Duodenal Perforation Research Articles

Concurrent laparoscopic highly selective vagotomy with closure of duodenal ulcer perforations show good clinical results as primary repair alone.

To compare clinical and operative results between laparoscopic primary repair (LPR) alone and LPR with highly selective vagotomy (LPR-HSV) in patients with duodenal ulcer perforation. Clinical data from patients who underwent either LPR or LPR-HSV by resecting both sides of the neurovascular bundle using an ultrasonic or bipolar electrosurgical device for duodenal ulcer perforations, between 2010 and 2020, were retrospectively collected. Between-group differences in continuous and categorical variables were statistically analysed. Data from 184 patients (mean age, 49.6 years), who underwent either LPR (n = 132) or LPR-HSV (n = 52) were included. The mean operation time was significantly longer in the LPR-HSV group (116.5 ± 39.8 min) than in the LPR group (91.2 ± 33.3 min). Hospital stay was significantly shorter in the LPR-HSV group (8.6 ± 2.6 days) versus the LPR group (11.3 ± 7.1 days). The mean postoperative day of starting soft fluid diet was also significantly shorter in the LPR-HSV group (4.5 ± 1.4 days) than in the LPR group (5.6 ± 4 days). No between-group difference in morbidity rate was observed. The learning curve of the HSV procedure showed a stable procedure time after 10 operations. LPR with HSV may be a safe and feasible procedure for selective cases who are at high risk for ulcer recurrence.

S3390 A Unique Management Strategy for Migrated Biliary Stent Causing Duodenal Perforation

S3390 A Unique Management Strategy for Migrated Biliary Stent Causing Duodenal Perforation

Closure of a duodenal perforation with an over-the-scope clip complicated by colon entrapment (with video)

Closure of a duodenal perforation with an over-the-scope clip complicated by colon entrapment (with video)

Subcutaneous emphysema of the lower extremity and pneumoperitoneum after endoscopic retrograde cholangiopancreatography-related duodenal perforation.

Subcutaneous emphysema of the lower extremity and pneumoperitoneum after endoscopic retrograde cholangiopancreatography-related duodenal perforation.

A possible manifestation of pancreas divisum–pancreatic pseudocyst in an infant with no apparent history of pancreatitis: a case report

BackgroundPancreas divisum (PD), the most common pancreatic anomaly, is caused by the failure of pancreatic bud fusion in the embryo. Although most cases are asymptomatic, it can cause pancreatitis or epigastric pain. We report an unusual case of PD in an infant.Case presentationThe patient was a 9-month-old girl with no pertinent medical history. She had suffered vomiting and diarrhea for 1 week before transfer to our hospital. Her general condition was poor, and abdominal distention was noted. Blood tests revealed microcytic anemia with normal chemical markers. The parents reported no episode of pancreatitis. Ultrasonography revealed massive ascites, which was later found to be bloody. Enhanced computed tomography and magnetic resonance imaging depicted a cystic lesion, approximately 2 cm in size, anterior to the second portion of the duodenum. During exploratory laparotomy, a pinhole was identified on the cyst wall, which was mistakenly identified as a duodenal perforation, and direct closure was performed. Postoperative levels of serum amylase and inflammation markers were elevated, and the amount of ascites increased, impairing oral feeding. The level of pancreatic enzymes in the ascites was high. Imaging studies were repeated, but the cause of pancreatic fistula was not identified. Conservative therapy, including administration of total parenteral nutrition, antibiotics, and octreotide, was initiated, but the situation did not improve. Three months after admission, endoscopic retrograde cholangiopancreatography showed a thick dorsal pancreatic duct communicating with a hypoplastic ventral duct, which was indicative of PD. Contrast medium leaking from the dorsal duct near the minor ampulla revealed the presence of a pseudocyst. Stenting via the minor papilla was impossible because the minor papilla was obstructed. Instead, a stent was inserted into the ventral pancreatic duct. Endoscopic transgastric drainage of the cyst was effective, and the patient was discharged, 7 months after admission. The patient is healthy, but the gastric stent needs to be replaced regularly.ConclusionIn children, PD can manifest with pancreatic pseudocyst that causes pancreatic ascites, even in the absence of pancreatitis. This may be a previously unrecognized manifestation of PD in children, and clinicians need to be aware of it.

