Pdf a simple technique of decompressing the duodenum following difficult gastrectomies is. The approach allows completion of subtotal gastrectomy or hemigastrectomy and vagotomy for duodenal ulcer without. After a subtotal gastrectomy with a concomitant resection to the whole first part of the duodenum, an ultralow duodenal stump is difficult to close. In this method of duodenal stump closure, the stomach is transected proximal to the pylorus, where tissue is less fibrotic.
Management of the difficult duodenal stump the american journal. Cancer of the gastric stump after partial gastrectomy. End duodenostomy placement of tube through suture line closing duodenum effort to create controlled duodenal fistula. Difficult closures of the duodenal stump jama surgery. Introduction the epitome of an organ poorly designed to withstand the ravages of trauma. Management of the difficult duodenal stump in penetrating duodenal ulcer disease. Distal gastrectomy with b1, b2 anastomsis or free download as powerpoint presentation. Case presentation we report the case of a 69yearold caucasian man who developed duodenal stump obstruction due to an impacted gallstone after having previously undergone rouxeny gastrectomy.
The optimal treatment for adf consists of removal of the infected graft with in situ or extraanatomical repair and is associated with high mortality. An effective surgical treatment for repeatedly leaking. It occurs as a complication of billroth ii gastrectomy, usually on the fourth or fifth day after surgery. To avoid retained antrum syndrome, it is advisable histologically to verify the presence of duodenal brunner glands at the distal margin of resection by frozen section after antrectomy, particularly if scarring or active inflammation makes clear identification of the pylorus difficult.
The ultra low duodenal stump and its difficult management. A decision was made to use a transverse colon as a jump graft. It was anastomosed proximally to the esophagus and distally to the. Management of duodenal stump fistula after gastrectomy for. A 67yearold man who did not have any other combined medical illnesses underwent a distal gastrectomy with biloth ii anastomosis for gastric cancer. A comparative analysis of duodenojejunostomy with classical stump closure nissenbsteh. A safe and effective technical solution is proposed, based on. Us national library of medicine national institute of health.
What are some of the techniques that you can use when responding to the question of how to close a difficult duodenal stump. Classical technique of closing a difficult duodenal stump nissenbsteh has, up to now, not been compared with duodenojejunostomy dj in larger patient sets. However, when there is intense scarring or active ulceration with marked edema and inflammation, the closure and management of this difficult duodenum is of importance. We have developed a more tolerable and simpler technique for this dissection that allows any surgeon who has the skills to perform a gastric bypass to perform this dissection easily. Duodenal ulcer perforations are a common surgical emergency, but literature is silent on the exact definition, incidence, management and complications of large perforations of duodenal ulcers. Expectant management of perforated duodenal ulcer kings county hospital sylvia s. Modified bancroft procedure for the difficult duodenal stump.
A safer and simpler technique of duodenal dissection and. Conclusions duodenal stump obstruction after rouxeny gastrectomy is rare, and may be difficult to manage. Primary closure of the duodenal stump following gastric resection for peptic ulcer disease usually poses no problem. Distal gastrectomy with b1, b2 anastomsis or stomach. The duodenal stump is preserved in the bilroth ii to allow continued flow of bile. Some authors have extrapolated the concept of damage control for gdps, especially the large or giant subtypes and in reoperations after leakage. Management of the difficult duodenal stump in penetrating. Duodenal stump closure carries a leak rate of % and a mortality rate of 02% in recent series.
Schein states that the best way to avoid a difficult duodenal stump and its potentially lethal complications is not to create a stump at all. Early rupture of an ultralow duodenal stump after extended. Case report a possible variant of bouveret s syndrome. Leakage from the duodenal stump has been the most feared complication of the billroth ii reconstruction following gastric resection. It is due to improper closure of duodenal stump, especially when the. Leakage of the duodenal or antral stump complicating gastric resection. Outcomes of nonoperative treatment for duodenal stump. The management of large perforations of duodenal ulcers. The gastric mucosa in the duodenal stump is then dissected away from the submucosa into the duodenum. Safe answers section 4 gastric and duodenum flashcards. Another way of dealing with a difficult duodenal stump is to perform a bancroft closure. Duodenal stump obstruction after rouxeny gastrectomy is rare, and may be difficult to manage. Duodenal stump leakage after gastrectomy is one of serious complications related to severe morbidity or mortality. An aortoduodenal fistula adf is an unusual, but serious complication following surgical or endovascular aortic repair.
Endovascular treatment of aortic stump blowout after. Get a printable copy pdf file of the complete article. A possible variant of bouverets syndrome presenting as a. Difficult closures of the duodenal stump jama network. Duodenal stump leak anastomotic leak afferent loop obstruction gacsrti ouelt t. Leakage from the duodenal stump has been the most feared complication of the bilhoth ii recon struction following gastric resection. One closed drain was positioned at the duodenal stump area through the right upper abdominal wall. This study was designed to evaluate the effectiveness of laparoscopic single pursestring suture for reinforcement of duodenal stump. Department of general surgery, zhongshan hospital, fudan university, shanghai, china. Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. It involves the resection of at least twothirds of the stomach with a d2 lymph node dissection.
