Incidence and Management of Duodenal Trauma in a War Setting: Insights from a Military Hospital in Yemen

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This study evaluated the outcomes of duodenal injury management among patients with war trauma in Yemen, focusing on incidence, severity, surgical approaches, postoperative complications, and factors influencing success or failure. Patients and Methods: A retrospective analysis was conducted on 520 exploratory laparotomy cases from June 2019 to December 2022 at a military hospital in Yemen. Twenty-seven patients with confirmed duodenal injuries were included. Data on demographic characteristics, injury characteristics, surgical management, and outcomes were collected and analyzed. Results: The incidence rate of duodenal injuries was 5.2%. The cohort comprised predominantly young males, with a mean age of 21.93 years. Penetrating trauma accounted for 95.7% of cases. The mean Injury Severity Score (ISS) was 20.63, and most injuries were classified as AAST Grade II. The second duodenum part (D2) was the most commonly affected area. Associated injuries were frequent, particularly colonic (73.9%), chest (39.1%), and liver (29.6%) injuries. Surgical management primarily involved exploratory laparotomy (81.5%) and primary closure (66.7%). Postoperative complications were common, affecting 66.7% of patients, with sepsis (55.6%) being the most common. The success and mortality rates were 81.5%, and the mortality rate was 11.1%. Key risk factors for poor outcomes included higher ISS, grade III injury, damage control surgery, and shrapnel injury. Conclusion: Duodenal injuries in war trauma settings pose significant management challenges, with high rates of associated injuries and postoperative complications. Early diagnosis, appropriate surgical techniques, and vigilant postoperative care is crucial for improved outcomes. Further multicenter research is needed to validate these findings and enhance management strategies in diverse settings. Surgery Gastrointestinal Surgery Duodenal injuries war trauma exploratory laparotomy Injury Severity Score postoperative complications Yemen Introduction Duodenal injuries are a significant concern in war trauma because of their complexity and potential for devastating complications [ 1 , 2 ]. Managing such injuries poses a unique challenge to trauma surgeons, especially in military operations where the nature and severity of injuries can be complex and varied. The overall incidence of duodenal injuries in severely injured trauma patients ranges from 0.2–0.6%, and the overall prevalence in those suffering from abdominal trauma ranges from 3–5%1,2 [ 3 , 4 ]. Approximately 80% of these cases are secondary to penetrating trauma, which is commonly associated with vascular and adjacent organ injuries [ 5 – 7 ]. A historical analysis of duodenal trauma during major armed conflicts of the 20th century found a decline in deaths associated with duodenal trauma, from 80% during World War I to 41% during the Vietnam War [ 8 ]. This decline can be attributed to advancements in medical care and treatment strategies. Despite these advancements, duodenal injuries remain rare, and they have the potential for devastating complications. Literature indicates that these injuries occur in approximately 4.3% of all abdominal injuries, with penetrating trauma being the most common mechanism of injury [ 9 ]. The rarity and complexity of these injuries pose a significant challenge for trauma surgeons in war settings. The management of duodenal injuries in war trauma is complex, requiring optimal control of hemorrhage and contamination, potential associated injuries to nearby structures, and complex reconstruction options for higher-grade injuries [ 10 ]. Management is further complicated by limited specialized resources and the need for rapid decision-making [ 11 ]. These injuries pose significant challenges for early diagnosis and appropriate management. Consequently, the best surgical treatment algorithm remains controversial [ 12 – 14 ]. Mild to moderate duodenal trauma is typically managed via primary repair and simple surgical techniques. However, severe injuries require complex surgical techniques, such as duodenal diverticulization, pyloric exclusion with or without gastrojejunostomy, and pancreatoduodenectomy, often without significantly favorable outcomes and increased mortality rates [ 15 , 16 ] Postoperative complications are a significant concern in the management of duodenal injuries. The mortality rate ranges from 9.3–24%, with morbidity rates reaching up to 60% [ 13 , 17 – 23 ]. Complications such as fistulas and infections are common postoperative concerns [ 6 , 16 ]. Despite advancements in surgical techniques and critical care management, the outcomes of duodenal injury management in war trauma patients remain suboptimal. Additionally, there is limited literature on the management of duodenal injuries in war trauma patients. Most studies have focused on general abdominal trauma without a specific emphasis on duodenal injuries. Furthermore, the unique challenges posed by the war environment, such as limited resources, delayed access to definitive care, and complex injury patterns, are not well documented. In Yemen, ongoing conflict has resulted in a high incidence of war-related trauma, including duodenal injuries [ 24 ]. However, there is a paucity of data specifically addressing the management and outcomes of these injuries in such settings. This study aimed to fill this gap by providing a comprehensive analysis of duodenal injury management in patients with war trauma treated at a military hospital in Sana’a, Yemen. The novelty of this study lies in its focus on the specific challenges and outcomes associated with duodenal injuries in a war setting, which has not been extensively studied in the existing literature. By understanding the specific factors contributing to successful