Duodenal Repair Research Articles

WP6.4 - General Surgery Bootcamp: Improving Induction for Higher General Surgery Training

Abstract Aim To create an introductory course or “bootcamp” to assist new ST3s transition from working at core trainee to General Surgical Registrar level. Method Using previous expertise of “bootcamps” delivered in the region in similar specialities, a 3-day programme was designed to offer training in areas aligned to the curriculum and considered useful to newly starting higher surgical trainees. The course involved a mix of simulation-based workshops, lectures and skill-based labs. The programme was delivered by a senior faculty directing activity with support from industry partners and medical education/simulation expertise. A range of skills were targeted using animal, virtual and augmented reality models, low and high-fidelity simulation, and non-operative technical skills (NOTSS) in simulated ward and theatre environments. Results 26 trainees (23 new General Surgery ST3s, 3 returning to training) completed the bootcamp. Feedback questionnaires using a likert scale demonstrated clear improvements in trainees’ own skill perception in endoscopy, laparoscopy, open surgery and NOTSS. 100% of responding trainees’ were confident or strongly confident post course, compared to 69% before. We also showed an increase in confidence in laparoscopic suturing (77%), duodenal ulcer repair (69%) and operating in a stressful environment. Conclusions A transitional “bootcamp” can provide both tangible and intangible benefits. This project showed clear improvement in trainee confidence both in key practical and non-practical skills such as communication. It also enabled registrars to familiarise themselves with new colleagues, facilitating an early welcome from the region and embedded support network.

“Gastrointestinal Quality of Life After Congenital Duodenal Obstruction Repair: A Nationwide Long-term Follow-up Study”

BackgroundCongenital duodenal obstruction (CDO) is one of the most common gastrointestinal congenital anomalies. Still, patient-reported long-term results are limited. The aims of this study were to evaluate the long-term gastrointestinal quality of life (QoL), generic QoL, patient-reported scar appearance, and reinterventions after CDO repair. MethodsPatients who underwent surgery for CDO in Norway from 1995 to 2020 were invited to answer the validated questionnaires PedsQL and PedsQL gastrointestinal symptom scale and a study-specific questionnaire on general health and scar assessment. Parent-proxy reports were used for patients <12 years and patients with cognitive impairment. Scores were compared with an American and Norwegian control group for gastrointestinal and generic QoL, respectively. ResultsOf 186 eligible patients, eight were deceased, 25 had unretrievable contact information, and 79 did not respond. There were no significant differences between included (n = 74) and not included (n = 112) patients regarding baseline data. The mean follow-up time was 13.3 (SD = 6.6) years. Patients with CDO had significantly lower overall gastrointestinal QoL than controls (85.9 versus 90.0, p = 0.010). The most common symptoms were gas/bloating, constipation, food/drink limits, and reflux. Generic QoL was similar between the CDO population and controls (84.4 versus 85.3, p = 0.530). Twenty-one (28 %) patients had some degree of pain and/or concern related to the surgical scar. Nine (12 %) patients had reoperations related to the CDO repair; four due to adhesive small bowel obstruction. ConclusionA notable portion of patients report troublesome gastrointestinal symptoms and cosmetic concerns regarding their surgical scar after CDO repair. Even so, generic QoL was good. Level of evidenceIV.

Failed primary repair of blunt duodenal injury managed by tube duodenostomy, gastrojejunostomy and a feeding jejunostomy: a case report

BackgroundThe worldwide increase in road traffic crashes and use of firearms has increased the incidence of duodenal injuries. Upper gastrointestinal radiological studies and computed tomography (CT) in resource settings may lead to the diagnosis of blunt duodenal injury. Exploratory laparotomy remains the ultimate diagnostic test if a high suspicion of duodenal injury continues in the face of absent or equivocal radiographic signs. Although the majority of duodenal injuries may be managed by simple repair, high-risk duodenal injuries are followed by a high incidence of suture line dehiscence and should be treated by duodenal diversion.Case presentationWe report a case of a failed primary repair of a blunt injury to the second part of the duodenum (D2) in a 24-year-old African man. This was successfully managed by a tube duodenostomy, a bypass gastrojejunostomy and a feeding jejunostomy in a low resource setting.ConclusionsDetailed knowledge of the available operative choices in duodenal injury and their correct application is important. When duodenal repair is needed, conservative repair techniques over complex reconstructions should be utilised. The technique of tube duodenostomy can be successfully applied to cases of large defects in the second part of the duodenum (D2), failed previous repair attempts and with defects caused by different aetiology. It may remain especially useful as a damage-control procedure in patients with multiple injuries, significant comorbidities and/or haemodynamic instability.

