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. Burch jm1, cox cl, feliciano dv, richardson rj, martin rr. End duodenostomy placement of tube through suture line closing duodenum effort to create controlled duodenal fistula. The circumstances most likely to lead to stump failure include large greater than 2 cm, deep, posterior duodenal ulcers that have destroyed the posterior wall of the duodenum and when severe inflam mation and scarring distort and obscure the relationships of the duodenum, pancreas, and common bile duct.
This may not be the complete list of references from this article. Under these circumstances an antrectomy is the simpler procedure. Low fistula output may delay diagnosis, making it difficult to define fistula occurrence time 2. Although most duodenal perforations can be effectively managed using simple repairs, more complex injuries require complicated procedures. Duodenal stump fistula dsf remains one of the most serious. Us national library of medicine national institute of health. Distal duodenogastrostomy or proximal jejunogastrostomy in the. Post gastrectomy syndromes suny downstate medical center. We report a rare case where an enterolith in a duodenal afferent loop after distal gastrectomy led to obstructive jaundice, and subsequently, caused ileus by its movement into the. The gastric antrum, the pylorus, and the first portion of the duodenum form a unit from an. If this distal duodenal or short jejunal stump is too short for stoma creation and bowel. It involves the resection of at least twothirds of the stomach with a d2 lymph node dissection.
The approach allows completion of subtotal gastrectomy or hemigastrectomy and vagotomy for duodenal. Distal gastrectomy with b1, b2 anastomsis or free download as powerpoint presentation. The duodenal stump is unclamped and held by alice forceps equally at three points. This also refers to the potential benefit of a gastric and biliary diversion under such conditions. Copious and challenging dissection in a field of dense adhesions. Difficult closures of the duodenal stump jama surgery. 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. Scribd is the worlds largest social reading and publishing site. Management of the difficult duodenal stump ncbi nih. Most commonly presenting in the early postoperative period, there is significant variation in the surgical management of the difficult duodenal stump due to complexity. Management of the difficult duodenal stump in penetrating. 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 situated on the pylorus are not visible by this means.
Duodenal stump blowout is a feared complication of billroth ii reconstruction after gastrectomy. Pdf introduction duodenal stump disruption remains one of the. If you are new to merging pdfs, it can be difficult to figure out which pdf compiler is right for you. Marys hospital, college of medicine, the catholic university of korea, seoul, korea. Mucosal repair of posterior perforation of duodenal. Get a printable copy pdf file of the complete article. Leakage from the duodenal stump has been the most feared complication of the billroth ii reconstruction following gastric resection. Pdf delayed duodenal stump blowout following total gastrectomy.
Patients who present with upper gastrointestinal or pancreatobiliary pathology after previous gastric surgery should be managed in centres with the availability of. Drainage of the duodenal stump by way of catheterization has long been championed as a potential means of reducing the risk of blowout, albeit with some controversy. Our pdf merger allows you to quickly combine multiple pdf files into one single pdf document, in just a few clicks. With regard to the present series, 5 reoperations for duodenal stump leakage table 2 were necessary.
This technique have been used by one of us for many times with fairly good results. After a subtotal gastrectomy with a concomitant resection to the whole first part of the duodenum, an ultralow duodenal stump is difficult to close. Lateral duodenostomy placement of tube through lateral of 2nd portion of duodenum. Duodenal stump blowout, while much less common than in previous decades due to a marked reduction in the number of gastrectomies performed, continues to be one of the most dreaded complications following gastric resection. Conclusions duodenal stump obstruction after rouxeny gastrectomy is rare, and may be difficult to manage.
Management of the difficult duodenal stump in penetrating duodenal ulcer disease. Expectant management of perforated duodenal ulcer kings county hospital sylvia s. A safer and simpler technique of duodenal dissection and. Despite an overall decline in the incidence of gastric carcinoma, it remains the second leading cause of cancerrelated deaths worldwide, with the highest prevalence in korea. Grahams patch piece of omentum is used to cover the perforation.
