Moreover, a difficult duodenal stump increases the risk of tumor invasion. Patients between january 2010 and december 2014, a total of 1,230 patients underwent total or subtotal gastrectomy at our institution. Dsfrelated morbidity always leads to longer hospitalization times due to medical and surgical complications such as wound infections, intraabdominal abscesses. Aug 19, 2012 duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. In some recent reports, the leak rate of % and mortality can reach up to rate 50% 1,2. Unfortunately, the clinical condition of the patient worsens and complicated by stent migration. The purpose of our study was to evaluate four methods of duodenal stump closure in 200 patients. Classical technique of closing a difficult 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. Dec 01, 1991 management of the difficult duodenal stump jod m. Leakage from the urinary bladder or duodenal stump after pancreas transplantation with urinary bladder drainage of the graft is difficult to diagnose clinically. Primary closure of the duodenal stump following gastric resection for peptic ulcer disease usually poses no problem.
Here, we report a highly unusual case of a delayed duodenal stump perforation secondary to a golfball sized enterolith without evidence of a cholecystoenteric fistula or afferent loop obstruction in a patient with a remote history of distal gastrectomy with billroth ii reconstruction. The postoperative course was complicated by development of a duodenal stump fistula and subhepatic collection fig. We investigated the impact of duodenal stump reinforcement on dsl after laparoscopic gastrectomy with ry reconstruction for gastric cancer. Analysis of surgical prophylactic measures of sutures insufficiency of difficult duodenal stump in stomach resection by bilrotii in 110 patients with complications of duodenal ulcers required urgent surgery are presented. Especially in patients with locally advanced t4 distal gastric cancer, the duodenal wall is often edematous or friable after resection. Duodenal stump fistula following rouxeny gastrectomy.
Duodenal stump blowout is a feared complication of billroth ii reconstruction after. 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. 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 safer and simpler technique of duodenal dissection and. Here, we report a highly unusual case of a delayed duodenal stump perforation secondary to a golfball sized enterolith without. Leakage from the duodenal stump has been the most feared complication of. This also refers to the potential benefit of a gastric and biliary diversion under such conditions. Management of the difficult duodenal stump ncbi nih. Vgh weekly trauma rounds overview of traumatic duodenal. The ultra low duodenal stump and its difficult management.
When there was a threatening incompetence of the duodenal stump sutures, to prevent generalization of peritonitis the stump in 24 patients was covered with a hood of t. Management of the difficult duodenum request pdf researchgate. The incidence of duodenal diverticulum diagnosed by upper gi study is approximately 5%. However, complications like inflammation, perforation with retroperitoneal abscess. Opting for stump grinding assures you that the tree stump will be removed to a useful depth 300 mm, thus eliminating the hazards and safety risks of an exposed stump. Difficult duodenal stump in emergency surgery of duodenal. Outcomes of nonoperative treatment for duodenal stump. The duodenal stump is preserved in the bilroth ii to allow continued flow of bile salts and pancreatic enzymes 3. Historically duodenal leak has been a potentially devastating complication after billroth ii resections following emergency surgery for duodenal ulcer perforation. Duodenal ulcer duodenostomy duodenum gastrectomy humans. A and b, reproduced with permission from burch jm, cox cl, feliciano dv, et al. Pdf duodenal stump blow out from reinforced stapled.
Moreover, a difficult duodenal stump increases the. Dsf is related to high mortality 1620% and morbidity 75% rates. Mucosal or serosal patches and a pedicled graft with a free vascular pedicle created from stomach, jejunum or ileum tissue have been previously proposed without proven efficacy 5, 17, 18, 19. Incidence and prognosis of duodenal stump leakage in. This condition, known as the difficult duodenal stump, is the most significant risk factor for suture line leakage. Dec 04, 2020 management of the difficult duodenal stump. Leakage from the duodenal stump has been the most feared complication of the bilhoth ii recon struction following gastric resection.
Methodsthis retrospective study of 965 patients with gastric cancer who. This might explain the anecdotal observation of punctate duodenal stump blow out at the lateral edge of the transverse duodenal stump staple line 5. Detection of pancreatic fluid and urine leakage after. Difficult duodenal stump in emergency surgery of duodenal ulcer. Duodenal stump blowout is a feared complication of billroth ii reconstruction after gastrectomy. Ppt duodenal stump leakage powerpoint presentation. Combined aggressive distal gastrectomy and doubletract.
After a subtotal gastrectomy with a concomitant resection to the whole first part of the duodenum, an ultralow duodenal stump is difficult to close. A method of closing the difficult duodenal stump after a subtotal gastrectomy billroth ii is described herein. Seemingly, this punctate lateral edge is not spared from the risk of leak even if a continuous underrunning suture is inserted along the stapled line. The duodenal stump is implanted in the efferent jejunal loop and then an enteroenterostomy braun is performed. The research was limited to articles written in english and published between january 1988 and december 2014. Stump blowout, or duodenal blowout, is the leakage of the blind end of the duodenum. Modified bancroft procedure for the difficult duodenal stump. Classical technique of closing a difficult duodenal stump nissenbsteh has, up to now, not been compared with duodenojejunostomy dj in. This is secured with a pursestring suture, and the seromuscular layer is closed over the stump. Ali et al suggested duodenostomy in order to avoid complex surgical interventions, concomitant increased morbidity and longer hospitalization. Request pdf management of the difficult duodenal stump in penetrating duodenal ulcer disease. Tube pancreaticoduodenostomy for management of a severe. However, because of dysynchrony of food and bileenzyme entry, patients.
