A duodenal web, diaphragm or intraluminal diverticulum refers to a complete or incomplete obstruction at the duodenum due to a membranous web or intraluminal diverticulum. Delayed duodenal stump blowout following total gastrectomy for. Historically duodenal leak has been a potentially devastating complication after billroth ii resections following emergency surgery for duodenal ulcer perforation. Laparoscopic reinforcement suture of duodenal stump using. The six patients underwent seven laparoscopic operative procedures to treat their duodenal disease table 4. A technique to prevent duodenal blowout after difficult. Leakage from the duodenal stump has been the most feared complication of the billroth ii.
Surgical exposure surgical options cattellbraasch maneuver closure of the perforation primary repair duodenorrhaphy mucosal or serosal patch. The approach allows completion of subtotal gastrectomy or hemigastrectomy and vagotomy for duodenal ulcer without. Management of the difficult duodenal stump in penetrating. Complications immediate bleeding gastric retention dysphagia leakage of duodenal stump obstruction of the stoma acute pancreatitis late dumping syndrome diarrhoea steatorhoea enterogastric reflux recurrent ulceration iron deficiency anaemia risk of colorectal and gastric tumours. Sixty patients underwent distal gastrectomy with bii, and two patients had total gastrectomy. Mean operation time was 160 minutes, and the mean time for lars was 8 minutes. In the retrospective analysis of 17 consecutive children with chd who were treated with duodenal tube feeding for symptomatic ger, we found that clinical symptoms of persistent emesis or respiratory wheezing. Gastroenterology that part of the stomach that remains after partial resection.
Get a printable copy pdf file of the complete article. Difficult closures of the duodenal stump jama surgery jama. Additionally, this procedure enables decompression of the difficult duodenal stump. Disruption of a duodenal stump closure after surgery for duodenal ulcer continues to be a disaster. One of the most serious complications in the postoperative period after gastrectomy is a leakage from the duodenal stump. Duodenal stump leakage after gastrectomy is one of serious complications related to severe morbidity or mortality. Duodenal stump blowout is a feared complication of billroth ii reconstruction after gastrectomy. The effluent ducts of the pancreas and liver open into the duodenal cavity through a common aperture. Duodenal diverticulum is a rare disease that can be easily missed. Duodenal injuries challenges in management by habiba gad on prezi. The incidence of duodenal diverticulum diagnosed by upper gi study is approximately 5%. Pdf a technique to prevent duodenal blowout after difficult. In the era of gastrectomy for peptic ulcer disease, duodenal leak occurred after gastric surgery in 1 to 3 percent of patients 2,3. Despite the fact that the number of gastric cancer encounters with a difficult.
Risk factors for duodenal stump leakage after gastrectomy for. Multiple surgical modalities are available for dealing with this pathology. There is usually a small aperture at the center differentiating this from duodenal atresia. Although most staplers would produce at least two or three rows of staples, burying this line with a second layer using monofilament sutures placed. Morbidity was observed in three patients aspiration pneumonia, delayed gastric emptying with nausea and vomiting, and leakage of the duodenal stump. Aug 14, 20 these are rare nets of another part of the small bowel. 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.
Delayed duodenal stump blowout following total gastrectomy. Download fulltext pdf duodenal stump leak following a duodenal switch. Leakage from the duodenal stump has been the most feared complication of the billroth ii reconstruction following gastric resection. Herein, we introduced a new and simple surgical technique to reduce duodenal stump leakage during laparoscopic gastrectomy for gastric cancer. Most commonly presenting in the early postoperative period, there is significant variation in the surgical management of the difficult duodenal stump due to complexity. Burch jm1, cox cl, feliciano dv, richardson rj, martin rr. Pdf early rupture of an ultralow duodenal stump after. Therefore, a prospective phase ii study was designed for safety of this technique. Ng et al reported 80% 58 of 73 case of pdu were infected. However, complications like inflammation, perforation with retroperitoneal abscess. The esophagus enters the diaphragmatic hiatus at the level of t8.
