Gastric Decompression Research Articles

Hepatic portal vein gas in gastric outlet obstruction

A 55-year-old man presented to an emergency department with a history of abdominal pain and vomiting for one week. He had a history of having peptic ulcer perforation surgery. He appeared weak and frustration from pain, abdominal distension at upper abdomen without peritonitis sign on physical examination. Initial abdominal radiograph revealed pneumoperitoneum under both hemidiaphragms with markedly distension of stomach containing food content. Further computed tomography demonstrated evidence of gastric outlet obstruction without intra or extraluminal mass. There is also massive amount of portal venous gas in both lobes of liver. After patient resuscitation with intravenous fluid and nasogastric intubation for gastric decompression, his condition returned to normal, with no sign of peritonitis nor sepsis. Therefore, the upper gastrointestinal endoscopy showed gastric outlet obstruction from chronic peptic ulcers. The endoscopic balloon dilatation of the obstruction part was successful, and he was discharged home with full recovery in one week.

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN CHILDREN AND ADOLESCENTS: 15-YEARS' EXPERIENCE OF A TERTIARY CENTER.

Percutaneous endoscopic gastrostomy (PEG) is an important option for enteral nutrition for both children and adults. It is considered a safe, effective, and advantageous technique in comparison to other complementary feeding routes. It allows continuous feeding, the feeding of patients with swallowing disorders due to neurological causes or others, and the administration of non-palatable diets or medications, all with low rates of complications and mortality. This study aimed to evaluate the main indications and complications of PEG in pediatric patients. In addition, the impact on the nutritional status of patients undergoing PEG was also compared with weight, body mass index (BMI), and height according to references from the World Health Organization. This observational and retrospective study included 152 children and adolescents who underwent PEG between January/2003 and December/2018. Patients up to 18 years of age at the time of the procedure were included. Complications related to the procedure were classified as minor or major. Patients with PEG indication for nutritional supplementation were evaluated for weight gain, height, and BMI, using the Z score at the day of the procedure and six months, 1 year, and 2 years after the procedure. Indications for PEG were: swallowing disorder of neurological cause (67.1%), need for nutritional supplementation (25%), swallowing disorder of mechanical origin (6.6%), and indication of gastric decompression (1.3%). Minor complications occurred in 57.8% of patients and major complications in 9.8% of patients. The traction technique corresponded to 92.1% and puncture to 7.9%. The death rate was 1.3%. Thirty-eight patients had an indication for nutritional supplementation. In these patients, there was a gradual increase in both BMI and weight, reaching statistically significant differences (P=0.0340 and P= 0.0105, respectively). These differences were more evident in chronic renal disease patients. Height did not vary significantly (P=0.543). PEG proved to be an advantageous option as an auxiliary feeding method in pediatric patients. Dysphagia of neurological origin was the main indication followed by the need for nutritional supplementation. PEG has low frequency of major complications and mortality. This study also showed the importance of PEG in patients who need nutritional supplementation, as it enabled patients to move from undernutrition to normal weight ranges.

Robotic transthoracic diaphragmatic hernia repair.

Robotic transthoracic diaphragmatic hernia repair.

Laparoscopic-Percutaneous Combined Gastrostomy: Initial Experience and Description of a Technique.

