Duodenal Stump Research Articles

Prophylaxis of damage of extrahepatic biliary ducts and pancreatic ducts while performance of gastric resection in accordance to Billroth II method for complicated duodenal ulcers

Objective. To elaborate a method of mobilization and a method of closure of “complex handed” duodenal stump while operating for complicated giant penetrating pyloroduodenal ulcers with the aim to prevent iatrogenic damage of extrahepatic biliary ducts and pancreatic ducts and to improve the results of surgical treatment of this pathology.
 Materials and metods. In the investigation 46 patients were included, who were operated on for complicated giant penetrating pyloroduodenal ulcers. Giant pyloroduodenal ulcers have had more than 2.5 cm size. The method of duodenal mobilization and the method of suturing of a “complex” duodenal stump were proposed. The method of duodenal mobilization consists of duodenotomy in the zone of a cicatricial-ulcerative transformation and intraintestinal digital upper and anterior stretching towards yourself of all duodenal walls from adhesive process, what includes mobilization of upper-horizontal and of part of descending duodenum portiions, using incision of visceral peritoneum along right and left edges of colon on a distance, sufficient to form its stump without tension. The method of suturing of a “complex” duodenal stump consists of duodenotomy in the affected zone of circular ulcer process. This permits to determine a degree of ulcerative stenosis, to exterritorize the ulcer and after duodenal mobilization, using the above mentioned method, to apply the duodenal mobilized walls for formation of a stump. Application of a one-raw interrupted screw-up sutures permits to distribute the pressure load along all sutures what enhances a mechanical strength of the sutures placed.
 Results. Average duration of the operation have constituted 136.6 min (95% CI: 125.2; 152.0); a stationary stay - from 7 to 26 bed-days, 15.7 days (95% CI: 13.1; 18.2) at average. Among early postoperative morbidity there were: infection in the wound zone - 2 (4.3%), pneumonia (4.3%), stroke - 1 (2.2%), pulmonary thromboembolism - 1 (2.2%), insufficiency of the duodenal stump sutures - 1 (2.2%) observation. Postoperative mortality have constituted 4.3%, 2 patients died, in 1 (2.2%) pulmonary thromboembolism was the cause of the death, and in 1 (2.2%) - hemorrhagic insult. The duodenal stump sutures insufficiency and extensive serous-fibrinous peritonitis were revealed in the patient on the 6th postoperative day in 1 (2,2%) patient. In 1 year 31 patients were examined: while performing of fibrogastroscopy in 1 (3.2%) patient the ulcer of posterior wall of gastrojejunoanastomosis was revealed, in 7 (22.6%) - superficial gastritis, in 1 (3.2%) - erosive gastritis of gastric stump.
 Conclusion. The proposed procedure for duodenal mobilization and the method of the duodenal stump formation in a complicated giant circular pyloroduodenal ulcer permits to minimize a possibility of the stump sutures insufficiency occurrence as well as the prevention of iatrogenic damage of biliary and pancreatic ducts, involved in the ulcer infiltrate, injury, and may be recommended for application in clinical practice. Special attention must be drawn to duodenal decompression in postoperative period and to intestinal stimulation.

Uncut Roux-en-Y gastrojejunostomy after totally laparoscopic distal gastrectomy: Learning curve and surgical outcomes.

Totally laparoscopic distal gastrectomy (TLDG) is now widely used for early gastric cancer patients, but the selection of a reconstruction method after TLDG is still controversial. Roux-en-Y gastrojejunostomy is increasingly used in expectation of less gastritis and alkaline reflux despite its technical difficulty. The uncut Roux-en-Y gastrojejunostomy (uRYGJ) retains the advantages of Roux-en-Y reconstruction but helps prevent Roux stasis syndrome. The present study aims to introduce a single surgeon's experience of TLDG with uRYGJ and analyze the learning curve and surgical outcomes. We retrospectively reviewed the medical records of 124 consecutive patients who underwent TLDG with uRYGJ performed by a single surgeon between July 2014 and August 2015 at Asan Medical Center. The baseline characteristics and surgical outcomes were analyzed, and the learning curve was drawn based on the power-law model. The mean total operative time was 165 minutes, and the average length of hospital stay was 6.6 days. Complications included two cases of duodenal stump leakage, two intra-abdominal bleeding, two intra-abdominal fluid collection, one wound problem, two anastomotic strictures, 14 ileus, and no anastomotic leakage. There were five cases of endoscopically proven reflux gastritis/esophagitis and no Roux stasis syndrome. There were five recurrences and one mortality during the follow-up period. The learning curve leveled at the 15th case. The results of our study showed the safety and feasibility of uRYGJ, and that the technical difficulty of the procedure can be overcome with a short learning curve for experienced surgeons.

Lobaplatin in Prophylactic Hyperthermic Intraperitoneal Chemotherapy for Advanced Gastric Cancer: Safety and Efficacy Profiles.

