic trauma. The main reasons for the delay in diagnosis were missed pancreatic injury at initial operation (n = 4, 2 penetrating), failure to exclude blunt pancreatic injury before non-operative management (n = 4), delay in presentation (n = 3), underestimation of the severity of pancreatic injury on initial computed tomogram (n = 2), and missed diagnosis of blunt duodenal rupture with mild pancreatic injury (n = 1). CONCLUSIONS: In patients with blunt abdominal trauma and altered consciousness with few clinical signs, and no or mild associated abdominal injuries, we recommend additional diagnostic studies to exclude pancreatic rupture before starting non-operative management. Exposure and evaluation of the pancreas during laparotomy for trauma is essential.     

Traumatic lesions of the duodenum

Injuries of the duodenum are relatively uncommon on account of the organ's size and position. Since most of it is retroperitoneal, lesions involving it give rise to such subtle physical and radiological signs that the diagnosis is often overlooked in the early phase after injury. Twenty-six cases of duodenal injury are reviewed, 18 of which were due to penetrating wounds and the remaining 8 to blunt trauma. Anterior penetrating wounds were usually associated with other intraperitoneal lesions which caused more obvious physical signs and thus drew attention to the necessity for exploration. On the other hand, both blunt trauma and posterior stab wounds frequently caused isolated retroperitoneal duodenal lesions where the diagnosis was not evident on admission, but in which the insidious and progressive development of symptoms and signs drew attention to the need for laparotomy. Early repair combined with drainage of the retroperitoneal space resulted in a good result in 23 of 26 cases, 4 of whom, however, developed a temporary lateral duodenal fistula. Two of the 3 deaths were in patients who presented late and had associated pancreatic injuries while the third was due to an abdominal vascular injury.     

胰十二指肠合并伤的外科治疗体会

目的 探讨胰十二指肠外伤后手术方式的选择和手术效果。方法 对１９８８￣１９９８年１０年间手术治疗的８例胰十二指肠合并伤病人的临床资料进行了回顾性分析。结果：①１０年间收治胰腺外伤３２例,其中胰十二指肠合并伤８例（２６％）;②术前均未明确诊断,术中１例漏诊;③在十二指肠损伤修补的基础上,行胰腺清创６例,胰腺次全切除１例,胰尾加脾切除１例,其中５例行十二指肠憩室化术。④术后胰瘘４例,十二指肠瘘２例,腹     

Management of multiple trauma with mainly thoracic and abdominal injuries:a report of 1166 cases

Obiective: To discuss the diagnosis and treatment of multiple trauma with mainly thoracic and abdominal iniuries.Methods: A retrospective analysis was performed on data of multiple trauma cases with mainly thoracic and/or abdominal injuries.ResuIts: of 1166 cases,72.3%were found with shock.The operation rates of thoracic and abdominal injuries were 14.8%(119/804)and 83.5%(710/850)respectively(X2=780.683,P＜0.01).The operation rates of blunt and penetrating thoracic injuries was6.8%(42/617)and 40.6%(76/187)respectively(X2=131.701,P＜0.01).The operation rates of blunt and penetrating abdominal injuries were77.1%(434/563)and 96.1%(276/287)respectively(x2=50.302,P＜0.01).Theoperation rates of blunt thoracio-abdominal injuries were 6.8%(42/617)in thoracic region and 77.1%(434/563)in abdomen respectively (x2=544.043,P＜0.01).Among the cases of abdominal injuries,41 received arteriography embolism,with the efficacy of 95.1%(39/41).Total mortality rate was 6.1%.The mortality rates of blunt and penetrating injuries were 7.3%(62/854)and 2.9%(9/312)(x2=6.51,P＜0.005).The deaths were mainly due to large volume of blood loss.Conclusions: When both thoracic and abdominal injuries exist,laparotomy is frequently required rather than thoracotomy.Laparotomy is seldomly used for blunt thoracic injuries,but usually used forpenetrating thoracic and abdominal injuries.Mortality rate of penetrating thoracic and abdominal injuries is markedly lowerthan that of blunt injuries.Surgical operation is still important for those patients with penetrating thoracic or abdominal injuries.