Management of the difficult duodenum

Abstract

3 F s c t t a J enjoyed very much the article by Drs. Tsuei and Schwartz in he March/April 2004 issue about the management of the difcult duodenum. The excellent point they make—that medical reatment and nonresective surgical options “have reduced the umber of gastric resections performed for ulcer disease and; ence, reduced the need to contend with difficult duodenal losure —has to be reamplified. I believe that most, if not all, difficult duodenal closures” can be avoided by, first, not perorming a gastrectomy and, second, if gastrectomy is indicated, o it as gastro duodenostomy (Billroth I). Difficult duodenal stumps are invariably the product of Billoth II gastrectomy for chronic duodenal ulcer. I am continuusly amazed that surgeons are still removing stomachs for a enign disease limited to the duodenum, a disease so well ameable to modern anti-ulcer medications and alternative nonreective surgical methods. Almost 100 years ago, Charles H. ayo wrote: If anyone should consider removing half of my ood stomach to cure a small ulcer in my duodenum, I would un faster than he.” And Francis D. Moore of Boston said about astrectomy for duodenal ulcer: “in this operation a segment of n essentially normal stomach is removed to treat the disease ext door in the duodenum. It is like taking out the engine to ecrease noise in the gear box.” It appears that “in the era of elicobacter pylori doing a gastrectomy for peptic ulcer is like oing a lobectomy for pneumonia.” On rare occasions, however, such as perforation of a giant uodenal ulcer, source control cannot be achieved without a astrectomy. In this situation, as suggested initially by Erwin J. uerst, “restoration of the gastrointestinal continuity by gasroduodenostomy eliminates the problems of the technically ifficult duodenal stump.” During the 1980s, we were coninced with Fuerst’s method and used it whenever partial gasrectomy was unavoidable for complicated duodenal ulcer. In he 9 patients undergoing this procedure, there were no anasomotic leaks or strictures and all survived. And this is how we o it: After partial gastrectomy, a “neo lesser curvature” is ormed manually or with a liner stapler, leaving an open lumen o be anastomosed to the duodenum. After adequate “Kocherzation” of the duodenum, the division of the gastrohepatic mentum and the gastrocolic omentum (safe guarding gastric rterial supply) the gastric remnant would easily reach the dudenum without tension. Typically, the posterior wall (“lip”) of he duodenal stump is adherent to the now excluded crater of he duodenal ulcer, which is adherent to the pancreas. The