A ten-year retrospective review: does pyloric exclusion improve clinical outcome after penetrating duodenal and combined pancreaticoduodenal injuries?

Objectives: We sought to determine whether the performance of pyloric exclusion during repair of penetrating advanced duodenal injuries prevents postoperative duodenal fistulas and improves clinical outcome.

Methods: A retrospective chart review of patients from 1995 to 2004 with penetrating duodenal injuries >or=grade II and all combined pancreaticoduodenal injuries was performed. Patients managed either without or with pyloric exclusion were compared on the basis of age, sex, mechanism, injury grade, Injury Severity Score (ISS), hemodynamic stability, the presence of vascular injury or associated injuries, postoperative complications, length of hospital stay, and mortality.

Results: Fifteen of 29 patients were managed without pyloric exclusion and 14 with exclusion. Both groups were similar with respect to age, sex, mechanism, injury grade, ISS, hemodynamic stability, the presence of vascular injury, associated abdominal injuries, and mortality rates. A trend toward a higher overall complication rate (71% vs. 33%), pancreatic fistula rate (40% vs. 0%), and length of hospital stay (24.3 days vs. 13.5 days) was evident in the pyloric exclusion group. No duodenal fistula was detected in either patient group.

Conclusion: In our study population, the performance of pyloric exclusion for penetrating advanced duodenal injury and combined pancreatic and duodenal injuries did not improve clinical outcome. The trend toward a greater overall complication rate, pancreatic fistula rate, and increased length of hospital stay in the pyloric exclusion group suggests that simple repair without pyloric exclusion is both adequate and safe for most penetrating duodenal injuries.