H. N. Mashbari1, K. Chow1, M. Hemdi1, K. Danielson1, E. Smith-Singares1 1University Of Illinois At Chicago,Division Of Surgical Critical Care,Chicago, IL, USA
Introduction:
Complex pancreatic and duodenal injuries due to trauma continue to present a formidable challenge to the trauma surgeon. Duodenal trauma-related injuries have a described mortality of 5-30% and morbidity of 22-27%. Duodenal fistula formation subsequent to failure of attempted primary repair is associated with significant morbidity and mortality. No such data exists on the employment of duodenal stents as an adjunct in the management of complex duodenal injuries due to trauma, after failure of primary repair. The aim of this study is to document our experience with enteral stents in patients with complex duodenopancreatic traumatic injuries, and to determine if they are a viable option to treat duodenal fistulas in the hostile abdomen.
Methods:
A retrospective review of the trauma registry at a busy Academic Level I trauma center between 2010 and 2016 identified 4 patients who underwent endoscopically placed indwelling enteral covered metal stents after failure of primary duodenal repair in the form of high output duodenal fistulas. Drainage volumes were collected and classified according to source (i.e. drain data, laparostomy output data, and ileostomy output data) and phase of intervention (i.e. admission to fistula diagnosis, to stent insertion, upon removal, and until discharge).
Results:
The overall mortality was 0%. All treated patients experienced complete resolution of their complex duodenal fistulas. There was no statistically significant change in mean or slopes of daily laparostomy output, combined surgical drain output or ileostomy output across phases. There was a clinically significant difference in the mean combined drain output of 497ml/day after stent placement. When comparing the sum of all output sources, there was a statistically significant difference across phases (p=0.03) and “After Removal” was significantly less when compared to the reference phase (p=0.05). There was also a change in the directionality of the slope for the sum of all drain outputs with +13 ml/day2 prior to stent placement compared to -13ml/day2 after stent placement.
Conclusion:
Indwelling enteral-coated stents appear to be an effective rescue method for an otherwise inaccessible duodenal fistula after failure of primary repair. In this cohort, our data showed that duodenal stents produced a significant and durable change in overall drainage outputs as well as obvious reversal in the rate of daily fistulous yield change as an indicator of duodenal leak healing.