Dsf is a rare complication but is associated with a high morbidity and mortality rate. Duodenal stump rupture was managed successfully by end tube. High prevalence of helicobacter pylori infection in duodenal ulcer perforations not caused by nonsteroidal antiinflammatory drugs. Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. Difficult closures of the duodenal stump jama surgery. Duodenal perforation is a rare, life threatening injury associated with nonaccidental blunt abdominal trauma. High % of h pylori infections reported with perforated duodenal ulcers. In the wall of the upper portion of the duodenum are the socalled brunners glands, which, in structure and in the composition of the juice they secrete, are closely related to the glands of the pyloric portion of the stomach. When food passes from your mouth, it moves through the esophagus and into your stomach. Inadequate duodenal stump ds closure, inappropriate usage of cautery, excessive dissection skeletonization for more than 2 cm of the first part of the duodenum or overzealous suturing of the ds resulting in ischemia and necrosis, submucosal hematoma in the resection line of the ds, local pancreatitis, incorrect drain position, and acute. Duodenal stump fistula after gastrectomy for gastric.
Full text full text is available as a scanned copy of the original print version. The duodenal stump, the blind end of the afferent limb solid arrow in c, is noted in the right subhepatic space. 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. Duodenal article about duodenal by the free dictionary. Pdf duodenal stump leak following a duodenal switch. However, rupture of an ultralow duodenal stump necessitates advanced surgical skills and close postoperative observation. The esophagus deviates anteriorly and to the left as it enters the abdomen. Single pursestring suture for reinforcement of duodenal. The entire duodenal stump proved diffusely strictured, such that we switched to a capfitted gastroscope to limit perforation risks. The thoracic esophagus passes behind the right mainstem bronchus and the pericardium.
Although the authors did not specifically state that the method they described to manage a difficult duodenal stump was original with them, in glancing over their reference list, there was. An empty stomach is roughly the size of an open hand and when distended with food, can fill much of. Diagnostic delay is common, as the true history is concealed and signs may be minimal. This is the first part of the bowel after the stomach. Early rupture of an ultralow duodenal stump after extended surgery for gastric cancer with duodenal invasion managed by tube duodenostomy and cholangiostomy. Duodenal injuries are uncommon, but not so rare as to preclude a comprehensive understanding of treatment strategies by general surgeons. Management of the difficult duodenal stump sciencedirect. The present study reports a case of an early duodenal stump rupture after subtotal gastrectomy with resection of the. Duodenal ulcer is a open sore or lesion in the inner lining of the stomach or duodenum.
Management of the difficult duodenal stump ncbi nih. It is suggested that lateral ttube duodenostomy may serve as an alternative to prolonged nasogastric intubation, obviating several of the complications associated with the latter. Subcutaneous infiltration with emphysema around the drain site and mesenteric fat haziness with air densities around the duodenal stump site were observed figures 1a, b on computed tomography ct. Until now, no prospective clinical trial for duodenal stump leakage after laparoscopic or open gastrectomy for gastric cancer patients has been conducted. Giant duodenal ulcer perforation is an uncommon but difficult tomanage pathology with a high mortality rate. A good meditoon first establishes the normal anatomy and function, and then shows the development of the disease process. Distal gastrectomy with b1, b2 anastomsis or free download as powerpoint presentation. In most instances of partial gastric resection of the billroth ii type performed for duodenal ulcer, management of the duodenal stump presents no unusual proble. Management of the difficult duodenal stump the american journal. Congenital duodenal web leading to partial obstruction. Mar 21, 2017 i already introduced a technique of laparoscopic reinforcement suture lars on stapleline of duodenal stump using barbed suture for prevention of duodenal stump leakage. Links to pubmed are also available for selected references. Total parenteral nutrition, when added to prompt and adequate surgical drainage, has sharply reduced mortality and in many cases will eliminate the need for further operative intervention. Recanalization of the jejunum at enterically closed site was investigated endoscopically or fluoroscopically.