Duodenal injuries are uncommon duodenal injuries are both difficult to diagnose and repair due to its retroperitoneal location mortality is high in duodenal injuries 3. Pdf a technique to prevent duodenal blowout after difficult. The value of duodenal tube decompression for postgastrectomy management of the duodenal stump was demonstrated for the first time in 1954. This may not be the complete list of references from this article.
This also refers to the potential benefit of a gastric and biliary diversion under such conditions. Duodenal decompression is also recommended for the protection of the duodenal stump after gastrectomy for malignancy. Duodenal stump leakage dsl is a serious surgical complication after radical gastrectomy with rouxeny or billrothii reconstruction. We report the case of a 69yearold caucasian man who developed duodenal stump obstruction due to an impacted gallstone after having previously undergone rouxeny gastrectomy. Standard gastrectomy is the main surgical procedure performed with curative intent for gastric cancer. Difficult duodenal injuries remain a challenge to any general.
Case summary duodenal stump blowout is a feared complication of billroth ii reconstruction after gastrectomy. Here, we report a highly unusual case of a delayed duodenal stump perforation secondary to a golfball. The reconstructions after total or distal gastrectomy imply the formation of a duodenal stump with the exception of the billroth i gastroduodenostomy. Management of the difficult duodenal stump sciencedirect. The duodenal stump is then anastomosed to the pancreatic capsule or duodenal wall left in place on the pancreatic capsule. One common reasons that many surgeons do not perform a duodenal switch ds is lack of experience with the dissection over the head of the pancreas 1. Part of this mortality is caused by rebleeding or aortic stump ruptures. Russell martin, md, houston, texas leakage from the duodenal stump has been the most feared complication of the biuroth ii recon struction following gastric resection. Laparoscopic reinforcement suture of duodenal stump using. The purpose of our study was to evaluate four methods of duodenal stump closure in 200 patients. Over the years, tube duodenostomy has proven to be a safe and effective technique in the management of the difficult duodenal injury 12. A vertical incision through the anterior wall of the antral cuff and pyloric ring permits a useful modification of the bancroft procedure for management of the difficult duodenal stump.
Single pursestring suture for reinforcement of duodenal. Most commonly presenting in the early postoperative period, there is significant variation in the surgical management of the difficult duodenal stump due to complexity. The use of the double rouxeny conversion, consisting of an anastomosis of the tensionfree small bowel mucosa with appropriate blood supply to the duodenal stump, and jejunoduodenal antegrade drainage is a useful alternative for the treatment of the challenging duodenal stump blow out and the more complex repeatedly leaking duodenal stumps. Stump blowout, or duodenal blowout, is the leakage of the blind end of the duodenum. When dealing with gastric cancer with duodenal invasion, gastrectomy with distal resection of the duodenum is necessary to achieve negative distal margin. Classical technique of closing a difficult duodenal stump nissenbsteh has, up to now, not been compared with duodenojejunostomy dj in. However, definite surgical method for duodenal stump leakage is not established. Although most staplers would produce at least two or three rows of staples, burying this line with a second layer using monofilament sutures placed. The most successful method of managing the difficult duodenum, including the stump leakage, has been the tube duodenostomy technique, but it has not gained wide acceptance and is rarely used. The open end of the duodenum is then gently secured in. While lateral ttube catheter drainage of the duodenal stump has been described and used with success, contemporary approaches to tube duodenostomy typically involve introduction of a foley, pezzer, or straight catheter via the stump of the duodenum to approximately 5 cm see fig. This also refers to the potential benefit of a gastric and biliary diversion under. The causes of duodenal stump blow out include ischemia. This is secured with a pursestring suture, and the seromuscular layer is closed over the stump.
Lateral duodenostomy placement of tube through lateral of 2nd portion of duodenum. However, given that most of the studies have a small number of cases, it is difficult to establish possible risk factors. Duodenal stump blowout 1%3% gastrectomy,mortality up to 12% management duodenal decompression and drainage. The case files of 162 patients who underwent emergency laparotomy for duodenal ulcer perforations over a period of three years 2001 2003 were retrospectively. Perfect duodenal stump management has been the obsession of general abdominal surgeons for a long time and debates on the best methods of securing a safe stump have not really settled 3. Necrotizing fasciitis complicated by duodenal stump. Get a printable copy pdf file of the complete article 1. Qualitative or quantitative fecal fat may be useful in. Duodenal stump blowout is a feared complication of billroth ii reconstruction after gastrectomy.