闭合性十二指肠损伤14例诊治体会

目的总结闭合性十二指肠损伤的诊治体会,提高早期诊治水平。方法对2010-06—2015-06间收治的14例闭合性十二指肠损伤患者均给予手术治疗。回顾性分析其临床资料,以提高早期诊断率和治疗效果。结果本组术前确诊5例,术中确诊9例。术后死亡3例,分别为多脏器功能衰竭1例、腹腔大出血1例和急性肺栓塞1例。治愈11例中术后发生并发症4例,包括十二指肠瘘2例、腹腔脓肿1例和切口全层裂开1例。均经对症处理后痊愈,康复出院。结论详细询问病史,全面体格检查、结合影像学结果和细致术中探查,有助于对闭合性十二指肠损伤作出早期正确诊断,根据术中探查所见,个体化选择手术方式,是提高治疗效果的关键。     

腹部闭合性损伤96例诊治体会

目的探讨腹部闭合性损伤早期诊断治疗以及提高其治愈率,减少死亡率。方法回顾性分析96例腹部闭合性损伤患者的病因、诊治及死亡原因。结果所有患者手术治疗86例,非手术治疗10例;痊愈92例、死产4例。死亡者多为复合伤。结论正确的围手术期处理,快速综合评估伤情、早期诊断、早期剖腹探查,合理选择术式是提高腹部闭合性损伤成功率、降低死亡的关键。     

闭合性十二指肠损伤15例诊疗体会

目的　提高对闭合性十二指肠损伤的诊疗水平。方法　对本组闭合性十二指肠损伤1 5例的病因、伤情、探查时间、手术方法、术后并发症及死亡率作了统计和分析。结果　单纯十二指肠损伤 1例 ,多发伤 1 4例 ,并发症 7例 ,治愈 1 0例 ,死亡 5例 ,死亡原因均为创伤性休克或感染性休克。结论　早期诊断、及时探查和选择合适的手术方式 ,是提高疗效减少并发症、降低死亡率的关键     

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。     

闭合性十二指肠损伤33例临床分析

探讨闭合性十二指肠损伤的正确诊断及术式选择。以中国医科大学第四附属院2003年12月—2013年12月收治的33例闭合性十二指肠损伤患者为研究对象,对其临床资料进行回顾性分析总结。33例患者术前确诊26例,确诊率为78.79%;误诊7例,误诊率为21.21%,4例误诊为肝脾破裂、1例误诊为空回肠破裂、2例误诊为腹膜后血肿。治愈29例,治愈率87.88%;死亡4例,死亡率12.12%。18例发生术后并发症,并发症发生率为54.55%。临床中发现上腹部闭合性损伤患者应考虑并警惕发生闭合性十二指肠损伤的可能,闭合性十二指肠损伤治疗关键是早期正确诊断、及时手术,对临床上可疑但不能确诊的,应早期进行剖腹探查;选择正确合理的手术方式是降低十二指肠损伤并发症发生率和死亡率的保证。     

闭合性十二指肠损伤的诊治体会

目的　探讨闭合性十二指肠损伤的诊治特点。方法　对 14例闭合性十二指肠损伤的原因、部位、术式选择与并发症发生的关系以及愈合情况进行回顾性分析。结果　 2例术前明确诊断 ,其余手术探查时确诊。十二指肠瘘 3例 ;腹腔脓肿 2例 ;小肠梗阻 1例 ;伤口感染 3例。全组均治愈。结论　反复多次腹腔穿刺和X线检查对诊断有指导意义。强调术中十二指肠探查 ,防止漏诊 ;充分有效地十二指肠减压 ,空肠造瘘和生长抑素的使用可减少肠瘘的发生     

闭合性胰十二指肠损伤的诊治

目的:探讨闭合性胰十二指肠的诊治方法。方法:73例患者均行手术治疗,其中行十二指肠憩室化8例,胰十二指肠切除术6例,单纯修补30例,胰体尾切除14例,近端胰缝合修补、远端胰肠吻合4例,单纯腹腔引流11例。结果:术后并发症31例,再手术6例,死亡6例。结论:由于胰腺十二指肠的解剖结构和生理特点及较多的合并伤,使闭合性胰十二指肠损伤早期诊断较为困难复杂,术中对胰管损伤的准确判断是胰十二指肠损伤严重程度分级的重要标准和术式选择的主要依据,早诊断、早手术、合理的术式是减少并发症率、降低死亡率、提高疗效的关键。     

