Duodenal Repair Research Articles

EP.TH.691Necrotic Liver Abscess secondary to Duodenal Perforation caused by ingestion of a Fish Bone – A Case Report

IntroductionIngestion of foreign bodies are not uncommon, however enterohepatic migration of fish bones causing liver abscesses remains a rare phenomenon.Case ReportWe present the case of a 58-year-old female admitted with 11 days history of fever, rigors, shortness of breath and malaise associated with vomiting and diarrhoea. Her COVID-19 rapid antigen test was negative. She was tender in the left lower quadrant of her abdomen and inflammatory markers were markedly high so initial differential diagnosis included colitis and diverticulitis.Contrast Computed Tomography of the abdomen and pelvis showed an 8.1cm irregular hepatic lesion initially thought to be a multi-loculated abscess, malignancy or complex cyst. She was started on broad-spectrum antibiotics, escalated to Intensive Care Unit (ICU) and discussed at the hepato-biliary multi-disciplinary team (MDT) where magnetic resonance images demonstrated a perforated duodenum from a 2.5cm fish bone penetrating from the duodenal wall into the liver parenchyma causing a necrotic abscess.She underwent percutaneous drainage of the hepatic abscess. Endoscopic retrieval was then attempted; however, the fish bone was not visualised. Definitive management followed with laparoscopic removal of the fish bone and primary duodenal repair.DiscussionIdentification of the cause of the abscess during MDT discussion enabled prompt source control which was key in managing intra-abdominal sepsis – radiological drainage in the first instance prevented secondary peritonitis from a potentially ruptured abscess and enabled the patient to be de-escalated from ICU. Previous literature suggests endoscopic retrieval however, laparoscopic surgery remains safer for managing complications following removal of sharp foreign bodies.

Institutional Variation in Gastrostomy Tube Placement After Duodenal Atresia Repair in Children With Trisomy 21.

To compare institutional practice patterns for gastrostomy tube placement in neonates with duodenal atresia (DA) and trisomy 21. A retrospective review of the Pediatric Health Information System (PHIS) from 2015 to 2018 identified infants <10 days old with ICD-10 diagnostic codes for DA and trisomy 21, in addition to procedure codes for an intestinal bypass or duodenoduodenostomy. This cohort was then queried for gastrostomy tube procedure codes and diagnostic codes for associated co-morbidities. Two hundred and nine infants were identified with DA, trisomy 21, and an intestinal bypass. Fifty-seven (27%) underwent gastrostomy placement. Baseline characteristics of those with and without gastrostomy tubes were similar. Patients from 16 hospitals that placed no gastrostomy tubes (No-G-tube-Hospitals) were compared to children from 30 hospitals that placed at least one gastrostomy tube (G-tube-Hospitals). Open atresia repairs occurred more frequently at G-tube-Hospitals, but patients were otherwise similar. There was no difference in readmission at 12 months for gastrostomy placement between children from No-G-tube-Hospitals and those from G-tube-Hospitals that did not undergo gastrostomy during their index admission. One-third of institutions in this study did not place gastrostomy tubes during index admissions for neonates with trisomy 21 and DA, yet this did not negatively impact the length of stay or incidence of subsequent gastrostomy placement as a result. Future research is needed to determine factors that predispose patients to failure without gastrostomy, as well as best practices for post-operative management in these patients to reduce unnecessary tube placement.

Characterization of technical skill progress in a standardized rabbit model for training in laparoscopic duodenal atresia repair