What are some of the techniques that you can use when responding to the question of how to close a difficult duodenal stump. Controlled lateral wall duodenostomy was performed as an attempt to lower the intraluminal pressure of the afferent loop and good results had been observed in all three patients. Get a printable copy pdf file of the complete article 1. Disruption of a duodenal stump closure after surgery for ulcer disease has long been considered a disastrous postoperative complication, with significant morbidity from fistulas or intraabdominal sepsis and high mortality. Billroth ii partial gastrojejunostomy endtoside with blind closure of duodenum done for a proximal gastric ulcer 17. A possible variant of bouverets syndrome presenting as a. The purpose of our study was to evaluate four methods of duodenal stump closure in 200 patients. Difficult duodenal injuries remain a challenge to any general. The reconstructions after total or distal gastrectomy imply the formation of a duodenal stump with the exception of the billroth i gastroduodenostomy. Diagnosis and management of perforated duodenal ulcers. Perforation of duodenal diverticulum is a rare occurrence but has a potentially fatal outcome. The duodenal stump is now prepared for a gastroduodenal anastomosis or for closure by suture previously to a gastrojejunostomy.
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. We present a case of posterior perforation of duodenal diverticulitis, diagnosed on computed tomography and. We present two cases of a perforated duodenal ulcer following rouxeny gastric bypass and discuss the management of these patients. Management of duodenal stump fistula after gastrectomy for. 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. Duodenal stump leak anastomotic leak afferent loop obstruction gacsrti ouelt t. The diagnosis of a perforated duodenal ulcer in a rygp patient can be challenging, and there is variability in the surgical treatment, especially when it comes to the possible role of removing the gastric remnant. Standard gastrectomy is the main surgical procedure performed with curative intent for gastric cancer. Since the incidence of duodenal stump leakage is 1.
Outcomes of nonoperative treatment for duodenal stump leakage after gastrectomy in patients with gastric cancer bandar idrees ali, cho hyun park and kyo young song division of gastrointestinal surgery, department of surgery, seoul st. Case report international journal for case reports imedpub. Duodenal stump leakage free download as powerpoint presentation. Afferent loop syndrome presenting as enterolith after. 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. Other causes include ischemia and necrosis over zealous suturing increased tension on duodenal stump caused by acute afferent loop obstruction. Early rupture of an ultralow duodenal stump after extended.
Surgical treatment of inantition due to jejunal peptic ulcer and duodenoileal fistula. This also refers to the potential benefit of a gastric and biliary diversion under such. Management of the difficult duodenal stump sciencedirect. In the era of gastrectomy for peptic ulcer disease, duodenal leak occurred after gastric surgery in 1 to 3 percent of patients 2,3.
In the era of gastrectomy for peptic ulcer disease, duodenal leak. Although mortality following stump blowout has improved substantially since the dismal rates of the 1950s. 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. The ultra low duodenal stump and its difficult management.
Outcomes of nonoperative treatment for duodenal stump. Safe answers section 4 gastric and duodenum flashcards. Postgastrectomy duodenal leak, sometimes referred to as duodenal stump blowout, is an infrequent but potentially devastating complication of gastric surgery. Modified bancroft procedure for the difficult duodenal stump. A tube duodenostomy may be performed rather than to close the duodenal stump. It is a difficult surgical problem because of delayed diagnosis and the attendant risk of duodenal fistula following primary repair.
A safe and effective technical solution is proposed, based on. Surgical complications after intestinal transplantation in infants and. Duodenal stump obstruction after rouxeny gastrectomy is rare, and may be difficult to manage. Postrepair complex duodenal injury leakage is more common than postgastrectomy duodenal stump leakage. Proximally, it merges into the gastric an trum without a. Distal gastrectomy with b1, b2 anastomsis or stomach. Although most staplers would produce at least two or three rows of staples, burying this line with a second layer using monofilament sutures placed. Movavi pdf editor is simple and secure pdfediting software. Leakage of the duodenal or antral stump complicating gastric resection. It is due to improper closure of duodenal stump, especially when the duodenum is inflamed and oedematous. These methods for total laparoscopic operation are the most difficult and. Distal duodenogastrostomy or proximal jejunogastrostomy in.
Penetrating peptic ulcer into the head of pancreas. Duodenal stump closure carries a leak rate of % and a mortality rate of 02% in recent series. Here, we report a highly unusual case of a delayed duodenal stump perforation secondary to a golfball sized enterolith without. Classical technique of closing a difficult duodenal stump nissenbsteh has, up to now, not been compared with duodenojejunostomy dj in larger patient sets. The duodenal stump is preserved in the bilroth ii to allow continued flow of bile. Stump blowout, or duodenal blowout, is the leakage of the blind end of the duodenum. Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. When dealing with gastric cancer with duodenal invasion, gastrectomy with distal resection of the duodenum is necessary to achieve negative distal margin.