ObjectiveThis study aims to evaluate the safety and efficacy of lobaplatin in prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) for advanced gastric cancer.MethodsAdvanced gastric cancer patients who underwent radical gastric resection and/or prophylactic HIPEC were systematically reviewed in our department from January 2016 to June 2017. All enrolled patients were grouped in either HIPEC or non-HIPEC groups. Clinical data were collected and analyzed.ResultsA total of 129 patients were enrolled with 61 cases in the HIPEC group and 68 in the non-HIPEC group. The two groups were well balanced in terms of clinical characteristics. In patients of the HIPEC group, three suffered leakage from the duodenal stump or anastomosis, one suffered abnormal bleeding and two were found to have abnormal routine blood tests; no significant difference in adverse events between groups, however, was noted (p > 0.05) and most patients recovered uneventfully. During follow-up, peritoneal recurrence was significantly less among HIPEC patients (p = 0.029), with only three suffering peritoneal recurrence, as compared to 12 non-HIPEC patients. In addition, the estimated illness-specific 3-year disease-free survival rate was significantly higher in the HIPEC group as compared to the non-HIPEC group (89.4% vs.73.9%; p = 0.031).ConclusionLobaplatin in prophylactic HIPEC is safe for advanced gastric cancer patients after treatment by radical resection and can effectively improve illness-specific 3-year disease-free survival.

Management of duodenal stump fistula following gastrectomy for gastric cancer: a systematic review

Introduction: Duodenal stump fistula (DSF) after gastrectomy has a low incidence but a high morbidity and mortality, and is therefore one of the most aggressive and feared complications of this procedure. This study was designed to assess the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer.
 Methods: A systematic analysis of PubMed, MEDLINE, Current Contents, UpToDate databases, and the Cochrane Library Databases were carried out. A total of 80 manuscripts were retrieved and screened and nine studies published between 2009 and 2016 were selected. 241 cases of DSF were included in the study according to inclusion criteria. Only patients who underwent gastrectomy for gastric cancer were included in our review. Data about patient's characteristics, types of treatment, short and long-term outcomes were extracted and analyzed.
 Results: Three different approaches were applied: conservative (75 cases), surgical (138 cases) and percutaneous (59 cases). The overall mortality rate was 19% and significant complications were identified in 21% cases. Significant complications included sepsis, abscesses, peritonitis, bleeding, pneumonia and multiple organ failure. The conservative approach was reported in 5 studies including 75 patients who were clinically stable and complete resolution occurred in 92.3% of patients with a mean healing time of 35 days. Surgery was carried out if the patient was haemodynamically unstable or showed signs of sepsis. Overall outcome after surgery was poor with 31.1% mortality derived from six studies and in-hospital stay ranged from 1 to 1035 days (median 19). Percutaneous approach was often associated with conservative treatment and consisted of abscess drainage, biliary drainage or biliary diversion. The median healing time in this group was 42 days.
 Conclusion: Conservative approach is the first line of treatment in DSF, sometimes associated with percutaneous approach. Surgery should be reserved for severe cases or when conservative measures fail.
 Journal of Surgical Sciences (2018) Vol. 22 (1) : 62-66

Duodenal stump leakage. Lessons to learn from a large-scale 15-year cohort study

BackgroundDuodenal stump leakage is a challenging condition causing significant morbidity and mortality. The aim of this study is to identify the risk factors associated with duodenal leak and advocate modification to prevent the incident. MethodsA retrospective cohort study was performed to include patients who had gastrectomy with excluded duodenum in a single surgical centre in the period of Jan 2003–March 2017. Analysis of associated factors was performed. Patients with duodenal leak were further analyzed and the treatment strategy was reviewed. ResultsDuring the study period, 678 patients had gastrectomy with excluded duodenum. 502 patients had elective gastrectomy and 176 patients had emergency gastrectomy. 52 patients had subsequent duodenal stump leakage (7.7%). The existence of duodenal ulcer, intra-operative contamination, lower pre-operative haemoglobin and duodenostomy were the independent associated factors for duodenal leak. ConclusionThis is the largest cohort in studying associated factors regarding duodenal leak in both emergency and elective gastrectomy. The independent associated factors were identified. We advocate a conservative approach for duodenal leak with adequate drainage, nutrition and antibiotics.

Clinical Features and Therapeutic Management of Postoperative Eso-Gastro-Duodenal Fistulas – A 6-Year Retrospective Study

Abstract The postoperative digestive fistula is the most feared complication of gastrointestinal surgeries. We performed a retrospective study over a period of 6 years, in which we included 28 patients who developed postoperative esophageal, gastric or duodenal fistulae in the General Surgery Department of “Bagdasar–Arseni” Emergency Hospital. We assessed the risk factors for this complication, its management and its results. Most patients were males and the mean age was 61.1 years. For 15 patients, the surgeries were required for benign lesions while the rest of 13 patients had malignant disease. Regarding the type of the fistula, 14 were duodenal stump fistulas, 13 were anastomotic leakages and one was a dehiscence of a sutured duodenal ulcer. Six cases required emergency relaparotomy for sepsis and peritonitis. Sixteen patients had a favourable outcome while death occurred in 12 cases. The mortality was higher for patients with sepsis and peritonitis as the first clinical manifestations of fistula and with the need for an emergency reoperation.

