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
Authors: Choron Rachel L. , Teichman Amanda L. , Bargoud Christopher G. , Sciarretta Jason D. , Smith Randi N. , Hanos Dustin S. , Afif Iman N. , Beard Jessica H. , Dhillon Navpreet K. , Zhang Ashling , Ghneim Mira , Devasahayam Rebekah J. , Gunter Oliver L. , Smith Alison A , Sun Brandi L. , Cao Chloe S. , Reynolds Jessica K. , Hilt Lauren A. , Holena Daniel N. , Chang Grace , Jonikas Meghan , Echeverria Karla , Fung Nathaniel S. , Anderson Aaron , Fitzgerald Caitlin A. , Dumas Ryan P. , Levin Jeremy H. , Trankiem Christine T. , Yoon JaeHee Jane , Blank Jacqueline , Hazelton Joshua , McLaughlin Christopher J. , Al-Aref Rami , Kirsch Jordan M. , Howard Daniel S. , Scantling Dane R. , Dellonte Kate , Vella Michael , Hopkins Brent , Shell Chloe H. , Udekwu Pascal O. , Wong Evan G. , Joseph Bellal A. , Lieberman Howard , Ramsey Walter , Stewart Collin , Alvarez Claudia , Berne John D. , Nahmias Jeffry , Puente Ivan , Patton Joe H. , Rakitin Ilya , Perea Lindsey L. , Pulido Odessa R. , Ahmed Hashim , Keating Jane , Kodadek Lisa M. , Wade Jason , Henry Reynold , Schreiber Martin A. , Benjamin Andrew J. , Khan Abid , Mann Laura K. , Mentzer Caleb J. , Mousafeiris Vasileios , Mulita Francesk , Reid-Gruner Shari , Sais Erica , Marks Joshua , Foote Christopher , Palacio Carlos H. , Argandykov Dias , Kaafarani Haytham , Coyle Susette , Macor Marie , Manderski Michelle T. Bover , Narayan Mayur , Seamon Mark J. 
Published: April 2023

BACKGROUND
Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur.

METHODS
A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy).

RESULTS
The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA.

CONCLUSION
Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible.

LEVEL OF EVIDENCE
Therapeutic/Care Management; Level IV.