基层医院漏诊外伤性十二指肠破裂的原因及预防措施

目的：总结１２例漏诊原因，加强基层医院外科医师对外伤性十二指肠损伤的临床特点认识，提高诊断率。方法：近２０年收治的腹部外伤手术探查漏诊十二指肠损伤１２例进行回顾分析。结果：（１）因十二指肠损伤少见而放松警惕性，对十二指肠损伤具有诊断价值的创作机制、症状、体征缺乏系统的收集与分析，医疗装备落后未行针对性检查为基层医院术前漏诊具有共性的原因；（２）探查手术缺乏系统性、全面性、极少有经验丰富的高资医师参     

十二指肠损伤的临床诊断与治疗

目的:探讨十二指肠损伤的诊治特点。方法:分析10例十二指肠损伤诊断及治疗经过。结果:术前明确诊断2例,术中探查确诊6例,漏诊2例;治愈8例。死亡2例。结论:对上腹部外伤的病人,特别是有过呕吐血性胃液病史者,均应想到十二指肠损伤的可能,应注意严密观察,进行必要检查,术中认真探查以防漏诊;对十二指肠2、3段严重损伤者行简化十二指肠暂时性憩室化手术,术后疗效满意。     

介绍一种术中诊断十二指肠破裂的方法

外伤性闭合性腹膜后十二指肠损伤术前术中均易漏诊，尤其损伤不严重或系膜侧损伤。术中漏诊是十二指肠损伤死亡的主要因素之一。近10余年来，作手术治疗外伤性十二指晡拯伤24例，其中因未高度警惕其破裂而未进行十二指肠探查5例，其中包括外院转入3例，造成术中漏诊再次手术，3例治疗无效死亡，教训深刻。     

介绍一种术中诊断十二指肠破裂的方法

外伤性闭合性腹膜后十二指肠损伤术前术中均易漏诊,尤其损伤不严重或系膜侧损伤者。术中漏诊是十二指肠损伤死亡的主要因素之一。近10余年来,作者手术治疗外伤性十二指肠损伤24例,其中因未高度警惕其破裂而未进行十二指肠探查5例,其中包括外院转入3例,造成术中漏诊再次手术,3例治疗无效死亡,教训深刻。 近年来,采用“术中经胃管注气法”诊断可疑十二指肠破裂3例,1例腹膜后广泛巨大血肿,1例枪弹伤致小肠多发伤,另1例十二指肠系膜侧损伤,其共同持点,均为十二指肠小裂孔伤。     

降低闭合性十二指肠损伤探查漏诊的体会

文献报道十二指肠损伤术中漏诊率为１０％～２０％［１］，且多为复合伤，并发症多，病死率高，应该高度重视术中探查。本院１９８６至２０００年收治腹部损伤病例７１９例，其中闭合性十二指肠损伤２１例，十二指肠损伤术中探查漏诊率为４．７６％，报告如下。临床资料１．一般资料：闭合性十二指肠损伤病例２１例，男１８例，女３例；年龄１７～６７岁。损伤原因：腹部撞击伤１５例，腹部挤压伤４例，坠落伤２例。伤后就诊时间：１～２６小时。２．主要临床表现：１０例有不同程度的腹痛，伴弥慢性腹膜炎５例；腹腔内出血６例，伴失血性休…     

外伤性十二指肠损伤的诊治(附35例临床报告)

目的探讨外伤性十二指肠损伤的诊治方法。方法对我院收治的35例外伤性十二指肠损伤病例的诊断与治疗进行回顾性分析。结果35例均进行了手术治疗，治愈29例，死亡6例。死亡率为17．14％，术后并发症发生率为17．14％(6／35)。本组死亡病例均为在伤后12小时接受手术者。结论掌握好早期手术探查指征和选择合适的术式是治疗十二指肠损伤的重要原则。有效的腹膜外引流、腹腔内引流及充分的十二指肠液和胃液转流，是成功治疗十二指肠损伤的关键性措施。导致病人死亡的主原因是误诊和漏诊以至于延误手术时机。     

创伤性结肠损伤的特点及诊治体会

目的探讨创伤性结肠损伤的特点和救治体会。方法回顾分析我院1995年1月~2003年12月结肠外伤48例的临床资料。结果结肠损伤中刀刺伤占71%,腹部钝性伤占25%,火器伤4%。合并多发伤或多脏器伤35例,一期修补或切除吻合46例,结肠局部切除 近端造口2例,手术死亡1例,十二指肠损伤漏诊1例,术后死亡3例,切口感染及脂肪液化7例,严重腹腔感染3例。结论结肠损伤以开放性穿透性损伤为多见,常伴有其他脏器伤,且结肠损伤具有一定的隐匿性,易误诊、漏诊,引起严重感染,影响愈合。治疗上强调尽早手术,术中探查应全面仔细,谨防遗漏,一期修补或切除吻合对绝大多数结肠损伤是安全可靠的。     