Feasibility, safety and long-term efficacy of laparoscopic total gastrectomy combined with distal pancreaticosplenectomy for T4b gastric cancer

Objective: To explore the feasibility, safety and long-term efficacy of laparoscopic total gastrectomy combined with distal pancreaticosplenectomy for the treatment of T4b gastric cancer. Methods: A retrospective cohort study was performed. Clinical data of consecutive patients with T4b gastric cancer invading pancreatic tail undergoing laparoscopic or open total gastrectomy combined with distal pancreaticosplenectomy from January 2010 to December 2014 were analyzed retrospectively. Enrollment criteria: (1) primary gastric cancer confirmed by pathology as T4b adenocarcinoma; (2) chest+abdominal+pelvic enhanced CT indicated cancer invading pancreatic tail without distant metastasis, and R0 resection was evaluated as feasible before operation; (3) physical status was ECOG score 0 to 2, and was tolerant to operation. Patients with peritoneal implant metastasis and tumor invasion of other organs during operation, or changes in surgical methods for other reasons were excluded. All the operations were performed by the same surgical team, which had the experiences of more than 100 cases of laparoscopic and 100 cases of open radical gastrectomy with D2 lymph node dissection. The choice of surgical procedure was discussed by the surgeon and the patient, and decided according to the patient's intension. Patients were divided into the laparoscopic group and open group according to the surgical method. Intraoperative and perioperative findings were compared between the two groups. The 3-year disease-free survival rate were analyzed with Kaplan-Meier survival curve and compared by using log-rank test. Results: A total of 37 consecutive patients were enrolled, including 21 in the laparoscopic group and 16 in the open group, and no one receiving laparoscopic procedure was converted to open surgery. The baseline data of two groups were comparable (all P>0.05). Compared with the open group, the laparoscopic group had significantly longer operation time [(264.0±35.1) minutes vs. (226.6±49.9) minutes, t=2.685, P=0.011], significantly less intraoperative blood loss [(65.7±37.4) ml vs. (182.2±94.6) ml, t=-4.658, P<0.001], significantly shorter time to postoperative flatus [(2.8±0.7) days vs. (4.1±0.7) days, t=-5.776, P<0.001] and significantly shorter postoperative hospital stay [(13.3±2.8) days vs. (16.6±4.3) days, t=-2.822, P=0.008]. Morbidity of postoperative complications, including anastomotic leakage, pancreatic fistula, abdominal abscess, intraperitoneal hemorrhage and duodenal stump leakage, in two groups was similar [19.0% (4/21) vs. 4/16, P=0.705]. There were no cases of anastomotic bleeding or stenosis. The 30-day postoperative mortality was 0 in the laparoscopic group and 1/16 in the open group, respectively (P=0.432). The 3-year disease-free survival rates were 38.1% and 37.5% in the laparoscopic and open group, respectively (P=0.751). Conclusion: Laparoscopic total gastrectomy combined with distal pancreaticosplenectomy performed by experienced surgeons for T4b gastric cancer is safe and effective.

Risk Factors for Duodenal Stump Leakage after Laparoscopic Gastrectomy for Gastric Cancer.

PurposeDuodenal stump leakage (DSL) is a potentially fatal complication that can occur after gastrectomy, but its underlying risk factors are unclear. This study aimed to investigate the risk factors and management of DSL after laparoscopic radical gastrectomy for gastric cancer (GC).Materials and MethodsRelevant data were collected from several prospective databases to retrospectively analyze the data of GC patients who underwent Billroth II (B-II) or Roux-en-Y (R-Y) reconstruction after laparoscopic gastrectomy from 2 institutions (Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, and HwaMei Hospital, University of Chinese Academy of Sciences). The DSL risk factors were analyzed using univariate and multivariate analysis regression.ResultsA total of 810 patients were eligible for our analysis (426 with R-Y, 384 with B-II with Braun). Eleven patients had DSL (1.36%). Body mass index (BMI), elevated preoperative C-reactive protein (CRP) level, and unreinforced duodenal stump were the independent risk factors for DSL. DSL was diagnosed in 2–12 days, with a median of 8 days. Seven patients received conservative treatment, 3 patients received puncture treatment, and only 1 patient required reoperation. All patients recovered successfully after treatment.ConclusionsThe risk factors of DSL were BMI ≥24 kg/m2, elevated preoperative CRP level, and unreinforced duodenal stump. Nonsurgical treatments for DSL are preferred.

Para-aortic lymph node tracing and dissection in advanced gastric cancer: Effectiveness of carbon nanoparticles injection through the no. 12b lymph node.