Pancreaticobiliary Diseases with Severe Complications as a Rare Indication for Emergency Pancreaticoduodenectomy: A Single-Center Experience and Review of the Literature.

The pancreaticobiliary system is a complex and vulnerable anatomic region. Small changes can lead to severe complications. Pancreaticobiliary disorders leading to severe complications include malignancies, pancreatitis, duodenal ulcer, duodenal diverticula, vascular malformations, and iatrogenic or traumatic injuries. Different therapeutic strategies, such as conservative, interventional (e.g., embolization, stent graft applications, or biliary interventions), or surgical therapy, are available in early disease stages. Therapeutic options in patients with severe complications such as duodenal perforation, acute bleeding, or sepsis are limited. If less invasive procedures are exhausted, an emergency pancreaticoduodenectomy (EPD) can be the only option left. The aim of this study was to analyze a single-center experience of EPD performed for benign non-trauma indications and to review the literature concerning EPD. Between January 2015 and January 2022, 11 patients received EPD due to benign non-trauma indications at our institution. Data were analyzed regarding sex, age, indication, operative parameters, length of hospital stay, postoperative morbidity, and mortality. Furthermore, we performed a literature survey using the PubMed database and reviewed reported cases of EPD. Eleven EPD cases due to benign non-trauma indications were analyzed. Indications included peptic duodenal ulcer with penetration into the hepatopancreatic duct and the pancreas, duodenal ulcer with acute uncontrollable bleeding, and penetration into the pancreas, and a massive perforated duodenal diverticulum with peritonitis and sepsis. The mean operative time was 369 min, and the median length of hospital stay was 35.8 days. Postoperative complications occurred in 4 out of 11 patients (36.4%). Total 90-day postoperative mortality was 9.1% (1 patient). We reviewed 17 studies and 22 case reports revealing 269 cases of EPD. Only 20 cases of EPD performed for benign non-trauma indications are reported in the literature. EPD performed for benign non-trauma indications remains a rare event, with only 31 reported cases. The data analysis of all available cases from the literature revealed an increased postoperative mortality rate of 25.8%. If less invasive approaches are exhausted, EPD is still a life-saving procedure with acceptable results. Performed by surgeons with a high level of experience in hepatobiliary and pancreatic surgery, mortality rates below 10% can be achieved.

A case of duodenal perforation and pancreatic bleeding after flexible ureteroscopy for right renal pelvis UTUC

Upper tract urothelial carcinoma (UTUC) can be managed by flexible ureteroscopy (f-URS) and tumor laser ablation if kidney-sparing surgery is possible. This procedure can be affected by minor to serious complications, including life-threatening sepsis, ureteral strictures, and ureteral and renal pelvis injuries. The case of a 53-year-old man with history of high grade right renal pelvis and bladder tumor who undergone multiple endoscopic treatments and has already refused radical surgery is reported. F-URS and laser ablation with Thulium: YAG laser for UTUC recurrence of the right renal pelvis was performed, but the procedure was stopped due to significant bleeding which impaired vision. Postoperatively, the patient developed hematemesis and hemodynamic instability due to duodenal lesion and active bleeding documented at CT scan. An emergency exploratory laparotomy was performed to drain hemoperitoneum, repair duodenal lesion and concurrent radical right nephroureterectomy was carried out. A second surgery was necessary for repairing duodenal fistula. After 1 week the patient presented again with recurrent hematemesis and hemorrhagic shock. He underwent angiography and selective embolization of the duodenal branch of superior mesenteric artery and as well as branches of gastroduodenal artery successfully and the patient recovered with no other complications. This is the first case of duodenal perforation and pancreatic bleeding due to flexible ureteroscopy and laser ablation of right renal pelvis urothelial carcinoma.