Trends in Duodenal Injury Severity, Repair, and Mortality Over Time

IntroductionOutcomes for patients with traumatic duodenal injury are determined by the location of the injury, injury severity, and associated injuries. We hypothesized that there is an association among the increased frequency of firearm injuries, the severity of duodenal injuries, trends in repair techniques, and mortality. MethodsDuodenal injuries managed at an adult level 1 hospital from 2000 to 2022 were identified. Demographics, injury type, the American Association for the Surgery of Trauma (AAST) grade, type of surgical repair, and mortality data were obtained and aggregated into two periods (2000 to June 2011 and July 2011 to 2022) to evaluate trends over time. P values < 0.05 were considered significant. ResultsOne hundred eighty eight cases were identified. Duodenal injuries due to firearms increased over time (30% versus 55%, P < 0.001). The distribution of AAST injury grade shifted over time with fewer grade 1 and more grade 2 to 4 injuries in the later period (P = 0.002). AAST grade 2 injuries or higher were more likely due to firearms (P < 0.001). Despite more high-grade injuries, there was no change in the use of primary repair with or without tube drainage (61% versus 70%, P = 0.35) and there was no change in mortality (15% versus 17%, P value 0.62) between the time periods. ConclusionsThere was a proportional increase in the number of duodenal injuries caused by firearms. Higher grade duodenal injuries were more common with firearm injuries and were predominately repaired with simple techniques with no increase in mortality.

Multidisciplinary approach to a complex duodenal obstruction: From duodenal atresia to superior mesenteric artery syndrome

We present a 21yo female with a nausea, vomiting, and weight loss. Her history was remarkable for duodenal atresia repair as an infant. Following extensive evaluation, she was found to have progressive dilation of the proximal duodenum and loss of motility without obstruction (megaduodenum) which eventually lead to substantial weight loss resulting in superior mesenteric artery (SMA) syndrome. Given her symptomatic presentation, she was offered surgery and underwent a lateral duodenal tapering procedure and division of the ligament of Treitz and duodenal derotation (Strong procedure). Through the collaborative efforts of gastroenterology, pediatric surgery, radiology, and acute care surgery, she now has excellent functional status, has gained weight, and is asymptomatic. This case serves as an important example that congenital anomalies are a lifelong consideration when caring for patients

Congenital duodenal obstruction repair with and without transanastomotic tube feeding: a systematic review and meta-analysis

ObjectiveTo determine the impact of transanastomotic tube (TAT) feeding in congenital duodenal obstruction (CDO).DesignSystematic review with meta-analysis.PatientsInfants with CDO requiring surgical repair.InterventionsTAT feeding following CDO repair versus no TAT feeding.Main...

Association of Age at Duodenal Atresia Repair With Outcomes: A Pediatric NSQIP Analysis

PurposeNeonates with duodenal atresia (DA) are often born prematurely and undergo repair soon after birth, while others are delayed to allow for growth until closer to term corrected gestational age (cGA). Premature infants have been demonstrated to experience worse outcomes, but it is unclear whether delaying surgery mitigates the increased morbidity. This study evaluates the association of timing of DA repair with postoperative morbidity. MethodsWe retrospectively evaluated neonates undergoing DA repair from the National Surgical Quality Improvement Program-Pediatric database (2015–2020). A multivariable regression analyzed factors associated with composite morbidity, including cGA and age in days of life (DOL) at surgery. A propensity score matched analysis was completed in premature neonates born at ≤35 weeks gestation to compare outcomes at similar birth gestational ages (bGA) and birth weight who underwent early (<7 DOL) versus delayed (≥7 DOL) repair. Results809 neonates were included with a median bGA of 36 weeks (IQR 34–38), birth weight of 2.46 kg (IQR 1.96–2.95), and DOL at surgery of 2 (IQR 1–5). Infants born ≤35 weeks represented 35.23% of the cohort. On multivariable analysis, increasing cGA at surgery was associated with decreased morbidity (OR: 0.91, CI [0.84, 0.99]), and increasing DOL at surgery was associated with increased morbidity (OR: 1.02, CI [1.00, 1.04]). On propensity score matched analysis, delayed repairs were associated with increased postoperative ventilation (6 days vs. 2 days, p < 0.05); however, there were no differences in composite or surgical morbidity between early and delayed repairs. ConclusionsMorbidity after DA repair in neonates ≤35 weeks cGA is primarily driven by non-surgical causes, but delaying surgery does not appear to mitigate the risks associated with prematurity. It seems reasonable to consider repair in neonates around 33–34 weeks gestation without prohibitive risk factors. Optimal timing of DA repair requires a delicate balance between these factors. Level of EvidenceLevel III. Type of StudyRetrospective Cohort Study.