The relative effectiveness of tracers in guiding para-aortic lymph node dissection (PAND) in advanced gastric cancer is undefined. In this single-center, prospective study, we aimed to discuss the effectiveness of such tracers. Between January 2015 and January 2016, 90 consecutive patients with stage T4a gastric cancer were evenly assigned to receive 0.2 mL of carbon nanoparticles (a), methylene blue (b), or no tracer (c) injection through no. 12b lymph nodes before PAND. There was no difference in the baseline characteristics between the three groups. Group A vs. B or C had a higher number of dissected lymph nodes (34.1 ± 9.8, 25.5 ± 5.5, and 22.6 ± 3.7; P < 0.001; B vs. C: P =0.321) and no. 16a2/b1 para-aortic lymph nodes (PANs; 11.8 ± 4.8, 7.0 ± 1.2, and 5.5 ± 1.2; P < 0.001; B vs. C: P =0.178) and similar rates of lymph node metastasis (20.9 ± 17.5%, 19.1 ± 15.1%, and 23.6 ± 19.7%; P = 0.511), positive dissected PAN (23.3% [7/30], 16.7% [5/30], and 16.7% [5/30]), surgery duration (252.9 + 35.4, 244.4 ± 29.0, and 250.3 + 29.9 min; P = 0.421), and blood loss (266.7 ± 115.5, 270.0 ± 82.6, and 260.0 ± 116.3 mL, P = 0.933). There was no common bile duct damage by tracer injection, and one case of duodenal stump fistula, one abdominal infection, and two anastomotic leakages in Groups A-C, respectively, were treated successfully. In advanced gastric cancer treatment, carbon nanoparticle injection into no. 12b nodes appears to better trace no. 16a2/b1 PAN.

LESSONS LEARNED ANALYZING COMPLICATIONS AFTER LAPAROSCOPIC TOTAL GASTRECTOMY FOR GASTRIC CANCER.

ABSTRACT Background: Laparoscopic surgery has been gradually accepted as an option for the surgical treatment ofgastric cancer. There are still points that are controversial or situations that are eventually associated with intra-operative difficulties or postoperative complications. Aim: To establish the relationship between the difficulties during the execution of total gastrectomy and the occurrence of eventual postoperative complications. Method: The operative protocols and postoperative evolution of 74 patients operated for gastriccancer, who were subjected to laparoscopic total gastrectomy (inclusion criteria) were reviewed. The intraoperative difficulties recorded in the operative protocol and postoperative complications of a surgical nature wereanalyzed (inclusion criteria). Postoperative medical complications were excluded (exclusion criteria). For the discussion, an extensive bibliographical review was carried out. Results: Intra-operative difficulties or complications reported correspond to 33/74 and of these; 18 events (54.5%) were related to postoperative complications and six were absolutely unexpected. The more frequent were leaks of the anastomosis and leaks of the duodenal stump; however, other rare complications were observed. Seven were managed with conservative measures and 17 (22.9%) required surgical re-exploration, with a postoperative mortality of two patients (2.7%). Conclusion: We have learned that there are infrequent and unexpected complications; the treating team must be mindful of and, in front of suspicion of complications, anappropriate decision must be done which includes early re-exploration. Finally, after the experience reported, some complications should be avoided.

Surgical Outcomes and Follow-Up Results of 100 Cases of Laparoscopic Total Gastrectomy Using the Overlap Method with Stapled Closure.

PurposeThe overlap method is one of the most popular procedures for construction of an esophagojejunostomy and its common entry is usually closed with sutures. This study aimed to report long-term complications and surgical outcomes of the overlap method with stapled closure (OMSC), to compare them with those of laparoscopy-assisted total gastrectomy (LATG), and to analyze a learning curve.MethodsBetween January 2015 and August 2017, 100 consecutive patients underwent laparoscopic total gastrectomy with OMSC for gastric cancer and the patients’ medical records were reviewed. Their clinicopathologic characteristics, surgical outcomes, and long-term complications were investigated and compared with those of the LATG group. A learning curve of OMSC was analyzed using the Exponentially Weighted Moving Average chart.ResultsThe overall duration of surgery was shorter in the LATG group; however, there was no difference in patients with early gastric cancer. Hospital admission was shorter and the pain scale was lower in the OMSC group. There was no difference in the number of harvested lymph nodes, date of flatus, or incidence of postoperative morbidity. Both groups showed no duodenal stump leakage, anastomosis-related complications, recurrence, or mortality during the follow-up period. Petersen hernia was a notable long-term event following OMSC compared with LATG. At least 27 cases of surgery were required to reach a plateau in terms of surgery duration for OMSC.ConclusionOMSC is a safe option for the treatment of gastric cancer and has favorable long-term results and surgical outcomes. Closure of mesenteric defects and Petersen space should be considered.

