In this method of duodenal stump closure, the stomach is transected proximal to the pylorus, where tissue is less fibrotic. A safe and effective technical solution is proposed, based on. An aortoduodenal fistula adf is an unusual, but serious complication following surgical or endovascular aortic repair. This is secured with a pursestring suture, and the seromuscular layer is closed over the stump. Outcomes of nonoperative treatment for duodenal stump. The reconstructions after total or distal gastrectomy imply the formation of a duodenal stump with the exception of the billroth i gastroduodenostomy. One closed drain was positioned at the duodenal stump area through the right upper abdominal wall. A possible variant of bouverets syndrome presenting as a. Get a printable copy pdf file of the complete article. 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. Expectant management of perforated duodenal ulcer kings county hospital sylvia s. Get a printable copy pdf file of the complete article 1.
The approach allows completion of subtotal gastrectomy or hemigastrectomy and vagotomy for duodenal ulcer without. 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. It involves the resection of at least twothirds of the stomach with a d2 lymph node dissection. 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.
Necrotizing fasciitis complicated by duodenal stump. Over the years, tube duodenostomy has proven to be a safe and effective technique in the management of the difficult duodenal injury 12. A and b, reproduced with permission from burch jm, cox cl, feliciano dv, et al. This also refers to the potential benefit of a gastric and biliary diversion under. A safer and simpler technique of duodenal dissection and. The value of duodenal tube decompression for postgastrectomy management of the duodenal stump was demonstrated for the first time in 1954. 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. These few results suggest that antral ulcers are difficult to see with the gastroscope, particularly when they are close to the pylorus, and that ulcers. Difficult closures of the duodenal stump jama surgery. 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. Endovascular treatment of aortic stump blowout after. Primary closure of the duodenal stump following gastric resection for peptic ulcer disease usually poses no problem.
Qualitative or quantitative fecal fat may be useful in. 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. An effective surgical treatment for repeatedly leaking. Duodenal stump blowout 1%3% gastrectomy,mortality up to 12% management duodenal decompression and drainage. Part of this mortality is caused by rebleeding or aortic stump ruptures. The purpose of this study is to describe the details of the procedure for indication, technical approach, and postoperative care.
Leakage from the duodenal stump has been the most feared complication of the bilhoth ii recon struction following gastric resection. 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. Duodenal stump leakage dsl is a serious surgical complication after radical gastrectomy with rouxeny or billrothii reconstruction. Cancer of the gastric stump after partial gastrectomy. 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. 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. 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.
Pdf a simple technique of decompressing the duodenum following difficult gastrectomies is. Distal gastrectomy with b1, b2 anastomsis or free download as powerpoint presentation. 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. Case report a possible variant of bouveret s syndrome. Case summary duodenal stump blowout is a feared complication of billroth ii reconstruction after gastrectomy. Management of the difficult duodenal stump the american journal. The ultra low duodenal stump and its difficult management.
Management of the difficult duodenal stump in penetrating duodenal ulcer disease. It was anastomosed proximally to the esophagus and distally to the. Although most staplers would produce at least two or three rows of staples, burying this line with a second layer using monofilament sutures placed. Difficult duodenal injuries remain a challenge to any general. However, definite surgical method for duodenal stump leakage is not established. Duodenal decompression is also recommended for the protection of the duodenal stump after gastrectomy for malignancy.
The management of large perforations of duodenal ulcers. Leakage of the duodenal or antral stump complicating gastric resection. The optimal treatment for adf consists of removal of the infected graft with in situ or extraanatomical repair and is associated with high mortality. Here, we report a highly unusual case of a delayed duodenal stump perforation secondary to a golfball. Single pursestring suture for reinforcement of duodenal. Early rupture of an ultralow duodenal stump after extended. This also refers to the potential benefit of a gastric and biliary diversion under such conditions. Classical technique of closing a difficult duodenal stump nissenbsteh has, up to now, not been compared with duodenojejunostomy dj in larger patient sets. The purpose of our study was to evaluate four methods of duodenal stump closure in 200 patients. 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. Standard gastrectomy is the main surgical procedure performed with curative intent for gastric cancer. Duodenal stump blowout is a feared complication of billroth ii reconstruction after gastrectomy. This may not be the complete list of references from this article.
Duodenal stump closure carries a leak rate of % and a mortality rate of 02% in recent series. Management of the difficult duodenal stump in penetrating. Most commonly presenting in the early postoperative period, there is significant variation in the surgical management of the difficult duodenal stump due to complexity. Some authors have extrapolated the concept of damage control for gdps, especially the large or giant subtypes and in reoperations after leakage. Duodenal stump leakage after gastrectomy is one of serious complications related to severe morbidity or mortality. It occurs as a complication of billroth ii gastrectomy, usually on the fourth or fifth day after surgery. Modified bancroft procedure for the difficult duodenal stump. However, given that most of the studies have a small number of cases, it is difficult to establish possible risk factors. Safe answers section 4 gastric and duodenum flashcards. When dealing with gastric cancer with duodenal invasion, gastrectomy with distal resection of the duodenum is necessary to achieve negative distal margin.
Us national library of medicine national institute of health. A comparative analysis of duodenojejunostomy with classical stump closure nissenbsteh. After a subtotal gastrectomy with a concomitant resection to the whole first part of the duodenum, an ultralow duodenal stump is difficult to close. This study was designed to evaluate the effectiveness of laparoscopic single pursestring suture for reinforcement of duodenal stump. Introduction the epitome of an organ poorly designed to withstand the ravages of trauma. Pdf a technique to prevent duodenal blowout after difficult. Lateral duodenostomy placement of tube through lateral of 2nd portion of duodenum. Management of the difficult duodenal stump ncbi nih. Management of the difficult duodenal stump sciencedirect. It is due to improper closure of duodenal stump, especially when the. 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.
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. Herein, we introduced a new and simple surgical technique to reduce duodenal stump leakage during laparoscopic gastrectomy for gastric cancer. Conclusions duodenal stump obstruction after rouxeny gastrectomy is rare, and may be difficult to manage. End duodenostomy placement of tube through suture line closing duodenum effort to create controlled duodenal fistula. 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. Duodenal stump leak anastomotic leak afferent loop obstruction gacsrti ouelt t. The causes of duodenal stump blow out include ischemia. The open end of the duodenum is then gently secured in. Distal gastrectomy with b1, b2 anastomsis or stomach. Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality.
The case files of 162 patients who underwent emergency laparotomy for duodenal ulcer perforations over a period of three years 2001 2003 were retrospectively. Leakage from the duodenal stump has been the most feared complication of the billroth ii reconstruction following gastric resection. 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. Laparoscopic reinforcement suture of duodenal stump using. The duodenal stump is preserved in the bilroth ii to allow continued flow of bile. A decision was made to use a transverse colon as a jump graft. A 67yearold man who did not have any other combined medical illnesses underwent a distal gastrectomy with biloth ii anastomosis for gastric cancer.
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. Stump blowout, or duodenal blowout, is the leakage of the blind end of the duodenum. Difficult closures of the duodenal stump jama network. The gastric mucosa in the duodenal stump is then dissected away from the submucosa into the duodenum.