胰十二指肠损伤的诊断及治疗

报告胰十二指肠损伤３９例。原因多为车祸，术前诊断性腹腔穿刺阳性率高，多数病例全并腹部其它脏器复合伤。早期手术，仔细探查胰十二指肠，避免术中漏诊，防止胰十二肠瘘和腹腔感染是手术成功的关键。损伤严重或超过１０小时手术者采用十二指肠憩室化手术比较可靠，本组治愈７９．５％（３１／３９），死亡２０．５％（８／３９）。     

外伤性十二指肠损伤的诊断与治疗

目的 探讨提高十二指肠损伤的早期诊断率和合适的治疗方法。方法 回顾性分析４０例十二指肠损伤患者的临床资料。结果 ４０例中３２例（８０％）为严重多发伤。致伤原因以挤压伤,撞击伤为主,占８２．５％。全部经手术治疗：行十二指肠修补术２４例,空肠十二指肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术８例,十二指肠改良憩室化手术６例,改良憩室化再简化手术２例,治愈３５例,死亡５例,死亡原因为多脏器损伤,创伤性休克及十二指肠瘘,感     

交通性多发伤中伴颅脑损伤146例临床分析

为了提高伴颅脑损伤的多发损伤病例的诊治水平，作者对交通性多发伤中伴颅脑损伤的１４６例进行了临床分析，通过合并伤和死亡病例的分析，发现此类病例有如下特点：（１）各部位伴发伤的伴发比率较大的前三位是：胸部损伤、肩外伤和小腿外伤；（２）死亡病例特点是：颅脑损伤严重，合并胸部外伤多，合并休克多；（３）由于此类病例常伴有严重失血，故有颅内血肿的患者，即使有高颅压存在，Ｃｕｓｈｉｎｇ三联征表现并不典型，手术清除血肿后，皿压会骤然下降；（４）患者常因意识障碍缺少主诉，急诊阶段容易漏诊或误诊。     

胰腺十二指肠损伤的诊治体会

目的探讨胰腺、十二指肠损伤的诊断及治疗经验。方法回顾性分析45例胰腺、十二指肠损伤患者,包括26例胰腺损伤、13例十二指肠损伤及6例胰十二指肠复合伤的临床资料。结果45例患者中33例（73．3％）合并伴发伤;CT诊断符合率为72．7％（8／11）;4例保守治疗,41例行手术治疗;共21例（46．7％）出现并发症,其中胰瘘9例;治愈38例（84．4％）,7例死亡（15．6％）。结论本病早期诊断困难,伴发伤多,并发症发生率及死亡率高。剖腹探查是诊断胰十二指肠损伤的主要方法,根据损伤部位、程度及全身情况选择合理术式,术后积极防治并发症是提高治愈的关键。     

Duodenal trauma: experience of a trauma center

In the past decade 93 patients with duodenal injury were treated at a trauma center. By chart review, the age, sex, mechanism of injury, time to initial exploration (and the reason for delay), laboratory results, associated injury, extent of duodenal injury, operative repair, use of drains and tube decompression, morbidity, and cause of death were tabulated in order to improve management of these injuries. Of 87 patients surviving until the time of operative repair 73% required no repair (four) or primary closure (59). The remainder had either resection with primary anastomosis (ten), diverticulization (12), or pancreaticoduodenectomy (two). All patients with penetrating trauma were immediately explored. Patients with blunt trauma were explored on the basis of the judgment of house staff and faculty. Overall mortality was 18%. Significant morbidity occurred in 49% of survivors. This urban experience was heavily weighted toward penetrating injury. In this group early death usually resulted from associated vascular injuries. Blunt duodenal injury was less frequently associated with immediate exsanguination. Mortality associated with blunt duodenal injury was usually the result of delayed diagnosis. In blunt duodenal trauma peritoneal lavage is not diagnostic and may often be misleading; in this series 50% of lavages were false negatives. Blunt duodenal trauma, particularly when combined with pancreatic injury or delayed repair, was a lethal combination. A high index of suspicion and aggressive diagnostic evaluation (CT contrast study/amylase) in the emergency department is required in equivocal cases to avoid morbidity and mortality.     

Conservative management of duodenal trauma: a multicenter perspective

The experience of eight trauma centers with duodenal injuries was analyzed to identify trends in operative management, sources of duodenal-related morbidity, and causes of mortality. During the 5-year period ending December 1988, 164 duodenal injuries were identified. Patient ages ranged from 5 to 78 years. There were 38 Class I, 70 Class II, 48 Class III, four Class IV, and four Class V injuries. Injury mechanism was penetrating in 102 (62%) patients and blunt in 62. Primary repair of the duodenal injury was performed in 117 (71%) patients, including 27 patients also managed with pyloric exclusion and 12 with tube duodenostomy. Duodenal resection with primary anastomosis was used in six (4%) patients and pancreatoduodenectomy was necessary in five (3%). There were 30 (18%) deaths. The cause of death was uncontrolled hemorrhage from severe hepatic or vascular injuries in 22 (73%) patients. In only two (1%) patients could death be attributed to the duodenal injury; each as the result of duodenal repair dehiscence and subsequent sepsis. Duodenal-related morbidity was documented in 29 (18%) patients, including 22 patients with intra-abdominal abscess, six with duodenal fistula, and five with frank duodenal dehiscence. In summary, this analysis demonstrated: 1) the great majority of duodenal injuries can be managed by simple repair; 2) tube duodenostomy is not a mandatory component of operative treatment; 3) pyloric exclusion is a useful adjunct for more complex injuries; 4) pancreatoduodenectomy is rarely necessary for civilian duodenal trauma; 5) morbidity following duodenal trauma is more dependent on associated intra-abdominal injuries than the extent of duodenal trauma; and 6) mortality following duodenal injuries is primarily related to associated vascular and hepatic trauma.     