448 Case Study of a Giant Duodenal Perforation: Where Is the Ampulla?

Abstract Concurrent duodenal and gallbladder perforation is a rare finding. Whilst cholecystoduodenal fistulas have been observed in literature, massive duodenal perforation with gallbladder erosion has not been recorded. We present the case of a 77-year-old female who was found to have a giant duodenal perforation (measuring 10cmx5cm) with an associated gallbladder perforation as well. On patient’s first presentation, a Computed Tomography of the abdomen was performed due to abdominal pain and constipation. Images showed pneumoperitoneum and intra-abdominal free fluid. Upon performing an explorative laparotomy, findings of duodenal and gallbladder perforations were observed. Distal gastrectomy, cholecystectomy and gastrojejunostomy were performed. Due to uncertainty of the location of the ampulla to the ulcer edges, a cholangiogram catheter was advanced into the Ampulla of Vater via the Cystic Duct to definitively identify it prior to D1/D2 stapling. Gastrograffin study was conducted on Day-5, showing good contrast flow. No major events occurred during her post operative recovery. The main concern is inadvertent stapling of D1/D2 together with the ampulla. The passage of a catheter down the Cystic Duct, into the Common Bile Duct and through the ampulla is a definitive way to locate its position. In addition, Common Bile Duct patency with cholangiography can be ensured. Intra-operative improvisation such as advancing a cholangiogram catheter into the ampulla would assist surgeons in safely resecting proximal duodenum especially when it encroaches on the D1/2 junction.

779 Endoscopic Repair of a Chronic Duodenal Perforation Complicated by a Contained Collection: A Case Report

Abstract Duodenal perforations are a surgical emergency with high mortality. Most perforations require open or laparoscopic surgical repair, whereby the ulcer is oversewn, sometimes using a Graham patch. However, surgery is not without complications. We report the case of a 70-year-old man with a chronic, perforated duodenal ulcer that was repaired endoscopically. The patient presented with a 1-month history of epigastric abdominal pain, exacerbated by eating, and associated with a weight loss of 3.5 stones. Examination revealed a hard, irregular mass in the epigastrium. CT imaging showed a 6.8cm x 5.2cm x 4.1cm collection with an air-fluid level communicating with the D2 duodenum and extravasation of contrast into the collection. The collection was unable to be drained under radiological guidance due to difficulty in visualising and accessing it. Surgical intervention was deemed difficult to due to the site and chronicity of the perforation. The patient underwent endoscopic repair. Two interrupted sutures were placed using an Apollo overstitch system. APC was applied to the edges of the perforation and an OVESCO clip was placed ontop. Repeat CT imaging did not show any evidence of recurrent perforation. Endoscopic repairs have mainly been performed as an adjunct to surgical repair or during ERCP procedures, primarily using endoclips. We present a case where endoscopic repair alone was successful in sealing a duodenal perforation whilst leaving the collection intact. We believe this case is interesting and with advances in endoscopy, endoscopic repair could provide a minimal invasive option for managing duodenal perforations, especially complicated, chronic ones.

Insidious and lethal course of duodenal perforation in crohn’s disease with retroperitoneal abscess formation and right kidney necrosis

A 60-year-old woman with a long history of Crohn‘s disease and rheumatoid arthritis was admitted to the emergency department due to progressive severe cramping with abdominal pain (right upper quadrant), subfebrile temperature, and obstipation since 3 weeks. She had been treated by her rheumatologist for rheumatoid arthritis with certolizumab pegol, prednisolone and leflunomide

Double Gastric and Duodenal Perforations at The Fousseyni Daou Hospital in Kayes in One Case

We report the observation of a patient presenting with acute generalized peritonitis. Emergency surgery found a double perforation, one on the stomach and the other on the duodenum. We performed a suture revival of the perforations plus a gastro-entero-anastomosis, then washed and drained the cavity. We discuss the diagnostic and therapeutic features of this rare condition.

Comparative study of laparoscopic versus open peptic perforation repair

Background: Peptic perforation is very common emergency in general surgery. Peptic perforation is the terminology used for perforation of duodenal ulcer or perforation of gastric ulcer. Peptic perforations require surgical intervention by Graham’s omental patch repair. This surgical intervention can be done by laparoscopic or open surgery. Methods: The study was carried out in 40 patients between June 2022 to April 2023. In this study, we have included all the patients who present to emergency department with peptic perforation either gastric or duodenal. Patients who present with gastric perforation with/due to carcinoma and peptic perforation with septicemia and ARDS are not included in this study. In this study, patients were randomly allocated in two groups: group A (n=20) includes laparoscopic peptic perforation repair. And group B (n=20) includes open peptic perforation repair. Author have compared two groups in terms of intraoperative time, post-operative hospital stay and post-operative complications like surgical site wound infection, post-operative pain. Results: This study shows that there is no significant difference in intraoperative time between two groups but significant decrease in hospital stay, surgical site wound infection and post-operative pain in group A patient than in group B patients. Conclusions: Laparoscopic peptic perforation repair significantly reduces post-operative pain, surgical site infection and hospital stay.