Investigation of treatment and analysis of prognostic risk on enterocutaneous fistula in China: a multicenter prospective study

Objective: To investigate the diagnosis and treatment for enterocutaneous fistula (ECF) in China, and to explore the prognostic factors of ECF. Methods: A multi-center cross-sectional study was conducted based on the Registration System of Chinese Gastrointestinal Fistula and Intra-Abdominal Infections to collect the clinical data of ECF patients from 54 medical centers in 22 provinces/municipalities from January 1, 2018 to December 31, 2018. The clinical data included patient gender, age, length of hospital stay, intensive care unit (ICU) admission, underlying diseases, primary diseases, direct causes of ECF, location and type of ECF, complications, treatment and outcomes. All medical records were carefully filled in by the attending physicians, and then re-examined by more than two specialists. The diagnosis of ECF was based on the clinical manifestations, laboratory/imaging findings and intraoperative exploration. Results: A total of 1521 patients with ECF were enrolled, including 1099 males and 422 females, with a median age of 55 years. The top three primary diseases of ECF were malignant tumors in 626 cases (41.2%, including 540 gastrointestinal tumors, accounting for 86.3% of malignant tumors), gastrointestinal ulcers and perforations in 202 cases (13.3%), and trauma in 157 cases (10.3%). The direct causes of ECF were mainly surgical operation in 1194 cases (78.5%), followed by trauma in 156 (10.3%), spontaneous fistula due to Crohn's disease in 92 (6.0%), radiation intestinal injury in 41 (2.7%), severe pancreatitis in 20 (1.3%), endoscopic treatment in 13 (0.9%) and 5 cases (0.3%) of unknown reasons. All the patients were divided into three groups: 1350 cases (88.7%) with simple ECF, 150 (9.9%) with multiple ECF, and 21 (1.4%) with combined internal fistula. Among the patients with simple ECF, 438 cases (28.8%) were jejuno-ileal fistula, 313 (20.6%) colon fistula, 170 (11.2%) rectal fistula, 111 (7.3%) duodenal fistula, 76 (5.0%) ileocecal fistula, 65 (4.3%) ileocolic anastomotic fistula, 55 (3.6%) duodenal stump fistula, 36 (2.4%) gastrointestinal anastomotic fistula, 36 (2.4%) esophagogastric/esophagojejunal anastomotic fistula, 29 (1.9%) gastric fistula and 21 (1.4%) cholangiopancreatiointestinal. Among all the simple ECF patients, 991 were tubular fistula and 359 were labial fistula. A total of 1146 patients finished the treatment, of whom 1061 (92.6%) were healed (586 by surgery and 475 self-healing) and 85 (7.4%) died. A total of 1043 patients (91.0%) received nutritional support therapy, and 77 (6.7%) received fistuloclysis. Infectious source control procedures were applied to 1042 patients, including 711 (62.0%) with active lavage and drainage and 331 (28.9%) with passive drainage. Among them, 841 patients (73.4%) underwent minimally invasive procedures of infectious source control (replacement of drainage tube through sinus tract, puncture drainage, etc.), 201 (17.5%) underwent laparotomy drainage, while 104 (9.1%) did not undergo any drainage measures. A total of 610 patients (53.2%) received definitive operation, 24 patients died within postoperative 30-day with mortality of 3.9% (24/610), 69 (11.3%) developed surgical site infection (SSI), and 24 (3.9%) had a relapse of fistula. The highest cure rate was achieved in ileocecal fistula (100%), followed by rectal fistula (96.2%, 128/133) and duodenal stump fistula (95.7%,44/46). The highest mortality was found in combined internal fistula (3/12) and no death in ileocecal fistula. Univariate prognostic analysis showed that primary diseases as Crohn's disease (χ(2)=6.570, P=0.010) and appendicitis/appendiceal abscess (P=0.012), intestinal fistula combining with internal fistula (χ(2)=5.460, P=0.019), multiple ECF (χ(2)=7.135, P=0.008), esophagogastric / esophagojejunal anastomotic fistula (χ(2)=9.501, P=0.002), ECF at ileocecal junction (P=0.012), non-drainage/passive drainage before the diagnosis of intestinal fistula (χ(2)=9.688, P=0.008), non-drainage/passive drainage after the diagnosis of intestinal fistula (χ(2)=9.711, P=0.008), complicating with multiple organ dysfunction syndrome (MODS) (χ(2)=179.699, P<0.001), sepsis (χ(2)=211.851, P<0.001), hemorrhage (χ(2)=85.300, P<0.001), pulmonary infection (χ(2)=60.096, P<0.001), catheter-associated infection (χ(2)=10.617, P=0.001) and malnutrition (χ(2)=21.199, P<0.001) were associated with mortality. Multivariate prognostic analysis cofirmed that sepsis (OR=7.103, 95%CI:3.694-13.657, P<0.001), complicating with MODS (OR=5.018, 95%CI:2.170-11.604, P<0.001), and hemorrhage (OR=4.703, 95%CI: 2.300-9.618, P<0.001) were independent risk factors of the death for ECF patients. Meanwhile, active lavage and drainage after the definite ECF diagnosis was the protective factor (OR=0.223, 95%CI: 0.067-0.745, P=0.015). Conclusions: The overall mortality of ECF is still high. Surgical operation is the most common cause of ECF. Complications e.g. sepsis, MODS, hemorrhage, and catheter-associated infection, are the main causes of death. Active lavage and drainage is important to improve the prognosis of ECF.