C shaped curvature curved around head of pancreas lies above umbilicus opp. These included a gastroenterostomy that was fashioned as a loop n 5 or in a rouxeny configuration n 1, and a pancreaspreserving distal duodenectomy 3 with a duodenojejunal anastomosis n 1. When dealing with gastric cancer with duodenal invasion, gastrectomy with distal resection of the duodenum is necessary to achieve negative distal margin. Two years later, she underwent egd for recurred acid regurgitation. Non operative management of perforated duodenal ulcers. The course of the efferent limb open arrows is more complex and difficult to follow. Duodenal varices were first described by alberti,15 and visualised endoscopically in 1973 by kunisaki et al. After cutting of duodenal stump, lars commenced with continuous invagination method or interrupted method using barbed suture. We aimed to analyze the risk factors for this problem, and to identify the methods used for its prevention and management. Shortest, dilated and most fixed proximal part of small intestine. Management of the difficult duodenal stump, the american journal of surgery 162, p. Emergency exploration was performed for suspected necrotizing fasciitis nf of the abdominal wall with or without peritonitis. It is due to improper closure of duodenal stump, especially when the duodenum is inflamed and oedematous.
Laparoscopic reinforcement suture lars of duodenal stump a. Duodenal diverticular perforation after small bowel. Anatomy of duodenum, duodenum structure, ppt of duodenum. A total of 1,230 patients underwent gastrectomy at our institution between 2010 and 2014.
Laparoscopic reinforcement suture lars of duodenal stump. Yes there is an acute form that can present early post operatively and mimic duodenal stump rupture and appears as a large fluid filled mass in ruq on ct needs also immediate surgery and jejunojejunostomy and rarely resection if the loop is gangrenous. However, when there is intense scarring or active ulceration with marked edema and inflammation, the closure and management of this difficult. Primary closure of the duodenal stump following gastric resection for peptic ulcer disease usually poses no problem. Historically it has occurred most frequently in billroth ii resections following emergency surgery for duodenal ulcer perforating in the pancreatic head and less frequently after resections for gastric cancer. Leakage from the duodenal stump has been the most feared complication of the. Modified bancroft procedure for the difficult duodenal stump. A technique to prevent duodenal blowout after difficult gastrectomies. 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. A duodenal ulcer is a raw area or open sore ulcer that develops when there is a break in the lining of the duodenum, the upper part of the small intestine which is connected to the stomach. 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. Jul 07, 20 anatomy of duodenum, duodenum structure, ppt of duodenum, power point presentation duodenum 1.
Cautious and patient pushandpull movements with intermittent abdominal compression were needed to finally reach the papilla in a strictly tangential position fig. Leakage of the duodenal or antral stump complicating gastric resection. Succession of duodenal polypoid lesion gastroenterology. We report three cases, all with other features typical of nonaccidental injury. We evaluated the clinical outcomes of the nonoperative management of postgastrectomy duodenal stump leakage in patients with gastric cancer. A duodenal stump fistula is one of the most severe complications after gastrectomy for gastric cancer. Postoperative anatomic and pathologic findings at ct.
We tested whether duodenal tube feeding effectively improves the clinical symptoms and body weight gain in children with congenital heart disease chd and gastroesophageal reflux ger. Duodenal stump leakage free download as powerpoint presentation. Gastric stump definition of gastric stump by medical dictionary. The stomach is distensible and on a free mesentery, therefore, the size, shape, and position may vary with posture and content. Most patients with duodenal diverticulum are asymptomatic.
