One hundred sixty-three patients were treated for blunt and penetrating trauma of the duodenum and small bowel over a 41/2-year period at a major trauma center. Blunt injuries, mostly a result of vehicular trauma, comprised 17% of the cases, while stabbing and firearm injuries made up the remainder. Laboratory data, including white blood cell count, amylase, and abdominal x-rays, were unreliable in predicting the presence of intestinal injury. Although only obtained in a few patients following blunt injury, computerized tomography (CT scan) of the abdomen was sensitive to intraperitoneal findings suggestive of or diagnostic for gastrointestinal injury. Speedy operative management is of the utmost importance; 63% of these patients were operated on in less than 2 hours from the initiation of medical treatment. The majority of intestinal damage can be repaired by simple closure or resection. Because of anatomic and physiologic considerations, complex operative procedures are required for the correction of some duodenal lesions. Our treatment of these injuries included frequent utilization of pyloric exclusion, as well as occasional diverticulization of the duodenum and pancreaticoduodenectomy. Delay in treatment and the magnitude and number of associated injuries contributed to increased morbidity and mortality, which was much higher in blunt trauma (21% versus 4% for penetrating injuries), especially when the duodenum was involved (36% mortality). Complications were also more common in the patients following blunt trauma and with multiple injuries. Infectious complications were the most frequent, with postoperative ileus or obstruction, hemorrhage, and iatrogenic complications occurring less often. In the majority of small bowel injuries, the management is straightforward and consists of operative repair as soon as possible. A high index of suspicion and reliance on diagnostic aids, such as CT scan, will speed the diagnosis of occult blunt intestinal injuries. Sound surgical judgment and facility with a variety of repairs is needed in the treatment of complex duodenal injuries.
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