BackgroundLaboratory skills training is an essential step before conducting minimally invasive surgery in clinical practice. Our main aim was to develop an animal model for training in clinically highly challenging laparoscopic duodenal atresia repair that could be useful in establishing a minimum number of repetitions to indicate safe performance of similar interventions on humans.Materials and methodsA rabbit model of laparoscopic duodenum atresia surgery involving a diamond-shaped duodeno-duodenostomy was designed. This approach was tested in two groups of surgeons: in a beginner group without any previous clinical laparoscopic experience (but having undergone previous standardized dry-lab training, n = 8) and in an advanced group comprising pediatric surgery fellows with previous clinical experience of laparoscopy (n = 7). Each participant performed eight interventions. Surgical time, expert assessment using the Global Operative Assessment of Laparoscopic Skills (GOALS) score, anastomosis quality (leakage) and results from participant feedback questionnaires were analyzed.ResultsParticipants in both groups successfully completed all eight surgeries. The surgical time gradually improved in both groups, but it was typically shorter in the advanced group than in the beginner group. The leakage rate was significantly lower in the advanced group in the first two interventions, and it reached its optimal level after five operations in both groups. The GOALS and participant feedback scores showed gradual increases, evident even after the fifth surgery.ConclusionsOur data confirm the feasibility of this advanced pediatric laparoscopic model. Surgical time, anastomosis quality, GOALS score and self-assessment parameters adequately quantify technical improvement among the participants. Anastomosis quality reaches its optimal value after the fifth operation even in novice, but uniformly trained surgeons. A minimum number of wet-lab operations can be determined before surgery can be safely conducted in a clinical setting, where the development of further non-technical skills is also required.

No Abdominal Drainage After Single-Port Laparoscopic Repair for Perforated Duodenal Ulcers

Nowadays, closure of the perforation with or without omental patch is the main surgical approach for most perforated duodenal ulcer. There have been limited high-quality studies to clarify the role of drainage after perforated duodenal ulcer laparoscopic repair. We performed this study to evaluate the role of abdominal drainage after simple closure for the treatment of low-risk perforated duodenal ulcer. A consecutive case series was conducted including patients with size of duodenal perforation no more than 5 mm who underwent single-port laparoscopic simple repair at Hue University of Medicine and Pharmacy Hospital from January 2012 to June 2018. In this study, sixty-five executive perforated duodenal ulcer patients with the size of the perforation no more than 5 mm, an ASA score equal or less than 3, and a Boey score of 0 or 1 were treated by single-port laparoscopic simple repair. All patients (100%) had a perforation of the anterior side of duodenum. The mean size of the perforations was 3.4 mm. We did not use abdominal drainage after single-port laparoscopic simple closure without omentoplasty. There were no documented leakage of the repair site and no residual abscess postoperatively. The mean analgesic use duration was 2.8 ± 0.8 days. The mean hospital stay duration was 5.6 ± 0.8 days. At 30-day follow-up, one patient (1.5%) had wound infection. No port-site hernia was found and there was no mortality. For small-size and low-risk perforated duodenal ulcer, no-drainage after single-port laparoscopic simple repair is safe and effective. The patients without abdominal drainage require less analgesic use and have short hospital stay.

Early Oral Feeding Compared With Traditional Postoperative Care in Patients Undergoing Emergency Abdominal Surgery for Perforated Duodenal Ulcer.

IntroductionEnhanced recovery after surgery (ERAS) protocols have been widely studied in elective abdominal surgeries with promising outcomes. However, the use of these protocols in emergency abdominal surgeries has not been widely investigated. This study aimed to evaluate ERAS application outcomes via early oral feeding compared to regular postoperative care in patients undergoing perforated duodenal ulcer repairs in emergency abdominal surgeries.Materials and methodsWe conducted a randomized controlled trial at the Surgical Unit 1 Benazir Bhutto Hospital from August 2018 to December 2019. A total of 42 patients presenting to the emergency department with peritonitis secondary to suspected perforated duodenal ulcer were included in the study. Patients were randomly assigned into two groups. Group A patients followed an ERAS protocol for early oral feeding, and Group B received regular postoperative care (i.e., delayed oral feeding). Our primary outcomes were the length of hospital stay, duodenal repair site leak, the severity of pain (via the visual analog scale), and postoperative ileus duration. Results were analyzed via IBM Statistical Product and Service Solutions (SPSS) Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp.). and chi-square and independent t-tests were applied.ResultsPatients who received early oral feeding (Group A) showed a shorter length of hospital stay, lower pain scores, and shorter postoperative ileus duration than patients in the traditional postoperative care group. Also, we noted no duodenal repair site leak in the early oral feeding group. The differences between the two groups were statistically significant (P<0.05).ConclusionsBased on our results, ERAS protocols that promote early oral feeding can be applied in patients undergoing emergency abdominal surgery for perforated duodenal repair. Early oral feeding in emergency surgery patients can reduce the patient burden on hospitals. In addition, early oral feeding can promote better outcomes and reduced economic burden for patients. Keywords: Perforated duodenal ulcer, ERAS protocol, randomized controlled trial, duodenal repair site leak, length of hospital stay, VAS score, postoperative ileus.

