Duodenal Repair Research Articles

Evaluation of repair in duodenal perforation with human amniotic membrane: An animal model (dog).

Background:There is a growing tendency toward application of human amniotic membrane (HAM) as a biologic substitute in various tissue injuries where a significant tissue loss is a matter of concern. In gastrointestinal injuries especially duodenal ones, some potential limitations in current surgical techniques contribute to not fully acceptable healing outcomes. Thus, this study was carried out to assess repair with HAM patch for duodenal defect in comparison with simple duodenoraphy in an animal model (dog).Materials and Methods:A total of 15 male German shepherd dogs weighing 23-27 kg were randomly divided into two groups. Group A with 10 dogs, which were a candidate for duodenal repair by amniotic membrane patch and Group B consisted of 5 dogs perform simple duodenorraphy. A precise control was made to match all conditions except surgical technique. Macroscopic and microscopic features of the healed duodenal lumen in both groups were recorded.Results:Gross evaluation revealed no difference in luminal diameter in both groups. Statistical analysis of duodenal diameter between both groups after operation also showed no significant difference (Pv = 0.789). Histological assessment indicated less inflammation with better wound healing in Group A.Conclusion:It seems that repairing duodenal wall defect with HAM would result in better histological outcomes compared with what is seen in simple duodenoraphy in animal models. However, there is no significant difference regarding surgical findings.

Suspension Sutures for Complex Neonatal Anastamoses

Introduction: Complex neonatal congenital defects pose a challenge for surgical repair utilizing minimally invasive techniques. We demonstrate a technique using suspension stitches to facilitate the thoracoscopic repair of esophageal atresia and laparoscopic repair of duodenal atresia. We detail the placement of a stitch that suspends the anastomosis. This lifts the surgical field up to facilitate visualization, provides a dynamic source of traction, and minimizes instrumentation of delicate tissue. Methods: Esophageal atresia: a 1-day-old 2900 g baby boy presented with an aberrant right subclavian artery, a left-sided aortic arch, proximal esophageal atresia, and distal tracheoesophageal fistula. Preoperative chest radiograph demonstrated a short gap. In the operating room (OR), he was placed on high-frequency oscillator ventilation and positioned in the exaggerated left lateral decubitus position (nearly prone). A thoracoscopic approach was used with a 3-mm equipment, ligating and dividing the azygous vein and tracheoesophageal fistula in standard fashion. A 4-0 absorbable, monofilament suture was placed through the chest wall near the spine, through the proximal pouch, through the distal esophagus, and back out the chest wall to bring the two ends of the esophagus together. This suspension stitch facilitated completion of the anastomosis with good visualization and minimal manipulation of the tissues. An 8F feeding tube was guided through the anastomosis and a 12F chest tube placed into the right hemithorax. Duodenal atresia: a 2-day-old 2700 g baby girl presented with trisomy 21, balanced AV canal, duodenal atresia, and annular pancreas. A radiograph demonstrated a double bubble with no distal gas. In the OR, she was intubated and positioned supine. A laparoscopic approach was used with the 3-mm equipment, first confirming normal rotation and identifying the proximal and distal ends of the duodenum with intervening annular pancreas. A 4-0 braided, absorbable suture was placed through the abdominal wall near the fundus of the gallbladder, through the proximal duodenum, through the distal duodenum, and back out the abdominal wall to bring the two ends of the duodenum together. This suspension stitch facilitated completion of the anastomosis with good visualization and minimal manipulation of the tissues. Results: Operative time for thoracoscopic esophageal atresia repair was 90 minutes. Nasogastric feeds were initiated with return of bowel function. An esophagram on postoperative day 5 showed no leak. Oral feeds were started and the thoracostomy tube removed. Repeat esophagram at 1 year showed no stricture. Operative time for laparoscopic duodenal atresia repair was 120 minutes. Feeds were initiated on postoperative day 7, once orogastric tube output had decreased. Conclusion: We demonstrate use of suspension stitches to line up difficult anastomosis. This technique is useful in a variety of settings and accomplishes the aforementioned goals of lifting the surgical field into view, provides traction that can be tightened/loosened as necessary, and minimizes tissue handling in this fragile patient population. Using this technique, we are able to routinely repair these congenital defects in neonates weighing as little as 1.7 kg. Suspension stitches provide another innovative method to build reproducible success in dealing with these difficult congenital anomalies. The authors have no relevant financial disclosures. Runtime of video: 5 mins

Incidence, Histology and Management of Intraluminal Thrombus at Post-Chemotherapy Retroperitoneal Lymph Node Dissection