or unsuccessful outcomes, our findings can inform the development of evidence-based guidelines and enhance the care of vulnerable patients. Materials and methods Study Design and Setting This retrospective observational study was conducted at a military hospital in Yemen. The study period was from June 2019 to December 2022. The hospital serves as the primary treatment center for trauma cases, particularly those arising from conflict-related injuries. Study Population The study included patients who underwent exploratory laparotomy due to abdominal trauma and were subsequently diagnosed with duodenal injuries. A total of 520 exploratory laparotomy cases were reviewed, out of which 27 patients with confirmed duodenal injuries were included in the study. Inclusion and Exclusion Criteria Inclusion Criteria : Patients who underwent exploratory laparotomy for abdominal trauma. Patients were diagnosed with duodenal injuries during laparotomy. Exclusion Criteria : Patients who did not undergo exploratory laparotomy. Patients without confirmed duodenal injuries. Data Collection Data were retrospectively collected from hospital records, including patient demographics, injury characteristics, surgical management details, and outcomes. The following variables were recorded: Demographics : Age, gender. Injury Characteristics : Mechanism of injury (penetrating or blunt), Injury Severity Score (ISS), anatomical location of duodenal injury, associated injuries. Surgical Management : Time from injury to operation, type of surgical approach (exploratory laparotomy or damage control surgery), primary surgical management technique (primary closure, Roux-en-Y duodenojejunostomy, primary repair along with triple decompression). Outcomes : Postoperative complications (sepsis, chest-related complications, wound-related complications, fistula formation), length of hospital stay, duration of intensive care unit stay, mortality, and short-term success rate (absence of leaks or fistulas at 30 days postoperatively). Statistical Analysis Data were analyzed using IBM SPSS Statistics (v.25). Descriptive statistics were used to summarize patient demographics, injury characteristics, and outcomes. Continuous variables were expressed as mean ± standard deviation (SD) or median (interquartile range, IQR), as appropriate. Categorical variables are presented as frequencies and percentages. Comparative analyses were performed to identify factors associated with successful versus unsuccessful outcomes. Chi-square tests were used for categorical variables, and independent samples t-tests were used for continuous variables. A p-value of < 0.05 was considered statistically significant. Results A total of 520 exploratory laparotomy cases were reviewed during the study period from June 2019 to December 2022, out of which 27 patients with confirmed duodenal injuries were included in the analysis. Demographic and Injury Characteristics The study analyzed 520 exploratory laparotomy cases, identifying 27 patients with duodenal injuries. The cohort comprised predominantly young males, with a mean age of 21.93 years. A significant proportion of injuries were caused by gunshot wounds (44.4%) and explosive devices (25.9%). The mean Injury Severity Score (ISS) was 20.63, indicating moderate to severe injuries. Associated injuries were common, with colonic injuries being the most common (73.9%), followed by liver injuries (29.6%) and chest injuries (39.1%) (Table 1) . Duodenal Injury Characteristics and Management Out of 520 exploratory laparotomy cases, 27 had duodenal injuries, with an incidence rate of 5.2%. The second duodenum part (D2) was the most commonly affected area. According to the AAST scale, 96.3% of the injuries were Grade II (laceration without ductal injury) and 3.7% were Grade III (laceration with ductal injury).The mean time from injury to surgery was 7.33 hours. Surgical approaches included exploratory laparotomy (81.5%) and damage control surgery (18.5%). Primary surgical techniques included primary closure (66.7%), primary repair with triple decompression (29.6%), and Roux-en-Y duodenojejunostomy (3.7%) (Table 2). Postoperative Outcomes Postoperative complications were common, occurring in 66.7% of patients. The most common complications were sepsis (55.6%), chest-related complications (50.0%), and wound-related complications (27.8%). The short-term success rate, defined as the absence of leaks or fistulas at 30 days postoperatively, was 81.5%. The mortality rate was 11.1% (Table 3). Risk Factors Influencing Management Outcomes Key risk factors influencing management outcomes included the presence of shrapnel injuries, Injury Severity Score (ISS), grade of duodenal injury, and surgical approach. Shrapnel injuries were a significant predictor of unsuccessful outcomes, with 100% of the unsuccessful cases having shrapnel injuries (p=0.012). Higher ISS was associated with unsuccessful outcomes (p=0.05). Grade III injuries had a significantly higher rate of unsuccessful outcomes compared to Grade II (p=0.033). Damage control surgery was associated with higher rates of unsuccessful outcomes compared with exploratory laparotomy (p=0.008) (Table 4). Table 1 . Demographic and injury characteristics Discussion 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. Conclusion This study highlights the complexity of managing duodenal injuries in war trauma settings, with a high incidence of associated injuries and significant postoperative complications. Key factors influencing outcomes include injury severity, timely surgical intervention, and postoperative care. The findings emphasize the need for early diagnosis, appropriate surgical approaches, and vigilant postoperative care to improve patient outcomes. Future research should focus on prospective studies and multi-center analyses to validate these findings and enhance the generalizability of the results. Abbreviations AAST American Association