Background: Gastrostomy is a widely used procedure that aims to obtain access to the stomach. Its purpose may be feeding or gastric decompression. Currently, the most common techniques are endoscopic and radiologic. Sometimes, these accesses are not available due to technical or patient-specific factors. In these cases, laparoscopic and percutaneous approaches combined could be an option. The aim of this study was to describe a laparoscopic-percutaneous combined gastrostomy procedure, feasibility, and complications. Materials and Methods: Retrospective descriptive observational study. All patients underwent laparoscopic-percutaneous combined gastrostomy required for feeding or decompressive gastrostomy. We analyzed variables: demographics, surgical indication, operation time, hospitalization stay, success, and morbidity/mortality associated to the procedure. Results: A total of n = 17 patients were recruited (58.8% women and 41.2% men), with mean age of 53. Regarding the indications of laparoscopic-percutaneous combined gastrostomy, 47% were due to upper gastrointestinal/head and neck tumor, 29.4% stomach location in a retrocostal position, 17.7% colonic interposition, and 5.9% acute gastric dilation of remnant after Roux-en-Y gastric bypass. The mean time of the procedure was 25 minutes, and mean hospitalization stay was 1.2 days. The success of the procedure was 100%. No complications and mortality associated with the procedure were reported. Conclusion: Laparoscopic-percutaneous combined gastrostomy is fast, feasible, safe, and cost effective. It is an option in patients where it is not possible to perform standard minimally invasive approaches.

Safety and efficacy of percutaneous transabdominal and transesophageal decompression gastric catheters for palliation of malignant bowel obstruction.

To evaluate the safety and primary technical success rate of gastric decompression via percutaneous transabdominal gastrostomy (PTAG) or percutaneous transesophageal gastric (PTEG) catheter placement for management of malignant bowel obstruction (MBO). A secondary purpose was to evaluate the safety and success rate for PTAG catheter placement in patients with both MBO and ascites. A single-institution retrospective review of 385 patients who underwent attempted decompression gastric catheter placement from March 2013 to August 2018 was performed. Medical records and imaging studies were reviewed. A subgroup of patients with concomitant MBO and ascites were identified. The primary outcome measures were procedural technical success and procedural complications. 394 decompression gastrostomy catheters were attempted from 2013 to 2018, n = 353 PTAG and n = 41 PTEG. The success rate was 95.5% (n = 337 of 353) for PTAG and 97.6% (n = 40 of 41) for PTEG. There were 63 total complications involving 47 (13.9%) patients following PTAG and 13 total complications involving 9 (22.5%) patients following PTEG, P = 0.16. For the subgroup of patients with MBO and ascites, the success rate was 94.8% (n = 182 of 192 patients), and there were 20 complications involving 17 (12.9%) of 132 patients. Gastric decompression for patients with MBO via PTAG or PTEG catheter placement is associated with high success rates and low complications.

Management of Congenital Duodenal Obstruction by Diamond-Shaped Duodenoduodenostomy

A prospective study of 20 patients with clinical diagnosis of duodenal obstruction done at pediatric surgery center in AL Khanssa maternity and children Teaching Hospital in Mosul from December 2006-January 2010, a detailed case-record of 20 consecutive newborn patients treated for duodenal obstruction. The aims of the study was to analyze our experience and to evaluate the clinical presentation, diagnosis, postoperative care, and outcome in infants with duodenal obstruction.The 20 patients were classified according to classification system modified from James A. O’Neill: duodenal web, atresia , annular pancreas and malrotation.The presumptive diagnosis and decision regarding the need for surgery was based on clinical findings and investigation of plain abdominal radiographs in all patients without the need of dye study. Abdominal ultrasound examination was done for all patient to evaluate the associated renal anomalies and echocardiogram was done for 15 patients because of suspicion of congenital heart disease.other laboratory investigation including complete blood count, serum electrolyte, blood urea and total serum bilirubin were done for all patients.the management strategy for all patients was outlined as follows: After initial evaluation, a nasogastric tube (NGT) was placed for gastric decompression. The operative procedures performed through supra umbilical transverse abdominal incision. The type of duodenal obstruction was assessed after mobilizing the ascending and transverse colon to the left and identifying any associated malrotation. Kocherization of duodenum then performed and a transpyloric tube was passed to determine if a windsock abnormality was present . In duodenal atresia intraoperatively injection of saline or air into the distal segment was done to rule out a second atresia. Using a single layer of interrupted suture with posterior knots tied inside and anterior knots tied outside by using 5-0 or 6-0 Vicryl (polyglactin) o Polydiaxonone suture(PDS) 5/0 to complete the anastamosis. The age of our patients were ranging from1day to 16 days and divided in to two groups from 1 up to 7 days. The Common clinical findings in our patients were bilious emesis, upper abdominal distension, failure to pass meconium . And accordingly the incidence of each symptoms and signs.The available investigations in our center at any time was the plain abdominal x ray, the finding in plain x-ray of abdomen was double bubble sign in 18(90%)of the patients and single gastric gas shadow in 2(10%) of patient. Abdominal ultrasound examination was done for all patients locking for any associated anomalies especially of the urinary tract. The finding was ectopic kidney in 1(5%) and hydronephrosis in 1(5%) of our patient. Echocardiography has been performed in 15 patients , abnormal in 2 male babies one of them had VSD and another one had ASD. Careful examination and follow up locking for associated anomalies were done and their types and percentile shows male patient have more associated anomalies than female.