Nasojejunal tube-related duodenal perforations: a multicenter experience.

Nasojejunal tube-related duodenal perforations: a multicenter experience.

Correlation of serum albumin level on postoperative day 2 with hospital length of stay in patients undergoing emergency surgery for perforated peptic ulcer.

Perforated peptic ulcer (PPU) is a common emergency surgical condition and a significant cause of morbidity and mortality worldwide. While advances in surgical techniques have improved outcomes for patients with PPU, many factors still affect postoperative hospital stay and overall prognosis. One potential factor is the serum albumin (SA) level, a widely utilized marker of nutritional status that has been associated with length of stay and complications in various surgical procedures. To clarify the correlation of SA level on postoperative day 2 with hospital length of stay (HLOS) in patients undergoing emergency surgery for perforated peptic ulcer (PPU). We retrospectively collected and analyzed clinical baseline data, including blood routine and SA levels, of patients who underwent emergency PPU surgery and postoperative treatment at the Lingnan Hospital, the Third Affiliated Hospital of Sun Yat-sen University between December 2012 and September 2021. Patients were grouped according to HLOS with 7 d as the cut-off value, and relevant indicators were analyzed using SPSS 26.0. Of the 37 patients undergoing emergency surgery for PPU referred to our department, 33 had gastric and 4 had duodenal ulcer perforation. The median HLOS was 10 d. There were 8 patients in the ≤ 7-d group (median HLOS: 7 d) and 29 patients in the > 7-d group (median HLOS: 10 d). The ≤ 7-d group had markedly higher SA on postoperative day 2 than the > 7-d group (37.7 g/L vs 32.6g/L; P < 0.05). The SA level on postoperative day 2 was a protective factor for patients with HLOS > 7 d (Odds ratio = 0.629, P = 0.015). The cut-off of SA on postoperative day 2 was 30.6g/L, with an area under the curve of 0.86 and a negative predictive value of 100% for the prediction of HLOS ≤ 7 d. The SA level on postoperative day 2 was associated with the HLOS in patients undergoing emergency surgery for PPU. The pre- and post-operative albumin levels should be monitored, and infusion of human SA should be considered in a timely manner.

IgG4-related disease of duodenal obstruction due to multiple ulcers in a 12-year-old girl

BackgroundImmunoglobulin G4-related disease (IgG4-RD) is a systemic inflammatory disease and affected individuals typically present with an increased infiltration of IgG4-positive plasma cells in the pancreas, hepatobiliary tract, and liver but rarely in the gastrointestinal tract.Case presentationA 12-year-old girl presented with vomiting and poor weight gain. Gastroscopy revealed duodenal stenosis and ulceration. Computed tomography revealed edematous duodenal wall thickening and air-fluid levels on the right side of the duodenum, which suggested duodenal perforation or penetration. She underwent pancreaticoduodenectomy, and IgG4-RD was diagnosed via histopathology.ConclusionsThis is the first pediatric case of isolated duodenal IgG4-RD resulting in duodenal obstruction after multiple ulcers. Gastrointestinal IgG4-RD should be among the differential diagnoses of unexplained gastrointestinal obstruction or ulceration even in children.

Duodenal perforation caused by deferasirox “case report”

Duodenal perforation caused by deferasirox “case report”

Pancreas-sparing partial duodenectomy as an alternative to emergency pancreaticoduodenectomy for a major duodenal perforation: a case report.