We determined the incidence, histology and management of intraluminal thrombus in a large group of patients treated with post-chemotherapy retroperitoneal lymph node dissection. We queried the testicular cancer database at our institution from January 1990 to June 2010. Tumor resection en bloc with major vascular structures and/or thrombectomy at post-chemotherapy retroperitoneal lymph node dissection was done in 240 patients, of whom 89 had a total of 98 intraluminal thrombi involving major vasculature. The site of the 98 thrombi was the inferior vena cava (72), aorta (1) and renal vein (20). Management of the 72 vena caval thrombi included cavectomy (36), partial cavectomy (9) and thrombectomy (27). For the 20 renal vein thrombi management included nephrectomy (18) and thrombectomy (2). The single aortic thrombus was managed by aortic resection and replacement. Pathological evaluation revealed bland thrombi in 31 cases, necrosis in 23, teratoma in 28, active germ cell cancer in 12 and sarcoma in 4. In 40 patients a total of 71 additional procedures were required, including nephrectomy in 32, liver resection in 6, bowel resection in 7, thoracotomy in 6, vertebral resection in 3, orchiectomy in 11, and duodenal repair, ureteroureterotomy, stent removal, cholecystectomy, appendectomy and paraspinal tumor removal in 1 each. There were 17 Clavien III or worse complications in a total of 11 patients, including 2 deaths. Average estimated blood loss was 1,165 ml (range 200 to 7,000) and average hospital stay was 9.3 days (range 2 to 70). The incidence of intraluminal thrombus at post-chemotherapy retroperitoneal lymph node dissection is 5.8%. Cancer pathology was observed in 44.9% of cases. Surgeons who perform post-chemotherapy retroperitoneal lymph node dissection should be well versed in vascular techniques with respect to the major vasculature.

A case of wedge resection of duodenum for massive gastrointestinal bleeding due to duodenal metastasis by renal cell carcinoma

BackgroundGastrointestinal bleeding due to duodenal metastasis from renal cell carcinoma is extremely rare. Several previous reports have shown that embolic therapy or pancreatoduodenectomy (radical surgical resection) could be effective in controlling this type of clinical complication. Management is entirely dependent on the general condition and concurrent metastases at other sites. Optimizing the therapeutic strategies thus deserves further discussion and exploration.MethodsIn this report, we describe a patient with severe co-morbidities who underwent successful palliative wedge resection of duodenum and direct duodenal wall defect repair without reconstruction of duodeno-jejunostomy for acute upper digestive tract hemorrhage caused by duodenal metastasis from renal clear cell carcinoma.ResultsThe patient recovered uneventfully and did not experience rebleeding and frequent vomiting after surgery. Since then (1.5 years) he has had no evidence of rebleeding.ConclusionsGastrointestinal bleeding due to duodenal metastasis of RCC may benefit from emergent resection even in the presence of severe co-morbidities, and for palliative treatment.

Giant duodenal ulcer perforation: a case of innovative repair with an antrum gastric patch

the treatment of a perforated giant duodenal ulcer (GUDs) represents a formidable surgical challenge regarding the duodenal wall defect repair in severe peritonitis setting. A high incidence of dehiscence and hospital mortality (15-40%- has been reported with the majority of the techniques). We report a case of GUDs perforation successfully treated with a subtotal gastrectomy and a gastric patch with the remnant antrum, for repairing the duodenal defect. a 63-years-old man with antecedents of peptic ulcer disease presents a large duodenal ulcer perforation with 48 hrs delay and associated with severe peritonitis and a retroperitoneal collection. A subtotal gastrectomy with Billroth II reconstruction and reconstruction of the duodenal defect with a patch of the remnant antrum was carried out. The patient was discharged at 17th postoperative day with good tolerance. the duodenal defect repair with a patch of the remant antrum, represents a valid alternative in similar circumstances. To our knowledge, it appears to be the first clinical description of this technique.

Repair of duodenal atresia under spinal anesthesia in a low-birth-weight preterm neonate: case report

Duodenal atresia is a well-recognized cause of neonatal bowel obstruction. General anesthesia with tracheal intubation is the traditional anesthetic technique for surgical correction of this condition. Metabolic abnormalities and fluid deficits coupled with residual anesthetics are known to increase the risk of postoperative apnea, prolonging the operating room time and delaying extubation. Spinal anesthesia (SA) is an accepted alternative to general anesthesia in formerly preterm infants. In the current literature, there are reports of successful use of SA for simple infraumbilical surgery and, occasionally, for upper abdominal surgery, but there is no information on the use of SA in neonates for duodenal atresia repair. We present a case of duodenal atresia in a preterm infant at a gestational age of 30 weeks with coexisting bronchopulmonary dysplasia successfully repaired under SA. Further studies that compare the adverse effects with the potential advantages of SA are warranted before future recommendations are made for neonates who are undergoing upper abdominal surgery.