CISOL: el dispositivo de cierre para sonda nasogástrica tipo Levin, en un estudio aleatorio controlado que evalúa su efectividad y seguridad

Background: The Levin-type nasogastric tube is indicated for gastric decompression, but due to its economic cost it is used to feed and administer medications in patients who cannot do it by themselves; its proximal end does not have a closure system. The study determined the effectiveness and safety of a device (Cisol), specially created for the proximal closure of the Levin-type nasogastric tube for adults compared to the conventional device (syringe).
 Methods: Study of experimental design, randomized of preventive type applied outside the clinical context, through which the effectiveness and safety of both devices were estimated and compared taking into account as markers: their weight, size and shape.
 Results: According to the evaluation of the participants, Cisol is considered effective and safe for the proposed purposes since its weight, size and shape would significantly favor patient comfort and handling compared to the syringe.
 Conclusions: The new CISOL design is safe to use, and has the potential to reduce risks related to traction and overweight at the proximal end of the probe, as well as contributing to patient comfort. The effectiveness and safety of the CISOL device differs from the effectiveness and safety of the conventional device (syringe) used to close the Levin catheter.

AB216. SOH21AS036. An unexpected cause of acute decompensation in an elderly inpatient

: We present the case of a 76-year-old patient initially admitted with epistaxis on a background of oral anticoagulation for atrial fibrillation and a hiatus hernia. On the second day of admission the patient became acutely dyspnoeic, hypoxic, hypotensive and tachycardic. Metabolic acidosis was present on blood gas analysis. Vasopressor support was commenced and the patient was intubated and sedated. Initial stabilisation allowed an urgent CT scan to be performed which diagnosed a left diaphragmatic hernia with the stomach, descending colon, distal transverse colon and obstructed proximal jejunum located within the left hemithorax. Complete atelectasis of the left lung and volume loss in the right hemithorax with mediastinal shift to the right were present. The patient was ventilated on pressure control ventilation. Initially, inspiratory pressures of 40 cmH2O were required to achieve tidal volumes of approximately 310–330 mL. Following orogastric tube insertion and gastric decompression, tidal volumes increased to approximately 420–440 mL and required inspiratory pressure decreased. Electrolyte replacement and vitamin K were administered to optimise the patient for surgery. The patient was transferred to a specialised surgical centre for emergency surgical intervention. This case highlights diaphragmatic hernia to be considered as a cause of life-threatening rapid decompensation in a patient with a history of a hiatus hernia and the ventilatory value of gastric decompression when the stomach lies in the thorax.

Routine Gastric Decompression after Pancreatoduodenectomy: Treating the Surgeon?