Analysis of 203 Patients with Penetrating Neck Injuries

Background  Selective nonoperative management (SNOM) of penetrating neck injuries (PNI) has steadily gained favor, but indications for surgery and adjunctive diagnostic studies remain debated. The purpose of the present study is to validate a protocol of SNOM of PNI based on physical examination, which further dictates complementary investigations and management. Patients and methods  A prospective observational study was conducted in a South African tertiary urban trauma center with a high prevalence of penetrating trauma. All consecutive patients admitted with penetrating neck injuries over a 13-month period were included. Results  A total of 203 patients were included in the study: 159 with stab wounds and 42 with gunshot wounds. A vascular injury was identified in 27 (13.3%) patients, pharyngoesophageal injury in 18 (8.9%) patients, and an upper airway injury in 8 (3.9%) patients. Only 25 (12.3%) patients required surgical intervention. A further 8 (3.9%) patients had therapeutic endovascular procedures. The remaining 158 (77.8%) patients, either asymptomatic or with negative work-up, were managed expectantly. There were no clinically relevant missed injuries. Conclusions  Selective nonoperative management of neck injuries based on clinical examination and selective use of adjunctive investigational studies is safe in a high-volume trauma center.     

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.     

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.     

Evaluation of unstable cervical spine injury: a 6-year experience

BACKGROUND: The diagnosis of the unstable cervical spine, and its subsequent management can be difficult and a missed cervical spine injury can obviously have devastating consequences. METHODS: This study describes a 6-year experience with these injuries and presents an algorithm for their evaluation. The case records of 100 consecutive patients who underwent an operative procedure for an unstable cervical spine injury were reviewed. RESULTS: The population and injury characteristics were similar to that of previous studies. The process of evaluation of the spine was robust but failed to identify two unstable ligamentous injuries not detected on initial radiologic examination. Ten patients whose injuries were missed at other hospitals were identified by using this system. CONCLUSION: A systematic, well-structured approach to the potentially injured cervical spine allows safe and effective diagnosis and management of these patients. Failure to adhere to basic principles will result in missed unstable cervical spine injuries.     

Applying Modern Error Theory to the Problem of Missed Injuries in Trauma

BACKGROUND: Modern theory of human error has helped reduce the incidence of adverse events in commercial aviation. It remains unclear whether these lessons are applicable to adverse events in trauma surgery. Missed injuries in a large metropolitan surgical service were prospectively audited and analyzed using a modern error taxonomy to define its applicability to trauma. METHODS: A prospective database of all patients who experienced a missed injury during a 6-month period in a busy surgical service was maintained from July 2006. A missed injury was defined as one that escaped detection from primary assessment to operative exploration. Each missed injury was recorded and categorized. The clinical significance of the error and the level of physician responsible was documented. Errors were divided into planning or execution errors, acts of omission or commission, or violations, slips, and lapses. RESULTS: A total of 1,024 trauma patients were treated by the surgical services over the 6-month period from July to December 2006 in Pietermaritzburg. Thirty-four patients (2.5%) with missed injuries were identified during this period. There were 29 men and 5 women with an average age of 29 years (range: 21-67 years). In 14 patients, errors were related to inadequate clinical assessment. In 11 patients errors involved the misinterpretation of, or failure to respond to radiological imaging. There were 9 cases in which an injury was missed during surgical exploration. Overall mortality was 27% (9 patients). In 5 cases death was directly attributable to the missed injury. The level of the physicians making the error was consultant surgeon (4 cases), resident in training (15 cases), career medical officer (2 cases), referring doctor (6 cases). CONCLUSIONS: Missed injuries are uncommon and are made by all grades of staff. They are associated with increased morbidity and mortality. Understanding the pattern of these errors may help develop error-reduction strategies. Current taxonomies help in understanding the error process, but efforts must be made to develop innovative mechanisms that reduce the potential for error.     

Duodenal injuries

The lethal potential of duodenal trauma relates to the severity of the defect, associated injuries, expedient diagnosis, and adequacy of repair. A high index of suspicion must be used in patients sustaining blunt abdominal trauma. An aggressive approach to penetrating abdominal trauma will detect the majority of duodenal injuries in a timely fashion. The unique anatomic and physiologic characteristics of the duodenum demand careful selection of the operative repair to fit the injury. A classification scheme is reviewed that should help the surgeon select the appropriate procedure from a multitude of choices. Standard postoperative care is required. Adherence to these principles should result in acceptable morbidity and mortality in patients with duodenal injuries.