Intraluminal Erosion of Laparoscopic Gastric Band Tubing into Duodenum with Recurrent Port-Site Infections

Intraluminal erosion of a laparoscopic gastric band into the stomach has been reported as a complication of laparoscopic adjustable gastric banding. To our knowledge, however, intraluminal erosion of the band tubing into the duodenum has not been described. We report a 46-year-old man in whom a laparoscopic adjustable gastric band tubing eroded into the duodenal lumen, causing recurrent port-site infections. This complication was diagnosed on upper endoscopy and also, in retrospect, on an upper gastrointestinal barium study and computed tomography. The patient underwent surgical removal of the band and tubing, with a primary duodenal repair, and made a complete recovery without complications. Erosion of laparoscopic band tubing into the duodenum should be included in the differential diagnosis for recurrent port-site infections after laparoscopic adjustable gastric banding. Radiographic or endoscopic visualization of the intraluminal portion of the tubing may be required for confirmation. Definitive treatment of this complication entails surgical removal of the tubing from the duodenum.

Ladd's procedure as an adjunct to treating combined traumatic duodenal and spinal injuries

Traumatic duodenal injuries are a rare and complex challenge. The surgeon facing such an injury has several options to repair this injury: primary repair with or without a serosal patch, performing a pyloric exclusion, adding a gastrostomy and/or feeding jejunostomy, and performing a gastro-enterostomy in order to bypass the duodenum. All of these options have a significant failure rate with persisting duodenal leakage and long-term morbidity. An often overlooked insult is concomitant spinal injury that may lead to a distal duodenal obstruction due to compression by the superior mesenteric artery (SMAS). This combined injury is noted when the mechanism is a high velocity blunt trauma such as seat belt injury during a motor vehicle accident. The contribution of this obstruction to the failure rate of the duodenal repair has not been addressed yet. We describe a case in which this event was foreseen and a Ladd’s procedure was added to the duodenal repair. It is our impression that avoiding SMAS may enhance the chances of a successful duodenal repair.

Management of Pancreaticoduodenal Injuries

The nature of the pancreatic or duodenal injury itself influences mortality, and is co-dependent on the presence of multiple other injuries, which account for most of the early mortality. Intra-abdominal sepsis leading to multiple organ failure accounts for most of the late deaths, indicating the importance of early haemodynamic stabilization, adequate debridement of devitalized tissue and wide drainage. Most duodenal injuries can be adequately managed with primary repair or resection and anastomosis. The presence of a pancreatic injury certainly increases the likelihood of an anastomic leak from a duodenal repair. With a significant associated pancreatic injury a more conservative initial approach to the duodenal injury may be more appropriate. Pancreatic injuries should be treated by debridement and simple drainage unless there is clinically obvious duct involvement. For distal injuries with duct involvement, a distal pancreatectomy is indicated. In injuries to the pancreatic head with clinical duct involvement, complex procedures such as pancreaticoduodenectomy should not be performed in the unstable patient with multiple injuries. Debridement and wide external drainage may be implemented and the resulting fistula dealt with at a later operation, if necessary. Large, complex, combined pancreaticoduodenal injuries may require temporary duodenal ligation or a pancreaticoduodenectomy and subsequent reconstruction.

Emergent endovascular treatment of a bleeding recurrent aortoenteric fistula as a “bridge” to definitive surgical repair

We report the case of a 59-year-old man who developed a recurrent aortoenteric fistula (AEF) following previous aorto-bifemoral bypass grafting and subsequent AEF open repair with aorto-bifemoral graft excision and extra-anatomic reconstruction. The patient was treated emergently by means of endovascular plug deployment via a left brachial approach into the infrarenal aortic stump, obtaining recovery of hemodynamic stability. Five days later, he underwent elective relaparotomy, aortic plug removal, infrarenal aortic ligature, and duodenal repair. Endovascular strategies to rapidly stop bleeding associated with recurrent AEF may serve as a "bridge" to definitive open repair, as in the case discussed herein. Even if rare, recurrent AEF following previous prosthetic aortic graft excision and extra-anatomic revascularization represents a dreadful event. Since surgical treatment is technically demanding and time consuming in emergent settings, we present an "unconventional" endovascular option to obtain quick cessation of aortic bleeding.