BackgroundThe decision to routinely leave a nasogastric tube after pancreatoduodenectomy remains controversial. We sought to determine the impact of immediate nasogastric tube removal versus early nasogastric tube removal (<24 h) on postoperative outcomes. MethodsA retrospective review of our institution’s prospective ACS-NSQIP database identified patients that underwent pancreatoduodenectomy from 2015 to 2018. Outcomes were compared among patients with immediate nasogastric tube removal versus early nasogastric tube removal. ResultsA total of 365 patients were included in primary analysis (no nasogastric tube, n = 99; nasogastric tube removed <24 h, n = 266). Thirty-day mortality and infectious, renal, cardiovascular, and pulmonary morbidity were similar in comparing those with no nasogastric tube versus early nasogastric tube removal on univariable and multivariable analyses (P > 0.05). Incidence of delayed gastric emptying (11.1 versus 13.2%) was similar between groups. Patients with no nasogastric tube less frequently required nasogastric tube reinsertion (n = 4, 4%) compared to patients with NGT <24 h (n = 39, 15%) (OR = 3.83, 95% CI [1.39-10.58]; P = 0.009). ConclusionRoutine gastric decompression can be safely avoided after uneventful pancreaticoduodenectomy.

Enhanced Recovery Protocol for Boerhaave Syndrome: Our Experience

From its first description in 1724, the diagnosis and management of Boerhaave syndrome remain challenging till date. We share our management protocol for enhanced recovery in patients presenting more than 24 h following spontaneous esophageal rupture at a tertiary care center in India. A retrospective review of all patients diagnosed with Boerhaave syndrome and managed by the chief investigator in the Department of General Surgery at our institution in the last 3 years (2016–2019) was performed. After hemodynamic stabilization, an intercostal drainage (ICD) tube was inserted on the side of empyema to drain the collection. This was followed by an upper GI (UGI) endoscopy to confirm the site and size of perforation. No attempt at a therapeutic intervention was made during the procedure. A triple lumen tube was inserted under imaging at the same time for gastric decompression and advanced to the jejunum for enteric feeding. In patients with sepsis and persistent collection, a video-assisted thoracoscopic (VATS) drainage was performed. Twelve patients were admitted for Boerhaave syndrome. ICD was inserted for 9 patients and managed by us as per our enhanced recovery protocol. Three patients referred from other setup came with an ICD in situ showing signs of sepsis. Debridement and drainage by VATS was performed for these patients. No patient required prolonged ventilatory assistance, and there was no mortality. Gastric decompression, adequate and timely drainage of collection/s, and enteral nutrition form the pillars of enhanced recovery protocol for management of Boerhaave syndrome.

Nasogastric- vs. percutaneous gastrostomy tube for prophylactic gastric decompression after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

ObjectivesCytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with postoperative gastroparesis and ileus. In 2015, our practice shifted from using percutaneous gastrostomy tubes (PGT), to nasogastric tubes (NGT) for prophylactic gastric decompression after CRS-HIPEC. This study aimed to compare these methods for length of stay (LOS) and associated complications.MethodsPatients that underwent CRS-HIPEC for peritoneal metastases from colorectal cancer between 2014 and 2019 were included. Cases were grouped based on receiving NGT or PGT postoperatively. Multivariable linear regression determined the independent effect of decompression method on LOS, thereby adjusting for confounders.ResultsIn total, 179 patients were included in the analyses. Median age was 64 years [IQR:54–71]. Altogether, 135 (75.4%) received a NGT and 44 (24.6%) received a PGT. Gastroparesis occurred significantly more often in the PGT group (18.2 vs. 7.4%, p=0.039). Median LOS was significantly shorter for patients with a NGT (15 [IQR:12–19] vs. 18.5 [IQR:17–25.5], p<0.001). PGT was independently associated with longer LOS in multivariable analysis (Beta=4.224 [95%CI 1.243–7.204]). There was no difference regarding aspiration, pneumonia and postoperative mortality between groups.ConclusionsNGT should be preferred over PGT for gastric decompression after CRS-HIPEC as it is associated with fewer gastroparesis and shorter LOS.

Abdominal Wall Defects-Current Treatments.

