STAGED SURGICAL TREATMENT OF GUNSHOT ABDOMINAL WOUNDS WITH DUODENAL INJURY
DOI:
https://doi.org/10.32782/2226-2008-2026-1-4Keywords:
combat trauma, duodenal injury (DI), tactical surgery, medical evacuationAbstract
Background. Combat-related duodenal injuries (DI) are among the most complex abdominal traumas, with high mortality, septic complications, and lasting dysfunction. The most difficult decisions occur at Role 2, where limited resources hinder definitive care. The lack of a standardized algorithm contributes to poor outcomes. Objective. To develop and assess a surgical algorithm for DI adapted to the tiered system of military evacuation. Materials and Methods. Thirty service members with DI were studied: 20 managed with the proposed algorithm (main group) and 10 without (comparison). Injury severity was graded by AAST. Outcomes included mortality, complications, feeding initiation, and hospital stay. Results. Mortality was 10.0 % in the main group versus 80.0 % in the comparison (p < 0.001). Complications occurred in 85.0 % vs. 100 %. Enteral feeding started earlier (6.6 ± 0.4 vs. 8.6 ± 1.1 days, p < 0.05), and hospital stay was shorter (25.8 ± 4.2 vs. 42.9 ± 6.8 days, p < 0.05). The D2 segment was most often affected. Algorithm elements included FAST, laparo-centesis, and laparoscopy at Role 2; CT and endoscopy at Role 3; definitive repair and second-look surgery at Role 4. Conclusions. The algorithm reduced mortality and complications and allowed flexible tactical adaptation. At Role 2, strict damage control, avoidance of major reconstruction, and preparation for evacuation are essential. These findings support implementing a unified treatment pathway for DPI across the military medical system, adjustable to resources and battlefield conditions.
References
Butler FK Jr, Blackbourne LH, Eastridge BJ, et al., editors. Tactical Combat Casualty Care Handbook. 5th ed. Washington (DC): Joint Trauma System; 2023. Available from: https://jts.health.mil/assets/docs/TCCC-Guidelines-and-Curriculum/TCCC_Handbook_5th_Ed_2023_Final.pdf.
Ordoñez CA, Parra MW, Millán M, et al. Damage control in penetrating duodenal trauma: less is better – the sequel. Colomb Med (Cali). 2021;52(2):e4104509. https://doi.org/10.25100/cm.v52i2.4509.
NATO. Allied Joint Publication 4.10 (AJP-4.10): Allied Joint Doctrine for Medical Support. Edition B, Version 1. Brussels: NATO Standardization Office; 2020. Available from: https://www.coemed.org/files/stanags/01_AJP/AJP-4.10_EDC_V1_E_2228.pdf.
Department of Defense, Joint Trauma System. JTS Trauma System Toolkit. San Antonio (TX): Joint Trauma System; 2020. Available from: https://jts.health.mil/index.cfm/CPGs/cpgs.
Department of the Army, Office of The Surgeon General, Borden Institute. Emergency War Surgery. 5th ed. Falls Church (VA): Borden Institute; 2017. Available from: https://medcoe.army.mil/borden-tb-ews.
Obadiel YA, Albrashi AA, Saeed MA, Jowah HM. Incidence and Management of Duodenal Trauma in a War Setting: Insights From a Military Hospital in Yemen. Cureus. 2025;17(1):e77323. https://doi.org/10.7759/cureus.77323.
Park SJ, Shin HJ, Lee S. Time from Injury to Initial Operation May Be the Sole Risk Factor for Postoperative Leakage in AAST-OIS 2 and 3 Traumatic Duodenal Injury: A Retrospective Cohort Study. J Clin Med. 2022;11(12):3396. https://doi.org/10.3390/jcm11123396.
Coccolini F, Kobayashi L, Kluger Y, et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;14:56. https://doi.org/10.1186/s13017-019-0278-6.
Khoroshun E, Khomenko I, Shypilov S, Makarov V, Nehoduyko V, Petiunin O. Dosvid operatyvnoho likuvannia boiovoi travmy pidshlunkovoi zalozy [Experience in surgical treatment of combat-related pancreatic injury]. Med Nevidkladnykh Staniv. 2024;20(8). https://doi.org/10.22141/2224-0586.20.8.2024.1808 (In Ukrainian).
Pereira BM, de Campos Telles D, Vieira AL. Damage Control Pancreatoduodenectomy for Severe Pancreaticoduodenal Trauma: A Multicentric Case Series in Colombia. Panam J Trauma Crit Care Emerg Surg. 2020;9(1):19–24. https://doi.org/10.5005/jp-journals-10030-1262.
Navsaria PH. Military Trauma, Civilian Trauma. Vascular Trauma. Curr Trauma Rep. 2023;9(4):423–431. https://doi.org/10.1007/s40719-023-00277-y
Bellio G, Costantino F, Riviello R. Emergency surgery damage control procedures: which, when and how? – a narrative review of the literature. Ann Laparosc Endosc Surg. 2024;9:23. https://doi.org/10.21037/ales-23-44.
American Association for the Surgery of Trauma. Injury Scoring Scale. Lisle (IL): AAST; 2018. Available from: https://www.aast.org/trauma-acs-resources/trauma-tools/injury-scoring-scale.html.
Savoia P, Jayanthi SK, Chammas MC. Focused assessment with sonography for trauma (FAST). J Med Ultrasound. 2023;31(2):101–106. https://doi.org/10.4103/jmu.jmu_12_23.
Diggs LP, Gregory S, Choron RL. Review of Traumatic Duodenal Injuries: Etiology, Diagnosis, and Management. Am Surg. 2023;89(5):1989–1996. https://doi.org/10.1177/00031348211065091.
Cogbill TH, Moore EE, Feliciano DV, et al. Conservative management of duodenal trauma: a multicenter perspective. J Trauma. 1990;30(12):1469–1475.
Hollands M. Duodenal injuries: surgical management adapted to circumstances. Injury. 2003;34(3):167–172. https://doi.org/10.1016/s0020-1383(02)00373-1.
Choron RL, Teichman AL, Bargoud CG, et al. 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. J Trauma Acute Care Surg. 2023;95(1):151–159. https://doi.org/10.1097/TA.0000000000003972.
