Staged surgical strategy for the management of combat-related duodenal injuries according to level of care

Abstract

OBJECTIVE – to assess the impact of an enhanced staged surgical management algorithm, stratified by levels of care, on postoperative complications and mortality in combat-related duodenal injuries. MATERIALS AND METHODS. This prospective study included 51 military personnel with gunshot-induced duodenal injuries. Patients were assigned to an experimental group (n = 28) treated according to a newly developed algorithm and to a control group (n = 23) managed with a conventional approach. The groups were comparable with respect to age, injury mechanism, duodenal injury severity, overall injury severity, and peritonitis characteristics. Both parametric and nonparametric methods were used in the statistical analyses. RESULTS. Isolated duodenal injuries accounted for 13.7 % of cases, while multiple injuries were present in 86.3 %. In the experimental group, 82.1 % of patients received staged care across levels II, III, and IV, with complex reconstructive and combined surgical interventions such as duodenal diverticulization with gastroenteroanastomosis, pancreaticoduodenectomy, and percutaneous transhepatic cholecystostomy (biliary decompression) primarily performed at level IV care following stabilization. In the control group, the staged model was implemented in only 26.1 % of cases, while in the remaining cases, the main volume of surgical intervention was performed at level II care. A length of stay of less than 1 day at level II care was observed in 94 % of the experimental group, compared with 5 % of the control group (p = 0.001). The experimental group demonstrated significantly lower rates of duodenal suture failure (7.1 % vs. 52.2 %, p = 0.001), peritonitis (17.9 % vs. 47.8 %, p = 0.022), sepsis (17.9 % vs. 60.9 %, p = 0.002), and relaparotomies for recurrent peritonitis (14.2 % vs. 60.9 %, p = 0.007). Mortality was 13.4 % in the experimental group and 39.1 % in the control group (p = 0.043). The mean hospital stay was significantly shorter in the experimental group (18.2 ± 7.1 days) compared to the control group (29.3 ± 8.1 days; p < 0.001). CONCLUSIONS. The enhanced staged surgical management algorithm for combat-related duodenal injuries significantly decreases the incidence of severe postoperative complications, relaparotomy rates, length of hospital stay, and mortality.