Vascular graft infection with duodenal fistulization 10 years after hybrid endovascular aortic repair with renovisceral debranching: a case report

BackgroundA secondary aortoenteric fistula after an aortic graft replacement or endovascular aortic repair is a rare but devastating complication that leads to extremely high morbidity and mortality. Because reports of vascular graft infection with enteric fistulization complicating in a hybrid aortic repair with renovisceral debranching are limited, the management method such as the extent of removal of the infected graft, reconstruction procedures, and the ideal type of graft are still debatable.Case presentationWe report a successful case of a 73-year-old man presenting a vascular graft infection with duodenal fistulization, 10 years after hybrid endovascular aortic repair with renovisceral debranching for a 60-mm diameter of supra-renal abdominal aortic aneurysm. The patient had a history of polymyalgia rheumatica on oral prednisolone, perigraft seroma, deep vein thrombosis, and an allergy to rifampicin. The patient eventually recovered after partial removal of the grafts, in situ reconstruction using Fusion Bioline vascular prosthesis, primary duodenal repair, application of omental flap, and antibiotics without any evidence of re-infection after 1.5 years.ConclusionsAlthough hybrid endovascular aortic repair is considered advantageous, especially for the elderly and high-risk patients, due to the avoidance of extracorporeal circulation and thoracotomy; once a devastating complication happens, an optimal treatment method should be considered for patients with several comorbidities. Although our procedures provided favorable results, careful monitoring to avoid re-infection is mandatory.

Modified circumumbilical approach for duodenal atresia repair : A scarless surgery

Background: Duodenal atresia is a common congenital anomaly causing neonatal intestinal obstruction. The definitive treatment is to restore the intestinal continuity. Laparotomy via upper transverse abdominal incision has been described by many authors as a standard approach for duodenal atresia repair. Here we report a case of newborn underwent duodenal atresia repair via modified circumumbilical approach with satisfactory postoperative outcome. Case presentation: This is a case of premature baby boy, born at 32-week gestation with a birth weight of 1.5kg. Antenatally he was detected to have double bubble sign which was confirmed upon postnatal abdominal radiograph, suggestive of duodenal atresia. He was noted to have a fleshy lump at the umbilicus presumed to be a patent vitello-intestinal duct from the referring hospital. Subsequently he developed umbilical swelling suspicion of umbilical hernia with incarceration and scheduled for emergency umbilical exploration. A circumumbilical incision was made and found to have an umbilical defect with omental herniation, instead of a patent vitello-intestinal duct. A proximal midline incision was made as an extension to the circumumbilical wound enabling a duodenal kocherization and subsequently had duodeno-jejujonostomy anastomosis for the duodenal atresia repair. Postoperative recovery was uneventful with appealing cosmesis. Conclusion: A modified circumumbilical incision is an attractive alternative approach for a duodenal atresia repair. Apart from its cosmetic advantage, the approach provides adequate exposure for similar outcome with transverse abdominal incision.

A028 Duodenal injury and repair during a laparoscopic biliopancreatic diversion with duodenal switch

A028 Duodenal injury and repair during a laparoscopic biliopancreatic diversion with duodenal switch

Duodenal Atresia Repair: A Single-Center Comparative Study.