Challenges of endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrointestinal anatomy: A review article.

Endoscopic retrograde cholangiopancreatography (ERCP) is a combination of endoscopy and fluoroscopy that is commonly used in the management of pancreatobiliary diseases. ERCP can be challenging if performed in surgically altered anatomy, such as a Billroth II reconstruction, compared with native anatomy and usually has a lower success rate. We identified five emerging challenges in such patients. These are the choice of endoscope, the identification of afferent loop, reaching the duodenal stump, cannulation in the reverse position, and endoscopic sphincterotomy. Performing ERCP in patients with a Billroth II reconstruction needs adequate knowledge, proper skill, and experience to achieve a good clinical outcome.

Two cases of a perforated duodenal diverticulum after gastrectomy with Roux-en-Y reconstruction

BackgroundWhat type of reconstruction procedure should be applied is one of the important issues in surgery for gastric cancer. We have several options for reconstruction procedure after distal gastrectomy. The Billroth II and Roux-en-Y reconstruction have a duodenal stump while the Billroth I does not have it, which is the biggest structural difference in these procedures. An increase in intraduodenal pressure due to the formation of duodenum stump occasionally causes severe complication such as duodenal stump leakage; however, a duodenal diverticulum perforation after the Roux-en-Y reconstruction has not yet been reported. Herein, we report two cases of a perforated duodenal diverticulum after gastrectomy with the Roux-en-Y reconstruction.Case presentationThe first case was a 66-year-old man who presented to our hospital with an acute onset right-upper-quadrant abdominal pain. He had undergone laparoscopic distal gastrectomy with the Roux-en-Y reconstruction for the early gastric cancer 15 months before. A large periampullary diverticulum had been detected during the checkup before the gastrectomy. Abdominal contrast-enhanced CT showed a retroperitoneal fluid collection with gas present at the second part of the duodenum. Therefore, a perforated duodenal diverticulum with abdominal abscess was diagnosed, and an emergency laparotomy was performed. Pancreaticoduodenectomy was performed because of severe duodenal inflammation and surrounding tissue damage. The second case was a 52-year-old man who had undergone open distal gastrectomy for locally advanced gastric cancer. Multiple non-ampullary duodenal diverticula had also been identified during the preoperative checkup. On the 2nd postoperative day, he presented with a sudden-onset abdominal pain with peritoneal irritation signs, and intestinal fluid was identified through the intraperitoneal drainage tube placed in a suprapancreatic site during his previous gastrectomy. Therefore, an emergency laparotomy was performed. During laparotomy, a perforated diverticulum at the second part of the duodenum was detected. The perforated duodenum diverticulum was directly sutured with drainage of the retroperitoneal space.ConclusionsIt is necessary to recognize that the Roux-en-Y reconstruction after gastrectomy for gastric cancer patients with duodenal diverticulum might cause a perforation of the diverticulum.

Conversions of Roux-en-Y gastric bypass to duodenal switch (SADI-S and BPD-DS) for weight regain.

Duodenal switch is a choice of conversion when patients fail to lose or regain weight after Roux-en-Y gastric bypass (RYGB). This study aims to evaluate the effectiveness and safety of duodenal switch as a secondary operation for patients who presented with insufficient weight loss or weight regain after a RYGB. A retrospective chart review was performed on 15 patients who underwent a conversion of RYGB to single anastomosis duodeno-ileal bypass with sleeve (SADI-S) or biliopancreatic diversion with duodenal switch (BPD-DS) due to weight regain between December 31, 2013 and October 31, 2018. For the body mass index (BMI) analysis, the multilevel model for change was used. Of 15 patients, 10 underwent a conversion to SADI-S, and 5 underwent a conversion to BPD-DS. Also, 7 patients underwent the conversion in two-stages, while 8 did as single-stage. One patient had a duodenal stump leak after SADI-S, and another patient had a sleeve leak after BPD-DS. One patient underwent a reoperation to increase the common channel 20months after the conversion to BPD-DS due to malnutrition. There was no mortality. Mean percentage of total weight loss (TWL) was 18.4% at 6months, 25.0% at 12months, 26.4% at 18months, and 25.7% at 24months after the conversion. The rate of decrease in BMI was slower in SADI-S patients than in BPD-DS patients (p < 0.01), adjusting for preoperative BMI. Conversions of RYGB to SADI-S and BPD-DS can provide significant additional weight loss. However, complications and malnutrition can develop after the conversion, and further research is needed for evaluating safety.

Single Purse-String Suture for Reinforcement of Duodenal Stump During Laparoscopic Radical Gastrectomy for Gastric Cancer.