Pdf duodenal stump blow out from reinforced stapled lines. In january 2012, a 68yearold woman underwent laparoscopic partial gastrectomy at our institute, with rouxeny reconstruction for an ulcerated gastrointestinal stromal tumor. 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. Backgroundalthough duodenal stump leakage dsl is a relatively rare complication after gastrectomy with rouxeny ry reconstruction, it is difficult to treat and can be fatal. It occurs as a complication of billroth ii gastrectomy, usually on the fourth or fifth day after surgery. Autopsy results show that 22% of the population have duodenum diverticulum. Management of the difficult duodenal stump sciencedirect. Simple duodenal stump closure especially in cancer surgery. Postgastrectomy duodenal leak, sometimes referred to as duodenal stump blowout, is an infrequent but potentially devastating complication of gastric surgery. Leakage of the duodenal or antral stump complicating gastric resection. In conclusion, we believe that in the case of a lifethreatening complication in the small intestine which is difficult to access, singleballoon enteroscopy may be a viable alternative to surgical intervention. Duodenal stump closure carries a leak rate of % and a mortality rate of 02% in recent series.
Classical technique of closing a difficult duodenal stump nissenbsteh has, up to now, not been compared with duodenojejunostomy dj in larger patient sets. Duodenal stump fistula after gastrectomy for gastric cancer. Management of the difficult duodenal stump in penetrating 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. Percutaneous drainage of the collection, as well as percutaneous transhepatic biliary drainage. 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. Although most staplers would produce at least two or three rows of staples, burying this line with a second layer using monofilament sutures placed. Materials and methods the research was systematically performed on pubmed, embase and cochrane library databases cilea archive, bmj clinical evidence and uptodate databases by entering the strings duodenal stump fistula.
Duodenal diverticular perforation after small bowel. Most patients with duodenal diverticulum are asymptomatic. David ko, trauma surgeon online participants telephone participants. Pdf a lifesaving but inadequately discussed procedure. Management of duodenal stump fistula after gastrectomy for. The approach allows completion of subtotal gastrectomy or hemigastrectomy and vagotomy for duodenal ulcer without hazarding the primary cause of morbidity and mortality in such procedures, duodenal stump leakage resulting from difficult postpyloric dissection and insecure closure. May 28, 2019 background duodenal stump fistula dsf remains one of the most serious complications following subtotal or total gastrectomy, as it endangers patients life. Request pdf management of the difficult duodenum disruption of a duodenal stump closure after surgery for ulcer disease has long been. When dealing with gastric cancer with duodenal invasion, gastrectomy with distal resection of the duodenum is necessary to achieve negative distal margin. Difficult closures of the duodenal stump jama network. Get a printable copy pdf file of the complete article 1. Duodenal diverticulum is a rare disease that can be easily missed. The gastric mucosa in the duodenal stump is then dissected away from the submucosa into the duodenum.
Difficult duodenal injuries remain a challenge to any general. Surgical procedures, operative surgical wound dehiscence. One of the most serious complications after gastrectomy is leakage from the duodenal stump. A duodenal stump fistula dsf forming after a gastrectomy for gastric cancer is a lifethreatening complication. Burch jm, cox cl, feliciano dv, richardson rj, martin rr 1991 management of the difficult duodenal stump. Us national library of medicine national institute.
One hundred and fortyseven 74% patients had duodenal ulcers. Postoperative duodenal stump leakage was diagnosed in 19 patients 1. Multiple pancreaticoduodenal penetrating gunshot trauma. The plenk method in the authors modification was successfully applied in resection of the stomach for exclusion in 22 patients. 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. When there was a threatening incompetence of the duodenal stump sutures, to prevent generalization of peritonitis the stump in 24 patients was covered with a hood of the greater omentum and external drainage of this space was installed. Early rupture of an ultralow duodenal stump after extended. Other causes include ischemia and necrosis over zealous suturing increased tension on duodenal stump caused by acute afferent loop obstruction. Request pdf management of the difficult duodenum disruption of a duodenal stump closure after surgery for ulcer disease has long been considered a disastrous postoperative complication, with. Management of the difficult duodenal stump in penetrating. Leakage from the duodenal stump has been the most feared complication of the billroth ii reconstruction following gastric resection. Management of the difficult duodenal stump the american journal. Pdf duodenal stump reinforcement might reduce both.
When the injury is just below the ampulla of vater, however, resection of the damage may be difficult. Management of the difficult duodenal stump read by qxmd. Duodenal stump leak post curative gastrectomy for early gastric. Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. It is due to improper closure of duodenal stump, especially when the duodenum is inflamed and oedematous. Difficult closures of the duodenal stump jama surgery. The second most common fear is a duodenal stump leak. A comparative analysis of duodenojejunostomy with classical stump closure nissenbsteh. J m burch, c l cox, d v feliciano, r j richardson, r r martin.
1155 149 80 361 927 93 527 850 1111 1049 482 152 1169 1280 661 631 1028 859 1253 758 909 191 441 1328 569 1254 678 1447 1558 1592