Laparoscopic Repair of Near Complete Traumatic Duodenal Transaction in an Eight Years Old Child: A Case Report

Background: Traumatic duodenal perforation is a serious injury and is a result of major trauma and insult to the body. The management is difficult due to associated injuries and these children often need major resuscitation. The standard surgical treatment of traumatic duodenal perforation is laparotomy and repair of duodenal perforation. In children, laparoscopic repair of duodenal perforation is reported in only a few cases. Case: A repair of a near-complete duodenal transaction is not reported in the pediatric population. Herein, we report a case of an eight years old child who had a road traffic accident, and sustained multiple injuries and duodenal perforation, as confirmed by radiological evaluation including CT abdomen. The child was resuscitated, and later laparoscopy was performed, which showed gross bruising of the abdominal wall and a nearcomplete transaction at the level of 3rd part of the duodenum. Conclusion: Laparoscopic repair of the duodenum was performed using interrupted polyglycolic sutures. The child had a smooth post-op recovery and was discharged home in stable condition. At one-year follow-up, the child remained well and symptom-free. This case highlights the role of the safety of laparoscopic surgery in abdominal trauma and duodenal perforations.

Traumatic duodenal injuries in children: a single-centre study.

Traumatic duodenal injuries in children are rare, and few studies have documented duodenal injuries in children, especially in Australasia. This study assessed the mechanism, investigations, management and outcomes of children (aged <16 years) with duodenal injuries. Retrospective review was conducted over a 16-year period from a single paediatric trauma centre. Sixteen cases of duodenal injuries were identified: 15 cases of blunt duodenal injury and only one case of penetrating injury. Motor vehicular accidents were the most common cause of injury, followed by auto-pedestrian injuries and handlebar injuries. Only grade I and II injuries were identified. Computed tomography aided diagnosis in all cases of blunt duodenal injuries, especially given the variable nature of symptoms. Eight patients underwent laparotomy, of whom five required duodenal repair. Three patients underwent primary repair with omental patch, one patient underwent primary repair with gastrostomy and one patient underwent two-layered repair with t-tube duodenostomy. There were no delays in operative management within 24 h and no complications identified. In comparison to other paediatric trauma centres worldwide, the majority of duodenal injuries were low grade and attributed to blunt trauma. Computed tomography aided diagnosis in all cases of blunt duodenal injury. Primary repair of duodenal injuries was possible in the majority of cases requiring operative repair.

Percutaneous radiologic gastrostomy as bridge to definitive surgery in a very preterm infant with combined esophageal and duodenal atresia

Due to the rarity of the association of esophageal and duodenal atresia, no consensus exists regarding the optimal treatment strategy. However, a staged approach is advised in order to reduce morbidities and improve survival. We report a case of a very preterm infant with combined esophageal and duodenal atresia, treated successfully with a staged approach. Treatment consisted in percutaneous radiologic gastrostomy placement prior to tracheoesophageal fistula ligation and esophageal anastomosis, and in delayed duodenal atresia repair. The use of the radiologic approach for gastrostomy placement proved to be minimally invasive, effective and without complications, even in a very preterm baby.

A study on autonomous suturing task assignment in robot-assisted minimally invasive surgery.

Sutures are a set of standard actions which are accomplished by multi-instruments, researchers studied the robot autonomy of suturing, which was based on movement planning completed by a single instrument, but did not consider the assignment of suturing tasks to instruments. A method was proposed for the autonomous suturing task assignment to instruments, which built a comprehensive evaluation index under some constraint conditions to determine the optimal scheme of the suturing task assignment to instruments. An experiment of duodenal ulcer repair with a suturing operation was conducted under the guidance of a surgeon, and the results showed that the optimal scheme of the suturing task assignment was obtained by using the proposed method. The proposed method can be used for autonomous suturing task assignment, which is beneficial for improving the intelligence of robot operation.