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。     

68例闭合性腹部损伤患者的临床诊断与治疗

目的探讨闭合性腹部损伤的早期诊断和治疗方法,以降低病死率,提高治愈率。方法对68例闭合性腹部损伤患者的临床诊治资料进行回顾性分析。结果 68例患者行手术治疗61例,非手术治疗7例。治愈64例,死亡4例,其中2例死于合并重度颅脑损伤,1例死于多脏器功能衰竭,1例因腹腔严重感染、中毒休克死亡。结论严密观察病情,早期准确诊断并采取正确有效治疗措施,是提高闭合性腹部损伤患者抢救成功率,减少病死亡率的关键。     

闭合性十二指肠损伤的诊断与治疗

目的探讨闭合性十二指肠损伤的早期诊断与治疗方法。方法对30例闭合性十二指肠损伤患者均予以手术治疗,回顾性分析患者的临床资料。结果术前早期确诊5例(16.7%),受伤部位主要为十二指肠降部,共14例,占46.7%。全组死亡5例(16.7%),共发生各种并发症25例次。结论详细的受伤史,仔细的体格检查,术中全面仔细探查可提高早期诊断率。及时手术治疗、正确的手术方式及合理的营养支持,是提高生存率预防并发症的关键。     

Mesenteric injury after blunt abdominal trauma.

OBJECTIVE: To present our experience of mesenteric injuries after blunt abdominal trauma. DESIGN: Retrospective study. SETTING: University hospital, Greece. SUBJECTS: 31 patients with mesenteric injuries out of 333 who required operations for blunt abdominal trauma between March 1978 and March 1998. 21 were diagnosed within 6 hours (median 160 min, early group) and in 10 the diagnosis was delayed (median 21 hours, range 15 hours-7 days, delayed group). INTERVENTIONS: Emergency laparotomy. MAIN OUTCOME MEASURES: Mortality, morbidity, and hospital stay. RESULTS: There were no deaths. The diagnosis was confirmed by diagnostic peritoneal lavage in 17/21 patients in the early group whereas 7/10 in the delayed group were diagnosed by clinical examination alone. Most of the injuries (n = 23) were caused by road traffic accidents. 30 patients had injured the small bowel mesentery and 4 the large bowel mesentery. 25 of the 31 patients had associated injuries. There were no complications in the early group, compared with 6 wound infections and 1 case of small bowel obstruction in the delayed group (p < 0.0001). Median hospital stay in the early group was 11 days (range 3-24) compared with 23 days (range 10-61) in the delayed group (p = 0.004). CONCLUSION: Because delay in diagnosis is significantly associated with morbidity and duration of hospital stay we recommend that all patients admitted with blunt abdominal trauma should have a diagnostic peritoneal lavage as soon as possible     

Surgical treatment and outcome after delayed diagnosis of blunt duodenal injury.

OBJECTIVE: To review our experience of 18 patients with duodenal injuries after blunt trauma, the diagnosis of which had been delayed for more than 24 hours. DESIGN: Retrospective study. SETTING: Teaching hospital, Taiwan, R.O.C. SUBJECTS: 18 patients who presented with duodenal injuries between January 1986 and December 1995. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The reasons for the delay were: injuries not found during the first operation (n = 6), patients had not sought medical help (n = 6), and injuries treated conservatively at local hospitals (n = 5). There was one delay in our department because the patient lost consciousness. 12 patients were treated by pyloric exclusion with no deaths and four complications (one duodenal fistula and 3 retroperitoneal abscesses). The other 6 had various operations including pancreaticoduodenectomy, jejunostomy, and gastrostomy, with six complications and one death, giving an overall mortality of 6% and morbidity of 50%. Three patients developed delayed extensive retroperitoneal abscesses and all three were treated successfully by laparostomy. 16 of the 18 patients required enteral feeding through a jejunostomy. CONCLUSIONS: Though the complication rate was high, the use of pyloric exclusion and a feeding jejunostomy kept the mortality low. Enteral nutrition should be started early. Laparostomy is a good way to manage retroperitoneal abscesses. To avoid delay, patients at risk of duodenal injuries should be evaluated early by experienced trauma surgeons and any central retroperitoneal haematoma should be explored during the initial laparotomy.     