for the Surgery of Trauma D2 second duodenum section D3 third duodenal section D4 fourth duodenal section DVT Deep Vein Thrombosis ICU Intensive Care Unit IQR Interquartile Range IRB Institutional Review Board ISS Injury Severity Score SD Standard Deviation Declarations Acknowledgments The authors thank the medical staff at the military hospital in Yemen for their support and assistance with data collection. We acknowledge the invaluable contributions of our colleagues who provided insights and expertise that greatly facilitated the research. Disclosure Ethics Approval and Participation This study was conducted in accordance with the ethical standards of the Institutional Review Board (IRB) of the military hospital in Yemen. Due to the retrospective nature of the study, informed consent was waived. However, patient confidentiality was maintained throughout data collection and analysis, and all patient identifiers were removed from the dataset. Consent to publish the report Not applicable. Availability of Data and Materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing Interests The authors declare that they have no conflicts of interest. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' Contributions Y.A.O conceived and designed the study, collected and analyzed the data, and wrote the manuscript. M.A.S contributed to the study design, data analysis, and manuscript revision. H.M.J participated in data collection and provided critical revisions of the manuscript. All authors have read and approved the final manuscript. References Pandey S, Niranjan A, Mishra S, Agrawal T, Singhal B, Prakash A, Attri P (2011) Retrospective analysis of duodenal injuries: A comprehensive overview. 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Arch Surg 115:422–429. 10.1001/ARCHSURG.1980.01380040050009 Tables Characteristic Frequency Percentage Age Mean Age (± SD) 21.93± 4.075 Median Age (IQR) 22(16-36) Age ≤18 years 5 18.5% Age 19-30 years 21 77.8% Age ≥31 years 1 3.7% Gender Male 26 96.3% Female 1 3.7% Comorbidities Smoking 7 25.9% Qat Chewing 24 88.9% Shama Using 7 25.9% Mechanism of Injury Gunshot Wound 12 44.4% Explosive Device 7 25.9% Shrapnel 7 25.9% Blunt Injury 1 3.7% ISS Score Minor (1-8) 2 7.4% Moderate (9-15) 6 22.2% Severe (16-24) 11 40.7% Very Severe (>25) 8 29.6% Mean ISS (± SD) 20.63± 8.531 Median ISS (IQR) 21(6-38) Associated Injuries Colonic Injury 17 73.9% Liver Injury 8 29.6% Chest Injury 9 39.1% Small Bowel Injury 6 26.1% Stomach Injury 3 13.0% Kidney Injury 4 17.4% Head Injury 3 13.0% Vascular Injury 2 7.4% Diaphragm Injury 2 8.7% Gallbladder injury 1 4.3% Pancreatic Injury 1 3.7% Ureteric Injury 1 4.3% Spleen Injury 1 3.7% Abbreviations: SD, standard deviation; IQR, interquartile range; ISS, Injury Severity Score. Table 2: Duodenal Injury Characteristic (n=27) Characteristic Frequency Percentage Anatomical Location D1–first part 6 22.2% D2–second part 12 44.4% D3: third part 5 18.5% D4–fourth part 4 14.8% Grade of Injury (AAST Scale) Grade II 26 96.3% Grade III 1 3.7% Surgical Approach Exploratory Laparotomy 22 81.5% Damage Control Surgery 5 18.5% Primary Surgical Technique Primary Closure 18 66.7% Primary Repair with Triple Decompression 8 29.6% Roux-en-Y Duodenojejunostomy 1 3.7% Time from Injury to Operation Mean Time (hours ± SD) 7.33± 3.606 Median Time (IQR) 7(4) Abbreviations: AAST, American Association for the Surgery of Trauma; SD, standard deviation; IQR, interquartile range. Table 3: Postoperative Complications and Outcomes Characteristic Frequency Percentage Postoperative Complications Sepsis 10 55.6% Chest-related Complications 9 50.0% Wound-related Complications 5 27.8% Fistula Formation 3 16.7% Infection 3 16.7% Reoperation 4 22.2% Bile Leak 2 11.2% DVT 2 11.2% DIC 1 5.6% 30-day postoperative outcomes Success Rate 22 81.5% Mortality Rate 3 11.1% Time from enteral feeding to feeding Mean Time (days ± SD) 5.89 ± 2.778 Median Time (IQR) 5(2) Length of Hospital Stay Mean Length (days ± SD) 26.52 ± 23.037 Median Length (IQR) 24(28) Duration of ICU Stay Mean Duration (days ± SD) 6.74 ± 3.415 Median Duration (IQR) 5(2) Abbreviations: SD, standard deviation; IQR, interquartile range; DVT, deep vein thrombosis; DIC, disseminated intravascular coagulation. Table 4 : Significant Risk Factors Influencing Management Outcomes Risk Factor Successful (n=22) Unsuccessful (n=5) p-value Shrapnel Injury 0 (0.0%) 5 (100.0%) 0.012* ISS (Mean ± SD) 19.14 ± 7.803 27.20 ± 9.338 0.05* Grade of Duodenal Injury 0.033* Grade II 22 (84.6%) 4 (15.4%) Grade III 0 (0.0%) 1 (100.0%) Surgical Approach 0.008* Exploratory Laparotomy 20 (90.9%) 2 (9.1%) Damage Control Surgery 2 (40.0%) 3 (60.0%) Notes:* Chi-square tests were used to determine statistical significance for categorical variables. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4814801","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":332646217,"identity":"8932ac04-1944-4bdd-b291-12afd1ab68c2","order_by":0,"name":"Yasser Abdurabo Obadiel","email":"","orcid":"","institution":"Department of Surgery, Faculty of Medicine and Health Science, Sana’a University, Sana’a City, Yemen","correspondingAuthor":false,"prefix":"","firstName":"Yasser","middleName":"Abdurabo","lastName":"Obadiel","suffix":""},{"id":332646218,"identity":"df4e0dec-7d15-4268-afb7-10c583f594f8","order_by":1,"name":"Mohammed abdulkarem Saeed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIiWNgGAWjYBACgwM8IIqZgQ9ISiRUSMiBuAce4NFiCdPCBtZyxsYYrCUBjxZ7FC2MbWmJDSA+Pi1mx3sPfrpRYS3Pxp788MbDtsPp88MOPwTaYien24BDy5lzydI5Z9IN23ieGVsknDucu/F2mgFQS7Kx2QEcWm7kGEjnth1mbJNIMJNIKANqmZ0A0nIgcRsOLQY3cox/5/47bN8mkf5NIoHtcLrh7PQPhLSYSec2HE5sk8gB2tKWliAvnUPAljNnzKxzjqUnt/G8KbYABrLhBumcggMJBrj9YnC8x/h2To21bT97+sabPyok5OVnp2/+8KHCTg6XFiSQADUErNKAoHIkLfINRKkeBaNgFIyCEQQAL4xpifc/OiMAAAAASUVORK5CYII=","orcid":"","institution":"Department of Surgery, Military General