Option of staged treatment of a patient with a gunshot wound to the duodenum.

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Introduction.
According to the literature, trauma of the duodenum (Duodenum) with damage to the abdominal organs occurs in 0.93 - 10% (1,2,3,4). At the same time, duodenal lesions are one of the most difficult problems of emergency surgery. The number of complications in the postoperative period, in patients with duodenal injuries, develop in 25 - 72.5% of victims, and the mortality rate is 11 - 30% (1, 2,3,5). Isolated damage to the duodenum is quite rare due to its syntopy, especially with gunshot wounds. In most cases, several organs are simultaneously damaged (5,6,7), which poses a tactically and technically challenging task for the surgeon.
On an emergency basis, as a rule, suturing of bowel defects, decompression of the upper gastrointestinal tract, drainage of the abdominal cavity and retroperitoneal space are performed (8). It is desirable to provide an intraoperative opportunity for enteral nutrition. With single injuries, in most cases, this tactic is successful. However, such operations for multiple duodenal injuries with simultaneous damage to several vital organs in a serious condition of the patient, most often, end in failure of the duodenal sutures and the formation of external duodenal fistulas (9). In patients who have undergone shock, often in organ failure, an additional complexity is created by massive bile leakage and the associated water-electrolyte disturbances. This factor does not allow to adequately compensate for the patient's condition and creates a lack of time for making a decision about the operation, preparing the patient. Thus, patients with water-electrolyte and protein deficiency are often forced to the operating table.
The methods of surgical correction of complications that have developed after suturing the duodenum also differ in variety and are not always successful. For example, various methods of active drainage, plugging of fistulous passages are proposed, and the importance of eliminating duodenostasis is also emphasized (10, 11). For this purpose, disconnection of the duodenum is used, with the help of the imposition of gastroenteroanastomosis and interintestinal anastomoses (12). Also, to exclude the passage of bile, external drainage of the bile ducts is used. However, none of these methods in the case of multiple damage to the duodenum does not completely exclude the flow of bile and pancreatic juice into the duodenum, which significantly reduces the likelihood of a favorable outcome of the operation. In connection with this situation, some authors resort to pancreatoduodenal resections (13, 14, 15). This operation is quite traumatic, fraught with many complications, and in this group of patients it may not be feasible due to their somatic status.

We have proposed and carried out an operation involving the removal of the duodenum with multiple defects, but with the preservation of a small section of the posterior wall of the intestine with the Vater's papilla.
Clinical case.
Patient S., 30 years old, was admitted to the hospital 1 hour after the moment of a gunshot (bullet) penetrating wound to the right half of the abdomen in a serious condition (grade III shock). An emergency laparotomy was performed. At the operation - multiple intra - and extraperitoneal defects of the duodenum, localized in the descending and lower horizontal part of it (Fig. 2,3). In addition, multiple injuries of the ileum and ascending colon, crush injury of the right kidney, multiple injuries of the right lobe of the liver in S V - VI 6 * 2 cm, depth 2-2.5 cm were revealed (Fig. 1, 2, 3). The bile ducts are intact (Fig. 3). Blood loss of about 2.5 liters.

Fig. one
Damage to the liver (1), colon (2), ileum (3).

Fig. 2
Duodenal injury (1), crush injury of the right kidney (2).

Fig. 3
Damage to the liver (1), duodenum (2), crushing of the right kidney (3), injuries of the ileum (4) and ascending colon (5) intestine. Intact zone of the BDS (6).
Liver injuries and ileal defects were sutured. A right-sided hemicolectomy was performed with the removal of the ileostomy. The crushed right kidney was removed. After mobilization of the duodenum according to Kocher, its defects were sutured, decompression with a nasoduodenal probe was performed (Fig. 4). For the purpose of decompression of the bile ducts, a cholecystostomy was applied. Provided access for enteral nutrition by installing a nasointestinal probe below the level of damage. Drainages were brought to the zone of damage to the duodenum retroperitoneally In the postoperative period, the patient's condition stabilized, but remained severe, signs of renal failure began to increase.

Fig. 4
A cholecystostomy was imposed (1), duodenal defects were sutured (2), a right-sided hemicolectomy was performed (plugged end of the colon - 3), an ileostomy was removed (4).
On the 7th day, bile leakage appeared along the drainages from the retroperitoneal space. The failure of the sutures on the duodenum was diagnosed. There were no symptoms of diffuse peritonitis. The patient was transferred to the General Surgery Clinic of the St. Academician Pavlov. The examination revealed the failure of the duodenal sutures (the proximal level of bowel injury is 4 cm behind the pyloric pulp, the distal level is 5 cm from the Treitz ligament). At the same time, the integrity of the bile ducts was preserved. The presence of fluid accumulation in the abdominal cavity and retroperitoneal space is excluded. Drainage losses up to 1500 ml per day. Enteral feeding continued through a tube inserted behind Treitz's ligament. No discharge of the nutrient mixture through the drains was observed. After preoperative preparation and additional examination, repeated surgical treatment was performed.
At the operation - a pronounced adhesive process. Maximum changes in the upper floor of the abdominal cavity and in the area of ​​the previously damaged and sutured duodenum. After the division of the conglomerate, it was revealed that the "horseshoe" of the duodenum was destroyed, its anterior and lateral walls were almost completely absent. The papilla of Vater is preserved, bile flows from it. In the retroperitoneal space in the zone of suture failure, hematomas, inflammatory infiltrates were not revealed.
The duodenum is transected in the area of ​​the bulb. The destroyed walls of the duodenum were completely excised within the healthy tissues, leaving a portion of the posterior wall of the duodenum up to 5 cm in diameter in the area of ​​the Vater's papilla. A dedicated loop of the small intestine is connected to this zone, and a section of the duodenum with a large duodenal papilla is implanted into it. Later, a gastroenteroanastomosis and an interintestinal anastomosis according to Brown were applied (Fig. 5). Suspended nutritional jejunostomy was applied.