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.     

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).     

Colon injury after blunt abdominal trauma: results of the EAST Multi-Institutional Hollow Viscus Injury Study

BACKGROUND: Blunt injury to the colon is rare. Few studies of adequate size and design exist to allow clinically useful conclusions. The Eastern Association for the Surgery of Trauma Multi-institutional Hollow Viscus Injury (HVI) Study presents a unique opportunity to definitively study these injuries. METHODS: Patients with blunt HVI were identified from the registries of 95 trauma centers over 2 years (1998-1999). Patients with colon injuries (cases) were compared with blunt trauma patient undergoing a negative laparotomy (controls). Data were abstracted by chart review. RESULTS: Of the 227,972 patients represented, 2,632 (1.0%) had an HVI and 798 had a colonic/rectal injury (0.3%). Of patients diagnosed with HVI, 30.2% had a colon injury. No physical findings or imaging modalities were able to discriminate colonic injury. Logistic regression modeling yielded no clinically useful combination of findings that would reliably predict colonic injury. In patients undergoing laparotomy, presence of colon injury was associated with a higher risk of some complications but not mortality. Colon injury was associated with increased hospital (17.4 vs. 13.1, p < 0.001) and intensive care unit (9.7 vs. 6.9, p = 0.003) length of stay. Almost all colon patients (92.0%) underwent laparotomy within 24 hours of injury. CONCLUSION: Colonic injury after blunt trauma is rare and difficult to diagnose. No diagnostic test or combination of findings reliably excluded blunt colonic injury. Despite the inadequacy of current diagnostic tests, almost all patients with colonic injury were taken to the operating room within 24 hours. Even with relatively prompt surgery, patients with colon injury were at significantly higher risk for serious complications and increased length of stay. In contrast to small bowel perforation, delay in operative intervention appears to be less common but is still associated with serious morbidity.     

Traumatic injury to the diaphragm: timely diagnosis and treatment.

Traumatic injury to the diaphragm is a relatively uncommon injury with potential for considerable morbidity if the diagnosis is delayed or missed. This review of cases of traumatic diaphragmatic injury was undertaken in order to emphasize methods and timing of diagnosis and treatment. From 1986 through 1990, 43 cases of traumatic diaphragmatic injury were admitted to the trauma unit at Sunnybrook Health Sciences Centre, for an incidence of 2% of all new multiple trauma admissions. All patients were evaluated and treated by a dedicated trauma team. The left hemidiaphragm was injured in 32 patients, the right hemidiaphragm was injured in eight cases, and the injury was bilateral in three patients. Thirty-four patients had blunt trauma. The mean Injury Severity Score for all patients was 32. The diagnosis of diaphragmatic injury was made radiologically in 21 cases and at surgery in 22 cases. The diagnosis in all cases with penetrating trauma was made at the time of surgery. The interval between injury and definitive surgery was less than 12 hours in 39 of 43 patients. The diagnosis of diaphragmatic injury was delayed by more than 12 hours in only one patient. The other three patients were diagnosed soon after injury but their definitive surgery was delayed for other reasons. Surgical repair of the diaphragm was performed via laparotomy in 40 of 43 cases. Only one patient was repaired in a delayed fashion by thoracotomy for thoracic complications. A clear contrast can be drawn between blunt injuries and penetrating trauma.(ABSTRACT TRUNCATED AT 250 WORDS)     