Hospital, Sana’a, Yemen","correspondingAuthor":true,"prefix":"","firstName":"Mohammed","middleName":"abdulkarem","lastName":"Saeed","suffix":""},{"id":332646219,"identity":"3beefbca-aa89-4a6e-b1a4-de733070e78c","order_by":2,"name":"Haitham Mohammed Jowah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACAwaGBCB1QA7M4yFFizFJWkDgQGID0VrMGRgePuapuZM+f0YC44O3bQyJ/YS0WDYwJBvzHHuWu+FGArPhXKCWmQ2EHHaAIU06h+1w7gaJBDZpXqCWDQeI0vLvcLr8jAT23yAt+4nSktt2OIHhRgIbM9gWQn4xOAz0y9++w4YbzjxslpxzTsJ4BkFbjvckPpzx7bC8fHvywQ9vymxk+xsIWcPMkwBlMYLUSjgS1MHAwI7qEHvCOkbBKBgFo2CkAQCEAUMIrb03fgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0008-3815-3017","institution":"Department of Surgery, Faculty of Medicine and Health Sciences, Sana’a University, Sana’a, Yemen","correspondingAuthor":true,"prefix":"","firstName":"Haitham","middleName":"Mohammed","lastName":"Jowah","suffix":""},{"id":332646220,"identity":"d873bb27-d6f5-429a-b48f-dd0545fd799d","order_by":3,"name":"Ali Al-Brashi","email":"","orcid":"","institution":"Department of Surgery, Military General Hospital, Sana’a, Yemen","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Al-Brashi","suffix":""}],"badges":[],"createdAt":"2024-07-28 02:16:49","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4814801/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4814801/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61455813,"identity":"8d3ba684-cf4e-4b89-bbd8-2bda3add03b1","added_by":"auto","created_at":"2024-07-31 03:26:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":784350,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4814801/v1/70fa1dbe-44c4-4fa4-9081-37f40f9e64e3.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eIncidence and Management of Duodenal Trauma in a War Setting: Insights from a Military Hospital in Yemen\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDuodenal injuries are a significant concern in war trauma because of their complexity and potential for devastating complications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Managing such injuries poses a unique challenge to trauma surgeons, especially in military operations where the nature and severity of injuries can be complex and varied. The overall incidence of duodenal injuries in severely injured trauma patients ranges from 0.2\u0026ndash;0.6%, and the overall prevalence in those suffering from abdominal trauma ranges from 3\u0026ndash;5%1,2 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Approximately 80% of these cases are secondary to penetrating trauma, which is commonly associated with vascular and adjacent organ injuries [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA historical analysis of duodenal trauma during major armed conflicts of the 20th century found a decline in deaths associated with duodenal trauma, from 80% during World War I to 41% during the Vietnam War [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This decline can be attributed to advancements in medical care and treatment strategies. Despite these advancements, duodenal injuries remain rare, and they have the potential for devastating complications. Literature indicates that these injuries occur in approximately 4.3% of all abdominal injuries, with penetrating trauma being the most common mechanism of injury [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The rarity and complexity of these injuries pose a significant challenge for trauma surgeons in war settings.\u003c/p\u003e \u003cp\u003eThe management of duodenal injuries in war trauma is complex, requiring optimal control of hemorrhage and contamination, potential associated injuries to nearby structures, and complex reconstruction options for higher-grade injuries [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Management is further complicated by limited specialized resources and the need for rapid decision-making [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These injuries pose significant challenges for early diagnosis and appropriate management. Consequently, the best surgical treatment algorithm remains controversial [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Mild to moderate duodenal trauma is typically managed via primary repair and simple surgical techniques. However, severe injuries require complex surgical techniques, such as duodenal diverticulization, pyloric exclusion with or without gastrojejunostomy, and pancreatoduodenectomy, often without significantly favorable outcomes and increased mortality rates [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePostoperative complications are a significant concern in the management of duodenal injuries. The mortality rate ranges from 9.3\u0026ndash;24%, with morbidity rates reaching up to 60% [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Complications such as fistulas and infections are common postoperative concerns [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Despite advancements in surgical techniques and critical care management, the outcomes of duodenal injury management in war trauma patients remain suboptimal. Additionally, there is limited literature on the management of duodenal injuries in war trauma patients. Most studies have focused on general abdominal trauma without a specific emphasis on duodenal injuries. Furthermore, the unique challenges posed by the war environment, such as limited resources, delayed access to definitive care, and complex injury patterns, are not well documented.\u003c/p\u003e \u003cp\u003eIn Yemen, ongoing conflict has resulted in a high incidence of war-related trauma, including duodenal injuries [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, there is a paucity of data specifically addressing the management and outcomes of these injuries in such settings. This study aimed to fill this gap by providing a comprehensive analysis of duodenal injury management in patients with war trauma treated at a military hospital in Sana\u0026rsquo;a, Yemen. The novelty of this study lies in its focus on the specific challenges and outcomes associated with duodenal injuries in a war setting, which has not been extensively studied in the existing literature. By understanding the specific factors contributing to successful or unsuccessful outcomes, our findings can inform the development of evidence-based guidelines and enhance the care of vulnerable patients.