The use of laparoscopy in the repair of duodenal atresia has been increasing. However, there is no consensus regarding which surgical approach has better outcomes. We aimed to compare the different surgical approaches and types of anastomoses for duodenal atresia repair. Patients who underwent duodenal atresia repair at a single pediatric center were identified between January 2006 and June 2022. Those with concomitant gastrointestinal anomalies or who required other simultaneous operations were excluded. The primary outcome was rate of complications, defined as rate of leak, stricture, and re-operation by surgical approach and technique of anastomosis. A total of 78 patients were included. The majority were female (51.3%, n = 40), with a median age of 4 days (IQR 3.0,8.0) and a median weight of 2.7kg (IQR 2.2,3.3) at repair. The re-operation rate was 7.7% (n = 6), of which two were anastomotic leaks, and four were anastomotic strictures. The leak rate was 5.6% (n = 1/18) for the open handsewn and 4.8% (n = 1/21) for the laparoscopic handsewn technique. The stricture rate was 12.5% (n = 1/8) for the laparoscopic-assisted handsewn, 9.1% (n = 2/22) for the laparoscopic U-clip, 4.8% (n = 1/21) for the laparoscopic handsewn, and none with laparoscopic stapled and laparoscopic converted to open handsewn techniques. No differences were found in complication rate when controlling for surgical approach. The method of surgical approach did not affect the outcomes or complications in the repair of duodenal atresia.

Laparoscopic repair of duodenal atresia using ministapler: Initial experience

• This study shows recent results of duodenal atresia repair by minimal invasive surgery using mini stapler vs laparoscopic hand sewn anastomosis in a tertiary hospital. • Duodenal atresia repair using ministapler for side to side DD anastomosis could make a challenging procedure more simple and reproducible in less expert hands.

Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial.

Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur. A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA. Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible. Therapeutic/Care Management; Level IV.

Frequency of Wound Infection after Duodenal Ulcer Perforation Repair

Aim: To determine the frequency of wound infection after duodenal ulcer perforation repair. Methodology: This descriptive Case series Study in the department of Surgery, Khyber Teaching Hospital from February 2021-July 2021, Peshawar. A total of 123 patients with perforated duodenal ulcer, included those aged 20 to 60 years. Immuno-compromised patients, CRF &amp; CLD were excluded. A single dose of broad-spectrum antibiotic was given prior to undergone open repair by a consultant surgeon followed by two more shorts of antibiotic given post operatively at the interval of 8 hours each. Patients were followed postoperatively for 4 weeks and surgical site infection was noted. Results: The study patients age ranged from 20 to 60 years, with a mean age of 43.77±9.35 years. Most of the patients 77(62.60%) were in the 20–40 years age range.Male to female ratio of these 123 cases was 2.1:1, with 83(67.48%) males and 40(32.52%) females. In our study, frequency of wound infection after duodenal ulcer perforation repair was found in 28(22.76%) patients. Conclusion: This study concluded that the clinicians should take some practical recommendations regarding control of surgical site infectionsin order to lower the morbidity and mortality of these specific patients. Keywords: perforated duodenal ulcer, open repair,surgical site infection.

Une Liaison Dangereuse: Spontaneous Pyeloduodenal Fistula.

We describe the case of a 76-year-old woman with a spontaneous nephroduodenal fistula. The patient was initially evaluated for gastrointestinal and urinary symptoms associated with fever and anemia, after which she was admitted with the diagnosis of right chronic pyelonephritis, hydronephrosis, and renal lithiasis. The fistula was diagnosed incidentally by percutaneous pyelography during a right nephrostomy and was later confirmed with an abdominal CT scan. A multidisciplinary decision was made to surgically treat the fistula (right nephrectomy plus duodenal repair); the surgery had a short-term positive outcome. We report a systematic review of the literature related to spontaneous pyeloduodenal fistulæ and their treatments.

Repair by Primary Closure of Traumatic Blunt Duodenal Injuries: Simple is Not Always Safe

IntroductionRecent literature on managing traumatic duodenal injuries suggests the superiority of primary repair. We hypothesized that duodenal trauma repair by primary closure might not be a safe strategy in an environment dealing predominantly blunt injuries with limited resources. MethodsData analysis was done from the prospectively maintained trauma registry. The study period chosen was from January 1, 2014 to December 31, 2018. Data of 63 patients were analyzed for demographics, injuries, management, and outcome. Logistic regression was used to identify mortality predictors. ResultsThe most common mechanism of injury was blunt (56/63, 88.9%). Forty (63.5%) patients had associated intraabdominal injuries. The most common American Association for the Surgery of Trauma grade of injury to the duodenum was three in 21 patients. Univariate analysis showed that mortality was associated with hypotension on presentation, higher duodenal grade, associated abdominal vascular injuries, primary closure, and duodenal leak. Logistic regression showed associated associated abdominal vascular injuries, primary closure, and leak remained significant predictors of mortality. ConclusionsPrimary repair was found to be an independent predictor of mortality. A patient's physiology is a critical determinant of the outcome. Liberal use of tube duodenostomy over primary repair seems reasonable for blunt duodenal injury management.

