Journal article
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
The journal of trauma and acute care surgery, v 95(1), pp 151-159
Jul 2023
PMID: 37072889
Featured in Collection : UN Sustainable Development Goals @ Drexel
Abstract
Complex repairs with adjunctive measures(CRAM) of duodenal injuries did not prevent leaks and did not reduce adverse sequelae when leaks did occur. This suggests CRAM is not a protective repair strategy and primary repair alone(PRA) should be pursued for all injuries if feasible.
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.
Metrics
Details
- Title
- 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
- Creators
- Rachel L. ChoronAmanda L. Teichman - Johnson UniversityChristopher G. Bargoud - Johnson UniversityJason D. Sciarretta - General University Hospital of PatrasRandi N. Smith - Grady Memorial HospitalDustin S. Hanos - Rutgers, The State University of New JerseyIman N. Afif - McGill UniversityJessica H. Beard - University of KentuckyNavpreet K. Dhillon - Rutgers, The State University of New JerseyAshling Zhang - University of KentuckyMira Ghneim - Yale New Haven HospitalRebekah J. Devasahayam - Medical College of WisconsinOliver L. Gunter - Washington HospitalAlison A Smith - General University Hospital of PatrasBrandi L. Sun - Yale New Haven HospitalChloe S. Cao - McGill UniversityJessica K. Reynolds - University of KentuckyLauren A. Hilt - Rutgers, The State University of New JerseyDaniel N. Holena - Medical College of WisconsinGrace Chang - Rutgers, The State University of New JerseyMeghan Jonikas - General University Hospital of PatrasKarla Echeverria - University of KentuckyNathaniel S. Fung - General University Hospital of PatrasAaron Anderson - McGill UniversityCaitlin A. Fitzgerald - Rutgers, The State University of New JerseyRyan P. Dumas - McGill UniversityJeremy H. Levin - Therapeutic GuidelinesChristine T. Trankiem - Penn State Milton S. Hershey Medical CenterJaeHee Jane Yoon - Hartford HospitalJacqueline Blank - McGill UniversityJoshua Hazelton - Penn State Milton S. Hershey Medical CenterChristopher J. McLaughlin - General University Hospital of PatrasRami Al-Aref - Rutgers, The State University of New JerseyJordan M. Kirsch - Rutgers, The State University of New JerseyDaniel S. Howard - Penn State Milton S. Hershey Medical CenterDane R. Scantling - McGill UniversityKate Dellonte - Rutgers, The State University of New JerseyMichael Vella - University of PennsylvaniaBrent Hopkins - JDSUChloe H. Shell - General University Hospital of PatrasPascal O. Udekwu - WakeMedEvan G. Wong - McGill UniversityBellal A. Joseph - McGill UniversityHoward Lieberman - General University Hospital of PatrasWalter Ramsey - McGill UniversityCollin Stewart - Rutgers, The State University of New JerseyClaudia Alvarez - Medical College of WisconsinJohn D. Berne - Rutgers, The State University of New JerseyJeffry Nahmias - University of California, Irvine Medical CenterIvan Puente - Rutgers, The State University of New JerseyJoe H. Patton - General University Hospital of PatrasIlya Rakitin - Rutgers, The State University of New JerseyLindsey L. Perea - Lancaster General HospitalOdessa R. Pulido - Rutgers, The State University of New JerseyHashim Ahmed - General University Hospital of PatrasJane Keating - McGill UniversityLisa M. Kodadek - Rutgers, The State University of New JerseyJason Wade - University of KentuckyReynold Henry - University of KentuckyMartin A. Schreiber - University of KentuckyAndrew J. Benjamin - Temple University HospitalAbid Khan - Washington HospitalLaura K. Mann - Spartanburg Regional Medical CenterCaleb J. Mentzer - Spartanburg Regional Medical CenterVasileios Mousafeiris - General University Hospital of PatrasFrancesk Mulita - McGill UniversityShari Reid-Gruner - Broward HealthErica Sais - University of KentuckyJoshua Marks - General University Hospital of PatrasChristopher Foote - General University Hospital of PatrasCarlos H. Palacio - Penn State Milton S. Hershey Medical CenterDias Argandykov - Penn State Milton S. Hershey Medical CenterHaytham KaafaraniSusette Coyle - Penn State Milton S. Hershey Medical CenterMarie Macor - Barnes-Jewish HospitalMichelle T. Bover Manderski - General University Hospital of PatrasMayur Narayan - General University Hospital of PatrasMark J. Seamon - General University Hospital of Patras
- Publication Details
- The journal of trauma and acute care surgery, v 95(1), pp 151-159
- Publisher
- Lippincott Williams & Wilkins; PHILADELPHIA
- Number of pages
- 9
- Resource Type
- Journal article
- Language
- English
- Academic Unit
- Surgery
- Web of Science ID
- WOS:001020223600023
- Scopus ID
- 2-s2.0-85164150729
- Other Identifier
- 991022057015804721
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- Collaboration types
- Domestic collaboration
- International collaboration
- Web of Science research areas
- Critical Care Medicine
- Surgery