We report two cases of giant duodenal ulcer perforation after neurosurgery for brainstem tumors that needed reoperation for. 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. Several tiny duodenal sessile polyps are noted on the anterior wall of bulb figure a. Esomeprazole 40 mgd was prescribed daily for 6 months. 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. Although the rygbp is effective in longterm weight reduction and prevention of obesityrelated complications, the short and longterm complications are now appearing in. Uptodate, electronic clinical resource tool for physicians and patients that provides information on adult primary care and internal medicine, allergy and immunology, cardiovascular medicine, emergency medicine, endocrinology and diabetes, family medicine, gastroenterology and hepatology, hematology, infectious diseases, nephrology and. In technically difficult duodenal stump closures, additional coverage of the stump with the back wall of the stomach can be obtained. Schwartz, management of the difficult duodenum, 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. Duodenal stump closure carries a leak rate of % and a mortality rate of 02% in recent series. The open end of the duodenum is then gently secured in place around the tube using a pursestring 3. The overall incidence of duodenal stump fistula dsf or duodenal stump leakage is reportedly between 1. Double contrast computed tomography is the most sensitive investigation to confirm clinical suspicion. I already introduced a technique of laparoscopic reinforcement suture lars on stapleline of duodenal stump using barbed suture for prevention of duodenal stump leakage. Know more about the symptoms, causes and treatment with this article. Stump blowout, or duodenal blowout, is the leakage of the blind end of the duodenum. However, definite surgical method for duodenal stump leakage is not established. The surgical treatment of morbid obesity using the rouxeny gastric bypass rygbp technique is being performed at an increasing rate, with more than 100,000 operations being performed each year in the united states alone. Duodenal stump leakage dsl is a serious surgical complication after radical gastrectomy with rouxeny or billrothii reconstruction. Download fulltext pdf duodenal stump leak followi ng a duodenal switch. Autopsy results show that 22% of the population have duodenum diverticulum.
This also refers to the potential benefit of a gastric and biliary diversion under such conditions. A case report article pdf available in international journal of surgery case reports 14c. Distal gastrectomy with b1, b2 anastomsis or stomach. These are rare nets of another part of the small bowel. Postoperative insufficiency of duodenal stump sutures caused by ascaris lumbricoides, magyar sebeszet. Duplication cysts are spherical and tubular structures covered by esophageal epithelium and with smooth muscle in their walls. Early rupture of an ultralow duodenal stump after extended. The management of large perforations of duodenal ulcers. It occurs as a complication of billroth ii gastrectomy, usually on the fourth or fifth day after surgery. Classical technique of closing a difficult duodenal stump nissenbsteh has, up to now, not been compared with duodenojejunostomy dj in larger patient sets. Our experience suggests that retrograde bladder and duodenal stump opacification should be a routine part of the ct evaluation performed to detect leakage from the urinary bladder or duodenal stump after pancreas transplantation. Duodenal stump leaks often lead to significant morbidity and mortality.
One of the most serious complications after gastrectomy is leakage from the duodenal stump. This study was designed to evaluate the effectiveness of laparoscopic single pursestring suture for reinforcement of duodenal stump. Duodenal ulcer is a bacterial infection caused by bacteria helicobacter pylori h. The value of duodenal tube decompression for postgastrectomy management of the duodenal stump was demonstrated for the first time in 1954.
Despite the efficacy of pharmacotherapy for gastrointestinal ulcers, severe cases of bleeding or perforation due to gastrointestinal ulcers still occur. Giant duodenal ulcers after neurosurgery for brainstem. Delayed perforation of the defunctionalized stomach after. Introduction the epitome of an organ poorly designed to withstand the ravages of trauma. 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. Necrotizing fasciitis complicated by duodenal stump. Jun 28, 2016 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. Esophagogastroduodenoscopy egd revealed reflux esophagitis. The thoracic esophagus enters the posterior mediastinum anterior to the aortic arch. Postgastrectomy duodenal leak, sometimes referred to as duodenal stump blowout, is an infrequent but potentially devastating complication of gastric surgery. This may not be the complete list of references from this article. Duodenal stump disruption is not a surgical anachronism, because it still. Duodenal stump fistula after gastrectomy for gastric cancer.
Free stl 3d models for download, files in stl with low poly, animated, rigged, game, and vr options. Outcomes of nonoperative treatment for duodenal stump. 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. Duodenal stump leakage was diagnosed in 19 patients 1.
Pdf a simple technique of decompressing the duodenum following difficult gastrectomies is described which can be applied across the country to. Full text is available as a scanned copy of the original print version. Here, we report a highly unusual case of a delayed duodenal stump perforation secondary to a golfball sized enterolith without. A 27yearold woman presented to the clinic with acid regurgitation of 3 years duration. Risk factors for duodenal stump leakage after gastrectomy. Detection of pancreatic fluid and urine leakage after. Scribd is the worlds largest social reading and publishing site.