Duodenal Leakage—Damage Control Using Modified Tube Duodenostomy

After emergency duodenal repair, the post-operative duodenal leakage rate ranges from 2 to 12% and is associated with high mortality. Furthermore, no standard management protocol is available in the high-risk post-operative duodenal leakage setting. We aimed to review our experiences of modified tube duodenostomy (one gastric opening for trans-gastric tube duodenostomy, trans-gastric feeding tube jejunostomy, and peri-duodenal external drainage) for high-risk post-operative duodenal leakage patient and describe outcomes and clinical characteristics. From 2008 to 2019, eight consecutive patients in a high-risk post-operative duodenal leakage setting underwent modified tube duodenostomy (mTD). Post-operative mortality or low of follow-up were developed in three patients, and these case details with post-operative duodenal leakage were reviewed. The modified tube duodenostomy operations were performed for duodenal ulcer bleeding and perforation in all eight patients. The leakage developed in five patients, and there were 2 deaths in early post-operative period because of multiple organ failure. In survived patients, mean post-operative intensive care unit (ICU) stay was 30.8 days, and mean overall hospital stay day was 89.8 days. Mean enteral feeding was started at 6.5 days post-operatively. In leakage-developed patients who survived, external peri-duodenal drainage and duodenostomy tube removals were performed at 38 and 50 days post-operatively. We describe for the first time modified tube duodenostomy, which in our experience is easy and simple. In particular, modified tube duodenostomy should be considered a surgical option in the high-risk post-operative duodenal leakage setting. According to our experience and despite its several limitations, modified tube duodenostomy was technically feasible in terms of long-term critical and general care in a peri-operative hemodynamically unstable state. However, to gain further information on the topic, we suggest multicenter studies be conducted to further delineate clinical outcomes and the clinical feasibility of modified tube duodenostomy.

Traumatic Duodenal Injury: Current Management Update

Although duodenal injuries are a rare entity of all trauma, they carry high risk of morbidity and mortality. The management of duodenal injuries should encompass a multidisciplinary approach. Optimal operative management of duodenal injuries has evolved in the last few decades. Isolated duodenal injuries are rare due to its proximity to major vascular and organ structures. Immediate mortality from duodenal injuries is due to hemorrhage from major vascular injuries. Non-operative management of isolated low-grade classification of duodenal injuries is accepted with close clinical and laboratory monitoring of patients. When operative management is necessary, recent evidence suggests simple repair over complex reconstructions that carry less morbidity and improved outcomes. When dealing with injuries to the duodenopancreas complex, reconstruction of the pancreaticobiliary system should involve expertise of hepatobiliary surgeons. Management of duodenal injuries and its complications should engage a multidisciplinary approach. Damage control techniques should be utilized in patients in extremis with associated major vascular injuries. Low-grade duodenal injuries may be monitored closely with clinical examinations and laboratory values. When duodenal repair is needed, conservative repair techniques over complex reconstructions should be utilized.

Aortoduodenal fistula after abdominal aortic aneurism resection: Two case reports

Introduction. Aortoenteric fistula (AEF) is rare and extremely difficult complication of aortic surgery. We presented two cases of secondary aortoduodenal fistula (SADF) as complication after aortic surgery. Case reports. In the first patient SADF happened 11 years after open abdominal aneurysmal resection with gastrointestinal tract (GIT) bleeding. After negative esophagogastroduodenoscopy (EGDS) we performed multislice computed tomography (MSCT) which revealed contrast leakage in duodenum from 10 cm wide visceral aortic aneurysm. The patient was treated with graft excision, aneurysmal reduction, sewing of proximal and distal aortal stumps, bowel repair followed by axillobifemoral bypass (AxFF). The patient dismissed on 30th postoperative day. The second case of ADF happened five months after endovascular reconstruction of abdominal aorta with GIT bleeding and fewer. During following 8 days, he had three negative EGDS. On MSCT we found signs of endoleak, free air in aneurysmal sac, and signs of blood in the intestine. On urgent operation we extracted stent graft, sewed proximal and distal aortal stumps, performed bowel repair and AxFF. The patient died a day after operation with signs of sepsis and multiple organ failure syndrome. Conclusion. Conventional treatment of ADF means extraanatomic AxFF with complete excision of infected graft or stent graft, with closure of aorta?s proximal and distal stumps and duodenal repair. Because of high mortality, prompt diagnostic evaluation and quick decision of an adequate operative treatment is necessary. Although European Society of Vascular Surgery recommendations, as a guide, are very helpful, there is no unique attitude about management of AEF, so each patient should be specifically treated.