Gastroschisis and omphalocele reflect the two most common abdominal wall defects in newborns. First postnatal care consists of defect coverage, avoidance of fluid and heat loss, fluid administration and gastric decompression. Definitive treatment is achieved by defect reduction and abdominal wall closure. Different techniques and timings are used depending on type and size of defect, the abdominal domain and comorbidities of the child. The present review aims to provide an overview of current treatments.

A Man With Two Gastric Bulbs

Question: An 82-year-old man presented to the emergency department with a 3-day history of dull epigastralgia. The physical examination was notable for distended abdomen and epigastric tenderness. Laboratory examination revealed elevated white blood cell count (14,200/μL), elevated serum lactate (3.1 mmol/L). A chest radiograph (Figure A) showed 1 sac with an air–fluid level around the right diaphragm symmetry to the gastric bulb below the left diaphragm. What is the diagnosis and how should it be managed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. A computed tomography scan of the chest (Figure B, C) showed hiatal herniation with involvement of gastric antrum and transverse colon. Epigastralgia may be related to transverse colon and gastric antrum trapped in the hernia sac. We inserted a nasogastric tube for gastric decompression. After esophagogastroduodenoscopy ruled out gastric malignancy, a laparoscopic hiatal hernia repair was performed. During the surgery, the space of hiatal hernia in the thoracic cavity was checked, and the hernia sac was separated from pleura. The hernia sac was removed. Abdominal pain was relieved after surgery.

Gastric Volvulus: A Multidisciplinary Approach and Conservative Treatment

Gastric volvulus can be defined as an abnormal rotation of the stomach. It can be both an emergency and a chronic intermittent problem. Being such a rare clinical entity and a difficult condition to diagnose, it is commonly diagnosed at the time of surgery or even at autopsy.We present the case of an 82-year-old independent female with a past medical history of hiatal hernia, who came to the emergency department with hematemesis and severe epigastric pain. An abdominal CT scan revealed an organoaxial stomach volvulus within the intrathoracic cavity.After initial treatment with gastric decompression, IV fluids and proton pump inhibitors, the patient was informed that the surgical intervention would be the only definitive curative treatment for her condition and denied the procedure. She was then discharged after clinical and analytical improvement. She was offered a conservative treatment and follow up by the internal medicine team. After a few months, the patient reported moderate improvement of her symptoms and less episodes of epigastric pain. She was pleased with the conservative management and denied any surgical or invasive procedures. A proximity contact was established with the family doctor, which she maintains.This case report is proof that rare entities can happen to patients presenting common symptoms and better resolutions come from multidisciplinary approaches.

Acute gastric dilatation in a patient with severe anorexia nervosa: a case report

BackgroundAcute gastric dilatation (AGD) leading to gastric necrosis and perforation has been reported to be a rare but fatal complication in young patients with eating disorders, particularly anorexia nervosa.Case presentationWe report a case of a Canadian female patient presenting with mild abdominal pain, with a history of anorexia nervosa, the binge/purge subtype, who was found to have severe acute gastric dilatation on subsequent computed tomography imaging. Her clinical course was uncomplicated after gastric decompression. The cause of her AGD was thought to be secondary to dysmotility disorder caused by her anorexia nervosa.ConclusionOur case report demonstrates the importance of clinical identification of AGD and subsequent diagnosis and management. Because of the urgency to rule out obstruction or perforation through consultation or additional imaging modalities, recognition and correct diagnosis of this condition is necessary for appropriate patient management. In addition, our case report adds to an underreported but important complication of anorexia nervosa.