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis retrospective observational study was conducted at a military hospital in Yemen. The study period was from June 2019 to December 2022. The hospital serves as the primary treatment center for trauma cases, particularly those arising from conflict-related injuries.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eThe study included patients who underwent exploratory laparotomy due to abdominal trauma and were subsequently diagnosed with duodenal injuries. A total of 520 exploratory laparotomy cases were reviewed, out of which 27 patients with confirmed duodenal injuries were included in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003e \u003cb\u003eInclusion Criteria\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatients who underwent exploratory laparotomy for abdominal trauma.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatients were diagnosed with duodenal injuries during laparotomy.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eExclusion Criteria\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatients who did not undergo exploratory laparotomy.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatients without confirmed duodenal injuries.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eData were retrospectively collected from hospital records, including patient demographics, injury characteristics, surgical management details, and outcomes. The following variables were recorded:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDemographics\u003c/b\u003e: Age, gender.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInjury Characteristics\u003c/b\u003e: Mechanism of injury (penetrating or blunt), Injury Severity Score (ISS), anatomical location of duodenal injury, associated injuries.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSurgical Management\u003c/b\u003e: Time from injury to operation, type of surgical approach (exploratory laparotomy or damage control surgery), primary surgical management technique (primary closure, Roux-en-Y duodenojejunostomy, primary repair along with triple decompression).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eOutcomes\u003c/b\u003e: Postoperative complications (sepsis, chest-related complications, wound-related complications, fistula formation), length of hospital stay, duration of intensive care unit stay, mortality, and short-term success rate (absence of leaks or fistulas at 30 days postoperatively).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using IBM SPSS Statistics (v.25). Descriptive statistics were used to summarize patient demographics, injury characteristics, and outcomes. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median (interquartile range, IQR), as appropriate. Categorical variables are presented as frequencies and percentages. Comparative analyses were performed to identify factors associated with successful versus unsuccessful outcomes. Chi-square tests were used for categorical variables, and independent samples t-tests were used for continuous variables. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 520 exploratory laparotomy cases were reviewed during the study period from June 2019 to December 2022, out of which 27 patients with confirmed duodenal injuries were included in the analysis.\u003c/p\u003e\n\u003ch2\u003eDemographic and Injury Characteristics\u003c/h2\u003e\n\u003cp\u003eThe study analyzed 520 exploratory laparotomy cases, identifying 27 patients with duodenal injuries. The cohort comprised predominantly young males, with a mean age of 21.93 years. A significant proportion of injuries were caused by gunshot wounds (44.4%) and explosive devices (25.9%). The mean Injury Severity Score (ISS) was 20.63, indicating moderate to severe injuries. Associated injuries were common, with colonic injuries being the most common (73.9%), followed by liver injuries (29.6%) and chest injuries (39.1%) (Table 1) .\u003c/p\u003e\n\u003ch2\u003eDuodenal Injury Characteristics and Management\u003c/h2\u003e\n\u003cp\u003eOut of 520 exploratory laparotomy cases, 27 had duodenal injuries, with an incidence rate of 5.2%. The second duodenum part (D2) was the most commonly affected area. According to the AAST scale, 96.3% of the injuries were Grade II (laceration without ductal injury) and 3.7% were Grade III (laceration with ductal injury).The mean time from injury to surgery was 7.33 hours. Surgical approaches included exploratory laparotomy (81.5%) and damage control surgery (18.5%). Primary surgical techniques included primary closure (66.7%), primary repair with triple decompression (29.6%), and Roux-en-Y duodenojejunostomy (3.7%) (Table 2).\u003c/p\u003e\n\u003ch2\u003ePostoperative Outcomes\u003c/h2\u003e\n\u003cp\u003ePostoperative complications were common, occurring in 66.7% of patients. The most common complications were sepsis (55.6%), chest-related complications (50.0%), and wound-related complications (27.8%). The short-term success rate, defined as the absence of leaks or fistulas at 30 days postoperatively, was 81.5%. The mortality rate was 11.1% (Table 3).