Bilioptysis due to a single transcavitary thoracoabdominal gunshot wound

A 27-year-old man was transported to our trauma center after sustaining a single gunshot wound. On arrival, he was hemodynamically stable and neurologically intact, with a non-tender abdomen and negative...

2274 Laparoscopic Primary Repair of Duodenal Perforation after Laparoscopic Para-Aortic Lymphadenectomy

Video Objective To present of laparoscopic primary repair of duodenal perforation after laparoscopic paraaortic lymphadenectomy for the patient with endometrial carcinoma. Setting Case study. University hospital in Korea. Interventions A 78-year-old Korean woman with postmenopausal bleeding and thickened endometrium presented to our department. The histopathology of biopsied endometrium revealed grade 1 endometrioid adenocarcinoma. The preoperative MRI shows an about 5cm sized tumor within the endometrial cavity suspicious myometrial invasion. We perform the laparosco pic staging surgery on April 2, 2019. No intraoperative complications were recognized. However, on postoperative day 1, the color of intra-abdominal drainage change from serosanginous to dark green. We strongly suspected small bowel perforation and perform secondary laparoscopic surgery immediately. Peritoneum and prior operative site were tinged with bile. We scrutinized the small bowel and finally found the perforation site on duodenum. The perforation occurred at the horizontal part of duodenum ventrally vena cava. We carried out laparoscopic primary repair with 3-0 vicryl. Double layer closure was done by interrupted suture in first layer and Lambert suture for second layer. Then, we placed drainage into the duodenal repair site and traced the small bowel meticulously. We reviewed the video of primary surgery. But there was no definitive procedure related with duodenal perforation. We thought that the thermal injury was occurred by ultrasonic cutting and coagulating device during the lymphadenectomy in pre-caval area just below duodenum or mechanical micro-perforation is made during lifting the duodenum by dissecting forcep. After duodenal repair, endoscopically guided placement of nasogastric tube was performed. Gastrography did not show any leakage at the site of duodenal repair on postoperative day 3. Conclusion Immediate laparoscopic primary repair of duodenal perforation after laparoscopic paraaortic lymphadenectomy is safe and feasible.

Development and Preliminary Validation of a Rabbit Model of Duodenal Atresia for Training in Pediatric Surgical Skills

Duodenal atresia is a congenital defect that requires advanced surgical skills. The objective of this study is to present an anatomical defect of duodenal atresia using a rabbit model and evaluate the preliminary experience for the training of surgical skills with pediatric surgeons. Adult white New Zealand male rabbits weighing 3.0 to 4.5 kg were used to create the defect. To simulate the bottom of the dilated blind pouch, the gastric antrum of the rabbit was obliterated using a 2-0 Prolene suture, and the cecal appendix was dissected to simulate the continuation of the duodenum. Participants performed laparoscopic duodenal atresia repair in this animal model using the iPhone trainer. Thirteen pediatric surgeons with experience in laparoscopic duodenal atresia repair assessed this model with a questionnaire on 5-point Likert-type scale. Overall, the simulated model of duodenal atresia obtained a general average score of 4.39. The highest observed average was for its physical realism, whereas the lowest score was in surgical experience. The global opinion of the model obtained a score of 4.40. In addition, all surgeons answered that this rabbit model showed the same complexity as newborns and young children in the repair of this type of defect. The inclusion of new models through rabbits in pediatric surgery programs will allow the development of advanced skills of pediatric residents and surgeons.