Fig. five
Vater's papilla was implanted (1), gastroenteroanastomosis was imposed (2), as well as interintestinal anastomosis according to Brown (3).
The postoperative period corresponded to the volume and severity of the surgery. In the postoperative period, there were no clinical signs of anastomotic leakage. Laboratory indicators are within the normal range. According to instrumental research methods, no pathology was revealed. The patient was discharged for outpatient treatment three weeks after surgery.
Examination after 6 months of data for the presence of strictures of the bile ducts, violations of the passage through the gastrointestinal tract were not found. The ileostomy was closed, and the ileotransverse anastomosis was applied. Currently, the patient feels well and has no complaints (surgery in 2014).
Discussion.
The proposed surgical tactics involves the removal of the duodenum with multiple defects, but with the preservation of a small section of the posterior intestinal wall with the Vater papilla, which is subsequently reimplanted into the disconnected loop of the jejunum. Thus, it is possible to avoid the imposition of potentially dangerous non-consistency sutures on the retroperitoneal part of the duodenum. In addition, the need to work on the bile and pancreatic ducts disappears, the pancreas is preserved.

The applied tactics made it possible to reduce the surgical trauma, as well as to restore the intestinal passage of bile while preserving the anatomical integrity of the biliary tract. The staging of the provision of medical care was observed, the timely evacuation of the patient to the specialized medical institution of the St. Academician Pavlov, which made it possible to keep the biliary tract intact, to minimize the risk of developing postoperative strictures of the biliary tract and repeated surgical interventions associated with this complication.

Conclusion.
In the event of complications after suturing damage to the duodenum in case of multiple damage to the duodenal tract without trauma to the biliary tract, we propose to perform duodenectomy according to the described technique, which will most likely prevent the development of a number of complications accompanying gastropancreatoduodenal resection and other common surgical interventions.

About the authors

Daria Vladimirovna Zuykevich

First St. Petersburg State Medical University. I.P. Pavlova

Author for correspondence.
Email: Florida1995@yandex.ru
ORCID iD: 0000-0002-7951-7402
SPIN-code: 9091-0883

surgeon, surgical department No. 3

Russian Federation, 197022,Russia, St.Petersburg,Lev Tolstoy, 6-8.

Dmitry Yuryevich Semenov

Moscow Regional Research Clinical Institute M.F. Vladimirsky, Moscow, Russian Federation

Email: semenov_du@mail.ru
ORCID iD: 0000-0003-2207-3414
SPIN-code: 2839-7241

M.D., Professor, Director of the Moscow
Regional Research Clinical Institute. M.F. Vladimirsky

Schepkina street, 61/2, building 1, Moscow, 129110, Russian Federation

Dmitry Viktorovich Kulikov

First St. Petersburg State Medical University. I.P. Pavlova

Email: fomka123.91@gmail.com
ORCID iD: 0000-0003-4126-2886
SPIN-code: 5887-3250

surgeon, surgical department No. 3

Russian Federation, 197022,Russia, St.Petersburg,Lev Tolstoy, 6-8

Yuri Sergeevich Chekmasov

First St. Petersburg State Medical University. I.P. Pavlova.

Email: doct.chek@gmail.com
ORCID iD: 0000-0001-6876-3571
SPIN-code: 3605-7489

surgeon, surgical department No. 3

Russian Federation, 197022,Russia, St.Petersburg,Lev Tolstoy, 6-8.

Elena Sergeevna Did-Zurabova

First St. Petersburg State Medical University. I.P. Pavlova

Email: didelena@mail.ru
ORCID iD: 0000-0002-0670-2682
SPIN-code: 4095-8759

surgeon, surgical department No. 3

Russian Federation, 197022,Russia, St.Petersburg,Lev Tolstoy, 6-8

Inna Dmitrievna Lazareva

First St. Petersburg State Medical University. I.P. Pavlova

Email: Dr_idl@mail.ru
ORCID iD: 0000-0003-0466-4560
SPIN-code: 7559-0213

surgeon, surgical department No. 3

Russian Federation, 197022,Russia, St.Petersburg,Lev Tolstoy, 6-8

References

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