Primary aortoenteric fistula following endovascular aortic repair due to type II endoleak

An 84-year-old female was lost to follow-up after endovascular aneurysm repair at another hospital with known type II endoleak. She later presented with presyncope and hematemesis. A referral center esophagogastroduodenoscopy showed possible duodenal diverticulum. She had recurrent symptoms and repeat computed tomography scan showed air within the aortic sac. At our center, she underwent stent graft explantation and axillofemoral reconstruction for a primary aortoenteric fistula. She was discharged and is doing well 5 months postoperatively. A high degree of suspicion for aortoenteric fistula is imperative in any patient with upper gastrointestinal hemorrhage after open or endovascular abdominal aortic aneurysm repair.

Minilaparotomy for Perforated Duodenal Ulcer

The usefulness of the minilaparotomy approach for perforated duodenal ulcer repair was retrospectively evaluated in 37 patients (26 men; mean age, 56.5 years). Simple closure with an omental patch by minilaparotomy (skin incision, < or = 7 cm) was successful in 86.5% of the cases, with an operative mortality of 2.7%. Compared with the results in historic control patients who underwent conventional open surgery (n = 27), a shorter operative time (P < 0.01), lower frequency of analgesic use (P = 0.03), earlier passage of flatus (P < 0.01), and shorter hospital stay (P = 0.04) were obtained in the patients undergoing minilapartomoy. The postoperative morbidity was identical between the two groups (16.2% versus 33.3%, P = 0.40). On multivariate analysis, a large amount of intraabdominal fluid was the only significant risk factor for extension of the minilaparotomy wound (P = 0.012). The minilaparotomy approach appears to be a feasible, safe, and less invasive approach compared with the conventional open approach and could be a useful alternative to the laparoscopic approach in selected patients with perforated duodenal ulcer.

Neglected, Traumatic Duodenal Rupture - Case Report

A case of neglected, double-site, post-traumatic duodenal rupture, which was overlooked at the emergency laparotomy due to intra-abdominal bleeding is presented. For nine days the excessive laceration remained asymptomatic, probably because of visceral adhesions. Both tears of the duodenum were eventually repaired, but symptoms and signs of high mechanical obstruction had developed afterwards, requiring repeated surgery (gastric decompression). Endoscopy performed 2 weeks after duodenal repair showed both, repair site and gastro-jejunal anastomosis permeable. All symptoms quickly with-drawn and the patient recovered. Possible causes of the atypical clinical course in this case were discussed.

Fetal extraperitoneal rectal perforation presenting after duodenal atresia repair

Fetal extraperitoneal rectal perforation (FERP) is a very rare condition, but prompt diagnosis and appropriate treatment produce overall good outcome. We report the first case of FERP known to be associated with duodenal atresia, which only became clinically apparent after duodenal atresia repair and initially presented a diagnostic difficulty. Our case was successfully treated with a defunctioning colostomy and subsequent excision of the pseudocyst cavity. Proximal atresias can mask the presentation of FERP, and this diagnosis should be considered in cases of neonatal perineal and buttock swelling.

Laparoscopic management of perforated peptic ulcer with single suture or single suture and modified taylor procedure

Background-Aim Peptic ulcer perforation represents a major cause of mortality and morbidity. Requiring emergency attention and surgical management, it traditionally involved open repair — laparotomy. In 1989, Mouret et al. applied the first laparoscopic sutureless fibrin glue omental patch for perforated duodenal ulcer repair. The aim of this study is to show that laparoscopic management of a perforated ulcer produces very good results and is a less invasive technique compared with open repair.

Should We Be Concerned About Jejunoileal Atresia During Repair of Duodenal Atresia?

During repair for duodenal atresia, it has been emphasized that inspection of the small bowel to identify a second atresia is required. The laparoscopic approach for repair of duodenal atresia has been criticized for its limitation to perform this step. Given that duodenal atresia and jejunoileal atresias do not share common embryologic origins, we question the validity of this concern. Therefore, we conducted a multicenter retrospective review of duodenal atresia patients to quantify the incidence of jejunoileal atresia in this population. After institutional review board approval (IRB #07-12-187X), a retrospective review was conducted on all patients who have undergone duodenal atresia repair at seven institutions over the past 7-12 years. Demographics and the presence or absence of a jejunoileal atresia were recorded. Four hundred eight patients with duodenal atresia were identified. The mean gestaational age was 36.3 ± 2.9 weeks, and the mean weight was 2.5 ± 0.8 kg. Mean age at operation was 19 days (range, 1-1314). There was a 28% incidence of trisomy 21. Two patients (0.5%) were identified as having a second intestinal atresia, and both were type IIIb. One patient was diagnosed at the time of duodenal atresia repair; the other was a delayed diagnosis. Both patients did well after repair. In this, the largest series of duodenal atresia patients compiled to date, the rate of a concomitant jejunoileal atresia is less than 1%. This low incidence is not high enough to mandate extensive inspection of the entire bowel in these patients, and a second atresia should not be a concern during laparoscopic repair of duodenal atresia.