2562 Duodenal Perforation From an Inferior Vena Cava Filter as a Rare Cause of Persistent Abdominal Pain

INTRODUCTION: Deep vein thrombosis (DVT) continues to be a significant source of morbidity for surgical patients. Inferior vena cava (IVC) filter placement is indicated for DVT in patients who have contraindications to anticoagulation or failure of anticoagulation. Over the last decade, there is exponential increase of IVC filter placement with increased complications reported. These include IVC penetration, IVC occlusion, insertion complication and filter migration. We report a rare case of symptomatic duodenal perforation by an IVC filter migration. CASE DESCRIPTION/METHODS: A 33-year-old female with a history of paraplegia secondary to motor vehicle accident, recurrent DVTs, and placement of IVC filter 10 years ago presented to the hospital for persistent epigastric pain for the past 5 years. Patient denied any nausea, vomiting, diarrhea, or hematochezia. Physical exam showed epigastric tenderness. Labs including complete blood count were unremarkable. CT scan showed a longstanding IVC occlusion with collaterals and displaced IVC filter into the duodenum and into the L3 vertebral body (Figure 1). An EGD confirmed prong migration to the second portion of the duodenum (Figure 2). This was distal to the ampulla and penetrating the duodenal wall with the tip embedding the opposite wall. Due to multiple workups being otherwise negative and symptomatic duodenal perforation of the IVC filter, she has been scheduled for an open IVC filter extraction with duodenal and caval repair. DISCUSSION: Duodenal and aortic perforations by IVC filters have been increasingly reported in the past 10 years although still rare. Penetration of the filter struts through the wall of the IVC can be asymptomatic. However symptomatic patients may present with epigastric pain, gastrointestinal bleeding and small bowel obstruction. Currently, there are no guidelines for the management of such patients. Most cases have been repaired using an open repair with excellent outcomes; however, endovascular retrieval and repair is being recognized as an alternative option especially in high risk patients. This case illustrates that even though IVC migration and perforation is a rare complication, it needs to be recognized as a potential cause for gastrointestinal symptoms in these patients. Retrievable IVC filters should always be removed if possible when deemed unnecessary to prevent complications such as migration from developing.

Assessment of PULP score in predicting 30-day perforated duodenal ulcer morbidity, and comparison of its performance with Boey and ASA, a retrospective study.

Background/aim: Scores commonly employed to risk stratify perforated peptic ulcer patients include ASA (American Society of Anesthesiologists), Boey and peptic ulcer perforation score (PULP). However, few studies assessed and compared the accuracy indices of these three scores in predicting post PPU repair 30-day morbidity. We assessed accuracy indices of PULP, and compared them to Boey and ASA in predicting post perforated duodenal (PDU) ulcer repair 30-day morbidity.MethodsRetrospective chart review of all PDU patients (perforated duodenal ulcers only) at the largest two hospitals in Qatar (N = 152). Data included demographic, clinical, laboratory, operative, and post repair 30-day morbidity. Area under the Curve (AUC), sensitivity and specificity were computed for each of the 3 scores. Multivariate logistic regression assessed the accuracy indices of each score.ResultsAll patients were males (M age 37.41 years). Post PDU repair 30-day morbidity was 10.5% (16 morbidities). Older age, higher ASA (≥3), Boey (≥1) or PULP (≥8) scores, shock on admission and preoperative comorbidities; and conversely, lower hemoglobin and albumin were all positively significantly associated with higher post PDU 30-day morbidity. PULP displayed the largest AUC (72%), and was the only score to significantly predict 30-day morbidity. The current study is the first to report the sensitivity and specificity of these three scores for post PDU repair 30-day morbidity; and first to assess accuracy indices for PULP in predicting post PDU repair 30-day morbidity.ConclusionPULP score had the largest AUC and was the only score to significantly predict post PDU repair 30-day morbidity.