EP-245 A snapshot review of the use of prophylactic antibiotics for emergency gastrointestinal surgeries: a tertiary care centre experience

Abstract Aim The administration of recommended prophylactic antibiotics on time for emergency gastrointestinal surgery (GIS) is effective in reducing surgical site infections (SSI) and expediting post-operative recovery. This audit aims to assess the optimum use of prophylactic antibiotics in patients undergoing emergency GIS. Methods The data of all patients undergoing emergency GIS over a 1-month period was reviewed according to UH Sussex NHS trust (microguide) guidelines. The data was extracted, transferred and analysed using Microsoft Excel. Results Forty-one patients underwent emergency GIS during the study period. Emergency GIS procedures included laparoscopic appendicectomy (n=20), open colorectal resections (n=5), laparoscopic colorectal resections (n=3), perforated duodenal ulcer repair (n=2), inguinal hernia repair (n=2), diagnostic laparoscopy (n=2), defunctioning ileostomy (n=2) and other (n=5). Recommended antibiotics were administered in 17 (41.5%) patients and 29 (70.8%) patients were administered antibiotics at the correct time. Surgical site infections (SSI) were seen in 6 (14.5%) patients, of which 2 (11%) patients were in the recommended-antibiotics group and 4 (16.5%) in the non-recommended antibiotics group (p= 0.05). Two patients (2/29; 6.8%) contracted SSI in the group which received antibiotics on time. The major factor behind using non-recommended antibiotics and not administering antibiotics at the recommended time was the continuation of antibiotics commenced at the time of admission. Conclusion A significantly higher proportion of patients undergoing emergency GIS were not administered the recommended antibiotics. Moreover, almost one third of patients were not administered antibiotics on time. Use of non-recommended antibiotics results in higher incidence of SSI in patients undergoing emergency GIS.

Internal reconstruction of an extended full‐thickness duodenal mesenteric laceration through an antimesenteric duodenotomy in a dog

AbstractA 4‐year‐old English setter was presented for acute vomiting secondary to suspected consumption of a foreign body. Unusually extensive full‐thickness lacerations along the mesenteric border of the descending duodenum were present in association with devitalisation of portions of the ascending duodenum. To preserve the duodenum, total duodenectomy with associated biliary tract diversion was not considered. Ascending duodenectomy was performed. The descending duodenal mesenteric lacerations were managed using an internal primary closure technique through an antimesenteric duodenotomy. This particular technique is described, and its potential complications are discussed in this case report. While the outcome of this case report was excellent, more studies are needed before recommending this technique as part of the instrumentarium of duodenal repair.

Pitfalls in laparoscopic duodenal atresia repair requiring modifications in approach based on literature review

Pitfalls in laparoscopic duodenal atresia repair requiring modifications in approach based on literature review

Platelet-rich Plasma Injection for Enterocutaneous Fistula: A Case Report

An ECF is an abnormal communication between the small or large bowel and the skin. PRP provides a variety of bioactive factors to promote wound healing. This case report details the use of PRP in the management of ECF. A 52-year-old male with a history of duodenal perforation and duodenal fistula repair surgery presented with intermittent discharge of light-yellow material from the drainage tube removal site. Symptoms had not improved after 7 months of dressing changes. The patient had no signs or symptoms of generalized sepsis or peritonitis. A diagnosis of ECF was made based on the symptoms and physical examination. One application of PRP was injected into the fistula, and the fistula closed within 2 weeks. At 6-month follow-up, the patient had neither fistula recurrence nor abdominal pain. The findings in this case report suggest that PRP can be used in the management of ECF in patients with no signs and symptoms of generalized sepsis or peritonitis to promote fistula closure and decrease time to healing.