\u003c/p\u003e\n\u003ch2\u003eRisk Factors Influencing Management Outcomes\u003c/h2\u003e\n\u003cp\u003eKey risk factors influencing management outcomes included the presence of shrapnel injuries, Injury Severity Score (ISS), grade of duodenal injury, and surgical approach. Shrapnel injuries were a significant predictor of unsuccessful outcomes, with 100% of the unsuccessful cases having shrapnel injuries (p=0.012). Higher ISS was associated with unsuccessful outcomes (p=0.05). Grade III injuries had a significantly higher rate of unsuccessful outcomes compared to Grade II (p=0.033). Damage control surgery was associated with higher rates of unsuccessful outcomes compared with exploratory laparotomy (p=0.008) (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. Demographic and injury characteristics\u003c/p\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eThis 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.\u003c/p\u003e\n\u003cp\u003eThe 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\u0026nbsp;[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\u0026nbsp;[6,26], highlights the significant impact of conflict and violence on trauma cases in our setting.\u003c/p\u003e\n\u003cp\u003eOur 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\u0026nbsp;[27]. This demographic profile is typical in conflict zones, where young men are more likely to be involved in violent encounters.\u003c/p\u003e\n\u003cp\u003eThe 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\u0026nbsp;[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.\u003c/p\u003e\n\u003cp\u003eAssociated 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.\u003c/p\u003e\n\u003cp\u003ePostoperative 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.\u003c/p\u003e\n\u003cp\u003eSeveral 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.\u003c/p\u003e\n\u003cp\u003eMortality 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.\u003c/p\u003e\n\u003cp\u003eOur 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.\u003c/p\u003e\n\u003cp\u003eDespite 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.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the complexity of managing duodenal injuries in war trauma settings, with a high incidence of associated injuries and significant postoperative complications. Key factors influencing outcomes include injury severity, timely surgical intervention, and postoperative care. The findings emphasize the need for early diagnosis, appropriate surgical approaches, and vigilant postoperative care to improve patient outcomes. Future research should focus on prospective studies and multi-center analyses to validate these findings and enhance the generalizability of the results.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAAST\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Association for the Surgery of Trauma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eD2\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esecond duodenum section\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eD3\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ethird duodenal section\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eD4\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efourth duodenal section\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDVT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDeep Vein Thrombosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eICU\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIQR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterquartile Range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIRB\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstitutional Review Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eISS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInjury Severity Score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eThe authors thank the medical staff at the military hospital in Yemen for their support and assistance with data collection. We acknowledge the invaluable contributions of our colleagues who provided insights and expertise that greatly facilitated the research.\u003c/p\u003e\n\u003ch2\u003eDisclosure\u003c/h2\u003e\n\u003ch2\u003eEthics Approval and Participation\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical standards of the Institutional Review Board (IRB) of the military hospital in Yemen. Due to the retrospective nature of the study, informed consent was waived. However, patient confidentiality was maintained throughout data collection and analysis, and all patient identifiers were removed from the dataset.\u003c/p\u003e\n\u003ch2\u003eConsent to publish the report\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAvailability of Data and Materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting Interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; Contributions\u003c/h2\u003e\n\u003cp\u003eY.A.O conceived and designed the study, collected and analyzed the data, and wrote the manuscript. M.A.S contributed to the study design, data analysis, and manuscript revision. H.M.J participated in data collection and provided critical revisions of the manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePandey S, Niranjan A, Mishra S, Agrawal T, Singhal B, Prakash A, Attri P (2011) Retrospective analysis of duodenal injuries: A comprehensive overview. Saudi J Gastroenterol 17:142. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/1319-3767.77247\u003c/span\u003e\u003cspan address=\"10.4103/1319-3767.77247\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVelez DR, Hustad L, Aaland MO, Maki CJ, Zreik K (2020) Duodenal Injury in the Dakotas: A 15-year review of duodenal injury in Level II trauma centers of North and South Dakota. 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Arch Surg 115:422. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/archsurg.1980.0138004005000910.1001/archsurg.1980.01380040050009\u003c/span\u003e\u003cspan address=\"10.1001/archsurg.1980.0138004005000910.1001/archsurg.1980.01380040050009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVelmahos GC, Kamel E, Chan LS et al (1999) Complex repair for managing duodenal injuries. Am Surg 65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/000313489906501016\u003c/span\u003e\u003cspan address=\"10.1177/000313489906501016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIvatury RR, Nallathambi M, Gaudino J, Rohman M, Stahl WM (1985) Penetrating duodenal injuries. Analysis of 100 consecutive cases. Ann Surg 202:153\u0026ndash;158. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00000658-198508000-00003\u003c/span\u003e\u003cspan address=\"10.1097/00000658-198508000-00003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSnyder WH, Weigelt JA, Watkins WL, Bietz DS (1980) Surgical management of duodenal trauma: concepts based on a Review of 247 Cases. Arch Surg 115:422\u0026ndash;429. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/ARCHSURG.1980.01380040050009\u003c/span\u003e\u003cspan address=\"10.1001/ARCHSURG.1980.01380040050009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean Age (\u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.93\u0026plusmn; 4.075\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedian Age (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22(16-36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge \u0026le;18 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge 19-30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e77.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge \u0026ge;31 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e96.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQat Chewing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShama Using\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMechanism of Injury\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGunshot Wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExplosive Device\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShrapnel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBlunt Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eISS Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMinor (1-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate (9-15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSevere (16-24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVery Severe (\u0026gt;25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean ISS (\u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.63\u0026plusmn; 8.531\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedian ISS (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21(6-38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssociated Injuries\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eColonic Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLiver Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChest Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSmall Bowel Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStomach Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKidney Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHead Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVascular Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiaphragm Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGallbladder injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePancreatic Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUreteric Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSpleen Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAbbreviations:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;SD, standard deviation; IQR, interquartile range; ISS, Injury Severity Score.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Duodenal Injury Characteristic (n=27)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnatomical Location\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD1\u0026ndash;first part\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD2\u0026ndash;second part\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD3: third part\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD4\u0026ndash;fourth part\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade of Injury (AAST Scale)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrade II\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e96.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrade III\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical Approach\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExploratory Laparotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDamage Control Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Surgical Technique\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary Closure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary Repair with Triple Decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRoux-en-Y Duodenojejunostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime from Injury to Operation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean Time (hours \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.33\u0026plusmn; 3.606\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedian Time (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7(4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: AAST, American Association for the Surgery of Trauma; SD, standard deviation; IQR, interquartile range.