LAPAROSCOPIC REPAIR OF PERFORATED DUODENAL ULCER PATCH VERSUS CONVENTIONAL SURGERY

Introduction: For many surgeries for duodenal ulcer Laparoscopic repair has become gold standard for many elective procedures such as ant reflux procedures, laparoscopic cholecystectomy and in colorectal surgery. Although in the emergency setting such as in the management of perforated duodenal ulcer Laparoscopic repair has been slow and limited. Since 1990, for the treatment of perforated peptic ulcer Laparoscopic repair has been used which has been widely accepted as an effective method. Duodenal ulcer is defined as a peptic ulcer which develops in the first part of the small intestine called duodenum and usually present as a perforation of acute abdomen. In perforated duodenal symptoms as severe and sudden onset abdominal pain that is worse in right upper quadrant and epigastrium and usually followed by nausea and vomiting. In this situation there is rapid generalization of pain and in examination shows peritonitis with lack of bowel sounds. Aim: The main objective of this study is to evaluate outcome of laparoscopic surgery in comparison with conventional surgery. Material and methods: All the patients with clinically diagnosed with perforated duodenal ulcers presenting within 24 hours of symptoms and undergoing surgery were included during the study period. Total 50 patients were included with age group 15-65 years. All the patients with perforated duodenal ulcers were included which go through either conventional open or laparoscopic without omental patch repair. Result: Total 50 patients were included in these studies which were divided into two group with 25 patients in each group as laparoscopic duodenal perforation repair group and conventional open repair group. Mean duration of operation (in minutes) was 105.4±10.4 in laparoscopic duodenal perforation repair group whereas mean duration of operation (in minutes) was 67.3±8.6 in conventional open repair group. Mean duration of number of doses of analgesics required in laparoscopic group and conventional open group as 9.5±1.7 and 17.2± 3.1 respectively. Out of 25 patients in each group of laparoscopic duodenal perforation repair group and the conventional open repair group the outcome were noted with their post operative complication as shown in table no 5 below. In Post-operative complications 21(84%) patients in laparoscopic duodenal perforation repair group and 14(56%) patients in conventional open repair group had no complications. 4 (16%) patients in the laparoscopic duodenal perforation repair group and 2(8%) patients in conventional open repair group showed Post-operative complications as chest infection. In the conventional open repair group patients present with wound dehiscence and wound infection and Wound dehiscence and chest infection were 4(16%) and 5(20%) respectively whereas nil in Laparoscopic duodenal perforation repair group. Conclusion: Duodenal ulcer perforation is a life-threatening emergency which required urgent management for the patients. Due to the advance in duodenal ulcer perforation closure by laparoscopy it becomes popular and favorite choice. With certain criteria, laparoscopic closure of perforated duodenal ulcer is safe and effective though it was associated with longer operating time and had no impact on the outcome. Hence laparoscopic closure was better in comparison to open repair for the earlier returns to normal daily activities.&#x0D; Keywords: Duodenal ulcer, Laparoscopic repair, Post-operative analgesia, conventional surgery

Primary repair of duodenal injuries: a retrospective cohort study from a major trauma centre in South Africa.

The management of duodenal trauma remains controversial. This retrospective audit of a prospectively maintained database was intended to clarify the operative management of duodenal injury at our institution and to assess the risk factors for leak following primary duodenal repair. This was a retrospective study undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. Operative techniques used for duodenal repair were recorded. Our primary outcome was duodenal leak in the postoperative period. Patients from January 2012 to December 2016 were included. All duodenal injuries were graded according to the American Association for the Surgery of Trauma (AAST) grading. Only patients who had a primary repair were included in the final analysis. During the five-year data collection period, a total of 562 patients underwent a trauma laparotomy; of which 94 patients sustained a duodenal injury. A primary pyloric exclusion and gastro-jejunostomy (PEG) was performed in three patients. These three were then excluded from further analysis. Of the 91 primary duodenal repairs, seven (8%) subsequently leaked. These were managed by PEG in three and by secondary repair and para-duodenal drainage in four. The two physiological parameters most associated with subsequent leak were lactate and pH level. There was a significantly higher mortality rate for those who leaked vs those who did not leak. Chi-squared test revealed a significant difference in the leak rate between AAST I (0%), AAST-II (1.6%) and AAST-3 (66.7%) grade injuries (p <0.01). The trend towards primary repair of duodenal injuries appears to be justified. However duodenal leak remains a significant risk in certain high risk patients and strategies to manage injuries in this subset requires further work.

PARIETAL PERITONEUM GRAFT FOR DUODENUM INJURIES IN AN ANIMAL MODEL.

ABSTRACTBackground: Duodenal injuries and their surgical procedure cause a high morbidity and mortality. Aim:To assess the overall effectiveness of the auto-graft of peritoneum in the treatment of the perforation of the duodenum, aiming to reduce surgery time, costs, complexity and mortality. Methods:Twelve New Zealand rabbits, ages 4-6 months, both sexes, underwent designed surgical grade III duodenal injuries that were repaired 18 h after. Rabbits were surgically treated with the proposed auto-graft of peritoneum. Results:No postoperative deaths were observed; the animals presented corporal weight increase and were euthanized six months later. There was no significant difference between both groups relating to the postoperative evolution or in the histological changes. Conclusion: Auto-graft of the peritoneum and posterior fascia is a useful option for duodenal repair and that is worth of evaluation for humans.