Traumatic duodenal hematoma in the pediatric patient

Twenty children with duodenal hematomas secondary to blunt trauma were treated between 1953 and 1983. The duodenal injury was isolated in ten cases and associated with intra-abdominal injuries in the others. In ten, the duodenal injury was suspected on admission and the diagnosis was confirmed within 24 hours by radiographic contrast studies. All ten were managed successfully with nasogastric suction and intravenous fluids. Ten patients underwent laparotomy for increasing abdominal tenderness and guarding. An isolated duodenal hematoma was found in four and treated by evacuation and/or gastroenterostomy. In five of the remaining six surgical patients, all of whom had multiple intra-abdominal injuries, the duodenum was left untouched. Three of these patients had postoperative contrast studies that showed early resolution of the duodenal hematoma. No duodenal stricture or leak developed in any patient. The children with isolated duodenal hematomas who were treated conservatively had a mean hospital stay of six days, whereas those treated surgically had a mean stay of 17 days. The ten patients with multiple intra-abdominal injuries had a mean hospital stay of 32 days. In this group, eight required total parenteral nutrition or nasojejunal feeds for nutritional support. In these patients, an isolated duodenal hematoma resulted in minimal morbidity and nonoperative management was usually successful. The presence of associated intra-abdominal injuries was responsible for the prolonged hospitalization and delayed return of normal intestinal function in some patients.     

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.     

EARLY MANAGEMENT OF ABDOMINAL TRAUMA THE ROLE OF DIAGNOSTIC PERITONEAL LAVAGE

This report reviews the contemporary value of diagnostic peritoneal lavage (DPL) in the assessment of abdominal trauma, and reports the methods and results of its application within one trauma centre (Washington Hospital Center). DPL was reserved for those patients where doubt existed as to the presence of intraabdominal injury, and gave a very accurate assessment of intraperitoneal injury. The complication rate was 0.4% and the accuracy of DPL was 97.7%. Except for laparotomy, DPL is the most sensitive indicator of haemoperitoneum available. It was first introduced with the aim of reducing the number of missed diagnoses of abdominal injury and it performs this task excellently when a low threshold for positivity is used. The open technique is safest and gives fewer false positive results, and the colorimetric method of analysis of lavage fluid is recommended, with strict adherence to advised criteria for negativity. A clinical algorithm is described, utilizing DPL, aimed at early diagnosis of all intra-abdominal injuries. This was extremely sensitive and failed in only one case in 384 (0.3%). The attendant, non-therapeutic laparotomy rate was 19%, and is regarded as acceptable within the aims of early diagnosis. In this series, there was no mortality or morbidity attached to the use of DPL or from non-therapeutic laparotomy, and there was only one delayed diagnosis in the entire series. No bowel, bladder, diaphragmatic, duodenal or pancreatic injuries were missed or diagnosed late.     

Is delayed laparotomy for blunt abdominal trauma a valid quality improvement measure in the era of nonoperative management of abdominal injuries?

BACKGROUND: Review of hemodynamically stable patients who undergo laparotomy for trauma greater than 4 hours after admission is an American College of Surgeons quality improvement filter. We reviewed our recent experience with patients who underwent laparotomy for trauma greater than 4 hours after admission to evaluate the reasons for delay, and to determine whether they were because of failure of nonoperative management or other causes. METHODS: The registry at our Level I trauma center was searched from January 1998 through December 2000 for patients who required a laparotomy for trauma greater than 4 hours after admission. Of 3,369 admitted blunt trauma patients, 90 (2.7%) underwent laparotomy for trauma, of which 26 (29%) were identified as delayed laparotomies greater than 4 hours after admission. RESULTS: The most common mechanism of injury was motor vehicle crash, the mean Injury Severity Score was 18, and 65% of the patients had significant distracting injuries. Five patients had laparotomy greater than 24 hours after admission. The average time to the operating room in the remaining patients was 8.6 hours. Clinical examination (61%) findings were the most common indication for operation. Gastrointestinal (GI) tract injury was the most common injury associated with delay in laparotomy (58%). CONCLUSION: GI tract injuries are the predominant injury leading to delayed laparotomy for blunt trauma (58%). Failed nonoperative management of solid organ injuries occurred less frequently (15%). Future efforts should concentrate on earlier identification of GI tract injury. Delayed laparotomy for blunt abdominal trauma is a valid quality improvement measure.