Surgical management of gastric dilatation and volvulus in dogs

Three dogs of different breeds presented to the clinics, with a complaint of abdominal distension, respiratory distress and anorexia were diagnosed to have gastric dilatation and volvulus. The findings of the clinical examination and radiography aided in the diagnosis of the condition and the treatment was initiated immediately after diagnosis in all the cases. Stabilization of the animal was performed by administration of intravenous fluids and other supportive drugs and attempts were made to decompress the stomach by administration of stomach tube. Decompression with stomach tube didn’t yield a positive result in any of the case and hence gastric decompression followed by gastric derotation was performed under general anesthesia. Out of three dogs one dog collapsed during the process of stabilization as it was presented in delay when compared to others. The other two dogs were monitored for the next four hours from the completion of surgery and then discharged from the ward. Postoperatively, antibiotics and analgesics were given besides administration of supporting drugs which showed an uneventful recovery in those two dogs.

Superior Mesenteric Artery Syndrome: A Single-institution Experience

Background: Superior mesenteric artery syndrome (SMAS) is a rare disease in adult. SMAS is characterized by acute, or, more commonly, chronic nonspecific symptoms due to duodenal obstruction and severe malnutrition with reduced arterio-mesenteric angle and distance. Surgical treatment may be necessary in most cases with chronic symptoms or when conservative treatment fails in SMAS. Methods: A retrospective chart review was performed on patients who underwent operation for SMAS from January 2008 to August 2020 in Cardinal Tien Hospital. Patients’ clinical presentations, surgical intervention, and outcomes. Results: Data from a total of 14 patients diagnosed with SMAS were analyzed, of which seven were diagnosed with SMAS by abdominal computed tomography and upper gastrointestinal series with water-soluble barium contrast. Six of the confirmed cases underwent surgery, namely, gastric decompression using a nasogastric tube, and correction of electrolyte imbalance. The nasoduodenal tube was placed through the obstructed duodenum to provide a high-nutrient fluid supplement. After conservative treatment failure, the patients underwent surgery. Of the six patients, four underwent duodenojejunostomy, one underwent a mini-laparotomy duodenojejunostomy bypass, and the last one underwent Roux-en-Y duodenojejunal bypass with duodenal feeding tube insertion. Conclusion: Patients with SMAS should initially be treated conservative. Surgical intervention should be considered in patients in whom conservative treatments were not effective. Complete resolution of all symptoms may not always be guaranteed after surgical intervention. Laparoscopy is currently widely used. In well-selected patients, minimally invasive or mini-laparotomy duodenojejunostomy is a safe and effective treatment for SMAS. The main advantages of mini-laparotomy duodenojejunostomy over other surgical approaches include half-length surgical incision and a shorter operative time. Duodenojejunostomy is rapidly becoming the standard procedure of this condition, and it has excellent outcomes comparable with those of open surgery.

Will the use of gastric tube guide facilitate the insertion of orogastric tube for gastric decompression in ASA I and II patients without any obvious/difficult airway posted for laparoscopic surgeries?

Gastric decompression and reduction in gastric volume is routinely practiced in clinical anaesthesiology and intensive care medicine and the use of oro-gastric tube to achieve decompression is widely known technique. Nonetheless, this may be challenging and is concomitant with severe complications including but not restricted to failure to pass the oro-gastric tube beyond crico-pharynx, coiling in oral cavity, upper airway trauma, laryngeal injuries, esophageal perforation, bleeding and post procedure throat discomfort. In clinical anaesthesiology and in intensive care medicine the orogastric tube insertion is mostly done after general anaesthesia induction. The procedure becomes all the more challenging due to the attenuation of airway reflexes and loss of consciousness rendered by general anaesthesia. The present study was conducted in the department of Anaesthesiology and Critical Care at a tertiary care center of Armed Forces to evaluate if the usage of the new gastric tube guide would ease and accelerate the placement of oro-gastric tube while simultaneously reducing the complications arising out of the procedure. Material and Methods: The present study is a first randomized controlled study done on live patients. The study was conducted on the patients undergoing elective laparoscopic surgery who required gastric decompression as the part of the procedure at the Department of Anaesthesiology and Critical Care, of a tertiary care hospital of armed forces.Study Design: Prospective randomized controlled study.Study Location: Tertiary care hospital of armed forces.Study Duration: Aug 2019 to Aug 2020.Sample Size: 100 patients.Subject and Selection Method: After taking ethical approval of the institute and informed consent from patients hundred patients aged between 18 to 65 years of either sex, accepted in Mallampati classification I and II and without any obvious airway abnormalities who were scheduled for elective laparoscopic surgery and required gastric decompression as a part of procedure were included in the study. The participants were then randomly assigned to one of the two groups of 50 patients each to undergo oro-gastric tube insertion using gastric tube guide and those without it.Results: Passage of the oro-gastric tube was successful during the first pass in 38 patients (76%) in the Group A i.e. gastric tube guide group against 15 (30%) patients in the group B i.e. non-gastric guide group. (4%) patients in Group A required three or more attempts against 11 (22%) patients Group B. The mean time taken for the passage of the oro-gastric tube successfully in the Group A was 21.90 ± 16.33 against 80.14 ± 49.78 secs in the group B (p<0.001). The results obtained support the observation that passage of the oro-gastric tube with the gastric tube guide is associated with a higher success rate in first attempt than without it. Moreover, it also shows that the time duration for securing oro- gastric tube is significantly low using gastric tube guide. Conclusion: The present study it was found that use of gastric tube guide avoids the shambolic and arduous measures of failed nasogastric tube insertions while significantly reducing the duration of procedure.