Background: Duodenal stump leakage (DSL) is a serious surgical complication after radical gastrectomy with Roux-en-Y or BillrothII reconstruction. This study was designed to evaluate the effectiveness of laparoscopic single purse-string suture for reinforcement of duodenal stump.Methods: A total of 183 patients harboring gastric adenocarcinoma following laparoscopic radical gastrectomy with Roux-en-Y or BillrothIIreconstruction and single purse-string suture for reinforcement of duodenal stump were retrospectively enrolled from Zhongshan Hospital of Fudan University (Shanghai, China) between January 2014 and December 2016. Operative variables and short-term complications were documented and analyzed. Clavien-Dindo classification system was used to identify surgical complications.Results: Among 183 patients, 108 (59.02%) patients received distal gastrectomy and 75 (40.98%) received total gastrectomy. 88 (48.09%) patients underwent Roux-en-Y reconstruction and 95 (51.91%) patients underwent Billroth-II reconstruction. The mean time of laparoscopic single purse-string suture was 5.01 ± 1.33 min (range from 3.6 to 10.2 min). Postoperative early complication occurred in 26 cases of the patients. There were 4 cases of system-related complications (2.19%), including 3 cases of pulmonary infection (1.64%) and 1 cases of cardiovascular event (0.55%); and 22 cases of surgery-related complications (12.02%), including 6 cases of intra-abdominal infection (3.28%), 4 cases of pancreatic leakage (2.19%), 4 cases of wound complications (2.19%), 3 cases of gastroparesis (1.64%), 2 cases of intra-abdominal bleeding (1.09%), 2 cases of ileus (1.09%), 1 cases of lymphatic leakage (0.55%), and no duodenal stump leakage.Conclusion: Reinforcement on duodenal stump using laparoscopic single purse-string suture during laparoscopic radical gastrectomy is simple and effective and could avoid the incidence of duodenal stump leakage to some extent.

1417 Gastric Outlet Obstruction Caused by Infiltrative Pancreatic Cancer Mimicking Benign Peptic Ulcer Disease

INTRODUCTION: Gastric outlet obstruction (GOO) is a known complication of peptic ulcer disease (PUD) and pancreatic cancer. Pancreatic cancer causing GOO can sometimes be missed on endoscopic ultrasound (EUS) due to limited access, thus presenting a diagnostic challenge. We report a case of pancreatic cancer causing GOO which was missed on EUS and GOO was attributed to the duodenal ulcers. CASE DESCRIPTION/METHODS: A 59-year-old man with medical history of diabetes and PUD presented with epigastric pain and persistent vomiting for last 2 months associated with weight loss. He had upper endoscopy 4 weeks prior that revealed multiple ulcers in second part of the duodenum. Exam was remarkable for epigastric tenderness. Laboratory data showed hypokalemic metabolic alkalosis and acute kidney injury. Liver function tests were normal. Considering patient's clinical presentation an underlying malignancy was high on differential. CT abdomen showed GOO with duodenal narrowing and a normal pancreas. Endoscopy showed duodenal bulb stricture which could not be traversed. Biopsy showed inflamed duodenal mucosa. EUS showed no pancreatic pathology. GOO was attributed to the duodenal ulcers noted on prior endoscopy and a Roux-en-Y gastrojejunostomy was performed. He returned 12 weeks later with painless jaundice and elevated liver enzymes. MRI abdomen revealed a 2.5 cm infiltrative pancreatic head tumor extending to the pancreaticoduodenal groove resulting in dilatation of the duodenal stump and bile duct. The patient underwent Whipple's pancreaticoduodenectomy. The histopathology showed pancreatic adenocarcinoma with distal involvement of the duodenal margin. DISCUSSION: Pancreatic cancer is the second most common malignancy causing GOO. EUS is the most sensitive diagnostic modality for pancreatic cancer with a sensitivity of 94%. However, its accuracy can be limited in setting of duodenal stricture and infiltrating type of the pancreatic lesion. The best station to evaluate the head and genu of the pancreas is second part of the duodenum. In case of duodenal stricture, EUS cannot be stationed properly and can miss an infiltrating pancreatic head lesion causing the GOO, which can be attributed to some other co-existent etiology like PUD, especially in the setting of normal liver tests and CT abdomen. This case also highlights the utility of MRI which is more sensitive than CT in diagnosing small pancreatic lesions and sometimes might be the only revealing modality in instances where EUS is limited by duodenal stricture.