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Postoperative Complications and Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSepsis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChest-related Complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWound-related Complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFistula Formation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBile Leak\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDVT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDIC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e30-day postoperative outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuccess Rate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality Rate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime from enteral feeding to feeding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean Time (days \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.89 \u0026plusmn; 2.778\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedian Time (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of Hospital Stay\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean Length (days \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26.52 \u0026plusmn; 23.037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedian Length (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24(28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of ICU Stay\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean Duration (days \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.74 \u0026plusmn; 3.415\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedian Duration (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAbbreviations:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;SD, standard deviation; IQR, interquartile range; DVT, deep vein thrombosis; DIC, disseminated intravascular coagulation.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e4\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e: Significant Risk Factors Influencing Management Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk Factor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuccessful\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=22)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnsuccessful\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eShrapnel Injury\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.012*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eISS (Mean \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.14 \u0026plusmn; 7.803\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27.20 \u0026plusmn; 9.338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.05*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade of Duodenal Injury\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.033*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrade II\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (84.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrade III\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical Approach\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.008*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExploratory Laparotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 (90.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDamage Control Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNotes:* Chi-square tests were used to determine statistical significance for categorical variables.\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Sana'a University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Duodenal injuries, war trauma, exploratory laparotomy, Injury Severity Score, postoperative complications, Yemen","lastPublishedDoi":"10.21203/rs.3.rs-4814801/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4814801/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eDuodenal injuries are a significant challenge in war trauma because of their complexity and potential for severe complications. This study evaluated the outcomes of duodenal injury management among patients with war trauma in Yemen, focusing on incidence, severity, surgical approaches, postoperative complications, and factors influencing success or failure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Methods: \u003c/strong\u003eA retrospective analysis was conducted on 520 exploratory laparotomy cases from June 2019 to December 2022 at a military hospital in Yemen. Twenty-seven patients with confirmed duodenal injuries were included. Data on demographic characteristics, injury characteristics, surgical management, and outcomes were collected and analyzed.\u003c/p\u003e\n\u003cp\u003eResults: The incidence rate of duodenal injuries was 5.2%. The cohort comprised predominantly young males, with a mean age of 21.93 years. Penetrating trauma accounted for 95.7% of cases. The mean Injury Severity Score (ISS) was 20.63, and most injuries were classified as AAST Grade II. The second duodenum part (D2) was the most commonly affected area. Associated injuries were frequent, particularly colonic (73.9%), chest (39.1%), and liver (29.6%) injuries. Surgical management primarily involved exploratory laparotomy (81.5%) and primary closure (66.7%). Postoperative complications were common, affecting 66.7% of patients, with sepsis (55.6%) being the most common. The success and mortality rates were 81.5%, and the mortality rate was 11.1%. Key risk factors for poor outcomes included higher ISS, grade III injury, damage control surgery, and shrapnel injury.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eDuodenal injuries in war trauma settings pose significant management challenges, with high rates of associated injuries and postoperative complications. Early diagnosis, appropriate surgical techniques, and vigilant postoperative care is crucial for improved outcomes. Further multicenter research is needed to validate these findings and enhance management strategies in diverse settings.\u003c/p\u003e","manuscriptTitle":"Incidence and Management of Duodenal Trauma in a War Setting: Insights from a Military Hospital in Yemen","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-31 03:18:17","doi":"10.21203/rs.3.rs-4814801/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"05b1dc45-21cd-4e82-9c5d-7a0ba1efc3b1","owner":[],"postedDate":"July 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":35221777,"name":"Surgery"},{"id":35221778,"name":"Gastrointestinal Surgery"}],"tags":[],"updatedAt":"2024-07-31T03:18:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-31 03:18:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4814801","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4814801","identity":"rs-4814801","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}