This study aimed to evaluate the outcomes of duodenal injury management among patients with war trauma in Yemen, focusing on the incidence, severity, surgical approaches, postoperative complications, and factors influencing success or failure. Our findings were consistent with the existing literature and provided critical insights into the unique challenges and considerations of war trauma.
The incidence rate of 5.2% for duodenal injuries among exploratory laparotomy cases in our study aligns well with reported incidence rates in the literature, ranging from 1% to 5% in cases of abdominal trauma [17,25]. This consistency underscores the reliability of our data in the context of global findings. Penetrating trauma was the predominant mechanism of injury, accounting for 95.7% of cases. This high prevalence of penetrating injuries, supported by similar findings in existing studies [6,26], highlights the significant impact of conflict and violence on trauma cases in our setting.
Our cohort predominantly consisted of young males, with a mean age of 21.93 years, mirroring the demographics reported in previous studies. For instance, the National Trauma Data Bank reported a median age of 27 years for patients with duodenal trauma, with 80% of the patients being men [27]. This demographic profile is typical in conflict zones, where young men are more likely to be involved in violent encounters.
The Injury Severity Score (ISS) in our study had a mean value of 20.63, indicating moderate to severe injuries. This result is comparable to those of other studies [28]. High ISS values indicate the severe nature of the injuries, which often involve multiple organ systems. The study revealed that most duodenal injuries were classified as AAST Grade II (96.3%), which is consistent with global patterns in which lower-grade injuries are more common [27]. Regarding anatomic location, injuries were most commonly found in the second duodenum part (D2) of the duodenum (44.4%), which is consistent with findings from other reviews [17,29]. This information is crucial for surgical planning and highlights the need for surgeons to be prepared for injuries at specific duodenal locations.
Associated injuries were frequent, with 73.9% of patients having colonic, 39.1% chest, and 29.6% liver injuries. These findings are in line with literature that emphasizes the high frequency of associated injuries due to the anatomical proximity of the duodenum to other vital organs [18,19]. The presence of multiple associated injuries complicates management and increases the risk of postoperative complications.
Postoperative complications were common, affecting 66.7% of patients. The most common complications were sepsis (55.6%), chest-related complications (50.0%), and wound-related complications (27.8%). These findings are consistent with existing literature, which reports high morbidity rates associated with duodenal injuries [28]. The high rate of sepsis underscores the need for vigilant postoperative care and early intervention to manage infections. One of the main complications of duodenal injuries is duodenal leaks, which can evolve into fistulas. The Memphis surgery group described a 19-year experience in managing these injuries and found that patients who developed duodenal leaks had longer hospital stays and higher rates of abdominal abscess formation [16,28]. Our findings agree with these observations, emphasizing the significant morbidity associated with duodenal leaks and the need for effective management strategies.
Several key risk factors influencing the outcomes of duodenal injury management were identified. Shrapnel injuries were particularly predictive of unsuccessful outcomes (p=0.012). Higher ISS were significantly associated with poorer outcomes, consistent with other studies [5,23,30]. These findings highlight the importance of early and accurate assessment of injury severity to guide treatment decisions and improve outcomes. The surgical approach choice was a critical factor in our study. Exploratory laparotomy was associated with better outcomes compared with damage control surgery, supporting studies advocating primary repair in less severe injuries [31,32]. However, complex procedures like Roux-en-Y duodenojejunostomy, were associated with poorer outcomes, highlighting the importance of selecting the surgical approach in determining patient outcomes. This finding indicates the need for careful surgical planning and the selection of the most appropriate technique based on the specific circumstances of each case.
Mortality in our study cohort was 11.1%, which is within the range of 3-30% reported in the literature [33]. This finding highlights the substantial risk of death associated with duodenal injuries, particularly during war trauma context. Early deaths were typically due to exsanguination from major vascular injuries, whereas late deaths were due to sepsis, duodenal fistula, and multiple organ failure. Factors such as associated pancreatic, common bile duct, and delayed injury recognition significantly increase mortality [20,34]. The high mortality rate associated with higher-grade injuries emphasizes the need for effective and timely management strategies to improve survival.
Our findings underscore the importance of early and accurate diagnosis of duodenal injuries to reduce treatment delays and improve outcomes. This requires the training of medical personnel in rapid assessment protocols, particularly in conflict zones where such injuries are prevalent. Additionally, the current study highlights the necessity of choosing an appropriate surgical approach based on injury severity and location. Primary repair for lower-grade injuries and complex repair for higher-grade injuries should be the standard practice to optimize patient outcomes. Moreover, the high incidence of postoperative complications, particularly sepsis and duodenal leaks, calls for enhanced postoperative monitoring and care protocols. Establishing standardized postoperative care routines can help mitigate these complications and improve patient recovery. Furthermore, our findings can inform the development of clinical guidelines and protocols for managing duodenal injuries in war zones. These protocols can standardize care, ensure treatment consistency, and ultimately improve patient outcomes across different settings. The current study also identified key areas for further research, including the development of advanced diagnostic tools, evaluation of surgical techniques, and exploration of novel postoperative care strategies. This approach can drive continuous improvement in the management of duodenal injuries.
Despite the valuable insights provided by our study, several limitations must be acknowledged. The retrospective study design limits the ability to establish causality. Additionally, the relatively small sample size may limit the generalizability of the findings. The study was conducted at a single center in Yemen, which may not represent the experiences of other regions or healthcare settings. There may also be issues related to the accuracy and completeness of the recorded data. Future studies should consider larger, multi-center designs to validate these findings and enhance their applicability.