2190 A Unique Case Demonstrating the Endoscopic Management of a Duodenal Stump Fistula

INTRODUCTION: Medical procedures continue to evolve towards being more minimally invasive leading to significant advances in the endoscopic management of transmural defects of the gastrointestinal (GI) tract. These are typically divided into three primary types; anastomotic leaks, perforations and fistulas. Once the site of injury has been identified, basic management involves surgical debridement and drainage with subsequent closure, diversion or both. We present a case of a complicated fistula and a novel approach to closing it. CASE DESCRIPTION/METHODS: A 35 year old female presented to the emergency room following blunt abdominal trauma from a horse kick. She sustained significant injuries to the small bowel requiring emergent surgical intervention and ultimately a duodenectomy with gastrojejunostomy. She was left with a 6cm blind limb of native post pyloric duodenum that was drained percutaneously with a 32Fr Malecot catheter. Gastroenterology was consulted to assist with endoscopic drain removal and management of the residual fistula tract. The Malecot was replaced with a 24Fr percutaneous gastrostomy tube with subsequent downsizing procedures every 2-3 weeks. The end result was a 3-4mm duodenal-cutaneous fistula with persistent output. After fulguration of the surrounding area with Argon plasma coagulation a single running suture of 5 stitches was placed using the OverStitchTM device and the external opening was allowed to close by secondary intention. At a 2 week clinic follow up she had returned to her usual activities and a barium upper GI series at 4 weeks post closure confirmed no stump leak. DISCUSSION: There is a paucity of data to guide the gastroenterologist on duodenal stump defects. In the setting of a planned surgical fistula such as in our patient, the most appropriate treatment option was successive downsizing of the tract with definitive closure via endoscopic suturing. The unique location of the fistula in a blind pouch precluded the use of a self-expanding metal stent, the defect was too large to close with a through-the-scope clip, and there was a theoretical concern of retention in the stump if a larger over-the-scope clip was employed. The high volume of bilious output through the fistula precluded the use of tissue adhesives as a monotherapy. Despite the desired outcome being achieved in our case we suspect this method of closure would be less successful in fistulas complicated by chronic inflammation, infection, or malignancy.

Mission (nearly) impossible: ERCP using an oblique cap with suction cannulation in a diffusely strictured duodenal stump after Billroth II with Braun enteroenterostomy.

Mission (nearly) impossible: ERCP using an oblique cap with suction cannulation in a diffusely strictured duodenal stump after Billroth II with Braun enteroenterostomy.

Efficacy of reinforcement on duodenal stump using single purse-string suture during laparoscopic radical gastrectomy for gastric cancer

Objective: To evaluate the efficacy of reinforcement on duodenal stump using single purse-string suture during laparoscopic radical gastrectomy for gastric cancer in preventing duodenal stump leakage. Methods: A descriptive cohort study was conducted to retrospectively collect clinical data of 211 patients with gastric adenocarcinoma who underwent laparoscopic radical gastrectomy with Roux-en-Y or Billroth Ⅱ reconstruction and reinforcement on duodenal stump using laparoscopic single purse-string suture in Zhongshan Hospital of Fudan University between January 2013 and December 2016. Of 211 patients, 136 were male and 75 were female with mean age of (57.5±11.1)(24 to 87) years. Tumors locating at gastric upper 1/3, middle 1/3 and low 1/3 were found in 62, 68 and 81 patients respectively. Eighty-three cases underwent total gastrectomy, 128 underwent distal subtotal gastrectomy, 107 underwent Roux-en-Y reconstruction and 104 underwent Billroth II reconstruction. The procedure of reinforcement on duodenal stump using single purse-string suture during laparoscopic radical gastrectomy was as follows: (1) after cutting the duodenal stump to about 2.0 cm in length, use a 3-0 single-strand absorbable suture to make a muscle layer purse at a distance of 1.0 to 1.5 cm from the duodenal stump; (2) use the purse line to make a slipknot; (3) push the duodenum stump into the purse with a needle holder or grasper; (4) tighten the knot of the purse string, and then make 4 to 5 knots for reinforcement. Postoperative complications were defined and graded according to the Clavien-Dindo grading criteria, and the incidence of early complications was recorded. Clinicopathologic features and postoperative outcomes were analyzed. Results: All patients completed operations successfully. The mean time of laparoscopic single purse-string suture was (5.1±1.6) (3.6 to 10.2) minutes. Postoperative early complication occurred in 31 cases (14.7%), of whom 27 cases developed surgery-related complications (12.8%), including 7 cases (3.3%) of peritoneal infection, 6 (2.8%) of pancreatic leakage, 4 (1.9%) of wound infection, 4 (1.9%) of gastroplegia, 2 (0.9%) of peritoneal hemorrhage, 2 (0.9%) of intestinal obstruction, 2 (0.9%) of lymphatic leakage, and no duodenal stump leakage; while 4 cases (1.9%) developed internal non-surgical complication, including 3 cases (1.4%) of pulmonary infection and 1 (0.5%) of cardiovascular event. The patient with peritoneal hemorrhage was healed after re-operation and all other patients were discharged uneventfully after conservative treatment. Four cases (1.9%) developed complications beyond grade III a of Clavien-Dindo criteria. Conclusion: Reinforcement on duodenal stump using laparoscopic single purse-string suture during laparoscopic radical gastrectomy with Roux-en-Y or Billroth II reconstruction is simple and effective, and can prevent the risk of development of duodenal stump leakage.