A 71-year-old woman underwent endoscopic submucosal dissection for early duodenal cancer at the second portion of the duodenum and developed acute peritonitis due to delayed duodenal perforation. Emergency laparotomy was performed. A huge perforation formed at the descending duodenum without ampulla involvement. Pancreas-sparing partial duodenectomy (PPD) with gastrojejunostomy was performed (250min operative time) with 50mL of intraoperative blood loss. She required intensive care for 3days and was discharged on postoperative day 21 with no severe complications. Emergency treatment for a major duodenal injury or perforation remains challenging because of high morbidity and mortality. An appropriate treatment should be considered according to the nature of the defect. Although PPD is an acceptable procedure for patients with a duodenal neoplasm, its use in emergency surgery is rarely reported. PPD is more reliable than primary repair or anastomosis using a jejunal wall, and less invasive than pancreaticoduodenectomy, for emergency treatment. We performed PPD in this patient because the duodenal perforation was too large to reconstruct and did not involve the ampulla. PPD can be a safe and feasible alternative surgical procedure to pancreaticoduodenectomy for a major duodenal perforation, especially in patients with a duodenal perforation that does not involve the ampulla.

Valentino's Syndrome: from History to Images. A Case-Based Literature Review

In the emergency setting, right lower quadrant pain is a common clinical scenario. While acute appendicitis is the most relevant cause, there is a wide differential diagnosis. Valentino syndrome is a rare entity in which gastric or duodenal perforation, usually secondary to peptic ulcer disease, presents clinically with right lower quadrant pain mimicking acute appendicitis. It has its origins in Rudolph Valentino, a famous American actor who died of sepsis following an undiagnosed perforated ulcer after an appendectomy. Nowadays, radiological images play a crucial role in this pathology, historically diagnosed using exploratory laparotomy. Through a clinical case and a review of the literature, we aim to describe the historical evolution of Valentino’s syndrome, illustrate its clinical and radiological characteristics and highlight the increasing role of imaging, particularly computed tomography, in its early prospective diagnosis and in guiding targeted treatment. Finally, it is important to consider this pathology when assessing acute abdominal patients with coexisting pneumoperitoneum and appendicitis.

Duodenal ulcer perforation and its consequences.

Duodenal ulcer perforation, a frequent surgical emergency, needs simple closure with indirect Graham's Omentopexy which is effective with excellent results in majority of cases despite patients' late presentation. The objective of the study was to determine the frequency of postoperative complications of perforated duodenal ulcer, conducted in the Surgery Department, Jinnah Postgraduate Medical Centre, Karachi, from March 20, 2018 to September 20, 2018. The study was a descriptive case series of 108 patients of both genders with perforated duodenal ulcer > 1 week old with ASA score I & II. Patients with trauma and comorbidities were excluded. The patients underwent laparotomy and peritoneal toilet, and after noting the site of perforation indirect Graham's Omentopexy was performed. Complications like duodenal fistula, peritonitis, and paralytic ileus, and patient's death within 10 days of surgery were noted. Age ranged from 18 to 50 years with mean age of 35.027±5.13 years, mean weight 71.120±12.77 kg, mean height 1.541 ±0.09 metres, mean BMI 29.975±4.99 kg/m2, and the mean duration of complaint was 4.194±1.30 weeks. Male predominance in 75 (69.4%) patients. Duodenal fistula was seen in 10 (9.3%) patients, peritonitis 12 (11.1%), paralytic ileus 14 (13%) and mortality was in 11 (10.2%) patients.

ERCP-induced perforation: review and revisit after half a century

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure. We aimed to investigate ERCP-induced perforations at our institution and conduct a comprehensive review of literature on ERCP-induced perforations (EIP) since the introduction of this procedure as a therapeutic intervention. Methods: This was a case-control study, in which charts of all patients diagnosed with ERCP-induced duodenal perforation were reviewed and compared to a control group without perforation. Patient’s sociodemographic and clinical data, including ERCP procedure-related data, were gathered. Results: A total of 996 ERCP procedures were performed; only 13 patients proved to have EIP. Obstructive jaundice was the most common indication for ERCP. The main predisposing factor was difficult cannulation (P = 0.003). In total, five patients required surgical treatment; the majority of them had type I perforation, whereas type IV was the most common in patients who were treated conservatively. The overall mortality rate was 15%, the surgical group had a slightly higher mortality rate. Conclusions: Fifty years after the introduction of ERCP for therapy, it remains an invasive procedure that carries significant morbidity and mortality, even in skilled hands or at high- volume units. Conservative management of perforation yields favorable outcomes in selected patients.