Inadvertent esophageal migration of endotracheal tube used to guide orogastric tube: An unfortunate complication in an intubated patient

In patients undergoing ambulatory laparoscopic surgeries, Ryles tubes are required only for the purpose of intraoperative gastric decompression. Insertion of nasogastric tubes can lead to nasal trauma, and hence, oral tubes provide a feasible alternative. In contrast to the nasopharyngeal cavity, whose anatomical orientation allows ease of insertion into the esophagus, oral insertion of Ryles tube is difficult on account of a larger cavity and potential for coiling. Various aids are often used to ease the insertion of these orogastric tubes. One such aid is the use of an oral endotracheal tube (ETT). This case report aims to bring to light, and the inadvertent complications may occur with the improper use of these aids, which in our case, was the misplacement of the said oral ETT.

Management of Duodeno-Jejunal Flexure Transection after Blunt Trauma - A Modified Approach.

Background: Small bowel injuries are infrequent after blunt trauma and typically affect fixed segment. Untimely management of such injuries, results in high-output entero-cutaneous fistula which increases morbidity and mortality. Treatment of duodeno-jejunal flexure transection has been traditionally done by pyloric exclusion with gastrojejunostomy, but more recent evidence suggests that end-to-end anastomosis or primary closure may be equally effective in which duodeno-jejunal anastomosis is protected via an external tube duodenostomy. Objective: The objective of the study is to provide a modification to the technique of management of duodeno-jejunal flexure injury, avoiding external tube duodenostomy. Material and Methods: Patients admitted from July 1, 2015 to June 1, 2018 were identified and examined for duodeno-jejunal flexure transection. Non-accidental injury cases were excluded. Results: In the study period, a total of 10 patients were admitted with duodeno-jejunal flexure transection. All cases were admitted 24 hours after the injury and presented with shock. After fluid resuscitation and investigations, they were taken for urgent laparotomy. The whole of duodenum was mobilised, the transected ends were debrided and end-to-end duodenojejunal anastomosis was performed in two-layer fashion. An 18-French Nasojejunal (NJ) tube was placed beyond the anastomosis, and an 18-French nasogastric (NG) tube was placed in the stomach for gastric decompression. A feeding jejunostomy was performed in all cases. Both NG and NJ tubes were removed after bowel movements started and FJ was removed on first follow up. There was no incidence of duodenum related complications, and all were doing well on follow up. Discussion and conclusion: Placing the nasojejunal and nasogastric tube eliminates the need for duodenostomy and gastrostomy, respectively. This method protects the duodeno-jejunal anastomosis and decreases the incidence of duodenum-related complications.