Pancreaticoduodenal injuries: re-evaluating current management approaches.

Pancreaticoduodenal injuries are uncommon owing to the protected position of the pancreas and duodenum in the retroperitoneum. Management depends on the extent of injury. This study was undertaken to document outcome of pancreaticoduodenal injuries and to re-evaluate our approach. A prospective study of all patients treated for pancreaticoduodenal trauma in one surgical ward at King Edward VIII hospital over a 7-year period (1998 - 2004). Demographic data, clinical presentation, findings at laparotomy and outcome were documented. Prophylactic antibiotics were given at induction of anaesthesia. A total of 488 patients underwent laparotomy over this period, 43 (9%) of whom (all males) had pancreatic and duodenal injuries. Injury mechanisms were gunshot (30), stabbing (10) and blunt trauma (3). Their mean age was 30.1+9.6 years. Delay before laparotomy was 12.8+29.1 hours. Seven were admitted in shock. Mean Injury Severity Score (ISS) was 14+8.6. Management of 20 duodenal injuries was primary repair (14), repair and pyloric exclusion (3) and conservative (3). Management of 15 pancreatic injuries was drainage alone (13), conservative management of pseudocyst (1) and distal pancreatectomy (1). Management of 8 combined pancreaticoduodenal injuries was primary duodenal repair and pancreatic drainage (5) and repair with pyloric exclusion of duodenal injury and pancreatic drainage (3). Twenty-one patients (49%) developed complications, and 28 required ICU admission with a median ICU stay of 4 days. Ten patients died (23%). Mean hospital stay was 18.3+24.4 days. The overall mortality was comparable with that in the world literature. We still recommend adequate exploration of the pancreas and duodenum and conservative operative management where possible.

The use of amniotic membrane in the repair of duodenal wounds in Wistar rats

In the search of a new material to repair duodenal wounds, a trial was conducted to assess the behavior of human amniotic membrane in the repair of the duodenal wall in rats. Fifty Wistar rats weighing between 250 and 350g, male, were submitted to duodenotomy and randomly distributed into two groups. Group A (n=8) had no treatment and was used as the control group. In Group B (n=42) the duodenal wound was treated with a patch of human amniotic membrane. All animals in Group A died. In Group B no changes were observed with regards to death or the formation of duodenal fistula. All animals presented peritoneal adherences in the region on the duodenal wall repair and intestinal obstruction was observed in two animals. Healing of the duodenal wall in the region of the patch took place progressively as the post-operatory period increased, with regeneration of the mucosa and of the smooth muscle layer. From the clinical standpoint, the amniotic membrane proved to be a biological tissue which served as a temporary seal and allowed the wound to heal by second-intention, with re-establishment of the duodenal wall structure.

Pneumatosis cystoides intestinalis of small bowel and cholecysto-duodenal fistula in stenosing peptic ulcer revealed by pneumoperitoneum

Pneumatosis of small bowel is a rare disease. Its association with a cholecysto-duodenal fistula is not often reported. This is the case of a 30-year-old man with a past medical history of duodenal ulcer, who presented in the emergency department for nonspecific abdominal pain. Abdominal X-ray revealed a pneumoperitoneum. Computed tomography showed a pneumoperitoneum, presence of air in the biliary tract and gas in the small bowel wall. Gastro-intestinal opacification revealed a cholecysto-duodenal fistula in a stenosing duodenal ulcer associated with pneumatosis cystoides intestinalis. The patient went on to have a truncal vagotomy and gastrojejunal anastomosis. A cholecystectomy and a duodenal repair were also performed. Computed tomography and a gastrografin study are very important for the diagnosis of pneumatosis cystoides intestinalis with cholecystoduodenal fistula in stenosing ulcer.

Duodenalperforation nach abdominalem Trauma

Duodenal perforation after a blunt abdominal trauma is a rare emergency situation that can result in life-threatening complications. We report on a woman who had a perforation of the duodenum after a supposed mild blunt abdominal trauma. Unremarkable at the initial presentation, the patient presented with acute abdominal pain and a retroperitoneal abscess five days after the initial trauma. The duodenal repair was performed with a Roux-Y anastomosis. Difficulties in diagnosis are very common, but the early recognition of the rupture is essential. The contrast-enhanced CT scan is the gold standard for diagnosis. Surgical management depends on the severity of the trauma and must be chosen on an individual basis.