Tube Duodenostomy Research Articles

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

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

Duodenal Diverticulum Perforation: A Rare Case Report and Review of the Literature

Aim: Duodenal diverticulum is the second most common diverticulum section in the gastrointestinal system, but perforation is rare. It is frequently diagnosed incidentally and has little clinical evidence. There are no certain treatment strategies for duodenal diverticulum perforation. Our aim is to identify perforated duodenal diverticulum cases published in the last 10 years through our case report and to evaluate different approaches to treatment. Case Report: A 58-year-old male was diagnosed central nervous system (CNS) tumor with a perforated duodenal diverticulum. Our case presented with abdominal pain and pneumoperitoneum on imaging. The patient was treated surgically with an omental patch, pyloric exclusion, retrocolic gastrojejunostomy, and tube duodenostomy. The patient died on the 10th postoperative day. Conclusion: Duodenal diverticulum perforation is a rare but fatal condition. CT is useful in diagnosis. If the patient is not in a septic condition, it can be followed conservatively. However, if the patient is in a septic condition, surgery may be required. Surgical options should be determined based on the perforation site and characteristics.

A case series on diagnosis, management and outcome of second part of duodenum perforation

Duodenal injuries are uncommon after Blunt and penetrating trauma to abdomen and are potentially life threatening. Iatrogenic injuries caused by interventional procedures like endoscopic retrograde cholangiopancreatography (ERCP) is only 1%. Duodenal trauma can often pose diagnostic and therapeutic challenges due to its subtle clinical features as 2nd part of duodenum being a retroperitoneal organ and its rarity to get injured following blunt trauma, and hence diagnosis and treatment are often delayed. These injuries are potentially life threatening because D2 being a high output zone, managing these injuries are very difficult and more complex surgery are warranted. Here we discussed about the outcomes of D2 perforation in blunt trauma, pathological D2 perforation, iatrogenic while attempting ERCP and also based on the time of presentation to casualty from the time of perforation and also comparing the size of perforation in trauma, iatrogenic, pathologic injuries and also different types of procedures they underwent Based on the severity of injuries, we conclude that time of presentation is the foremost factor in deciding the outcome of the patient with D2 perforation which was often delayed due to its anatomic location being retroperitoneal organ and D2 being a high output zone, often makes the surgical procedures unsuccessful with high risk of postoperative leaks and makes duodenal injuries as life threatening injuries. Thus careful monitoring and computed tomography (CT) abdomen for all suspicious blunt trauma abdomen cases can help in early identification of D2 injuries and immediate surgical intervention procedures with T tube diversion, tube duodenostomy, pyloric exclusion to decompress the high output D2 based on the size, site, output and time of perforation will improve the overall outcome of the patient.

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

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

Unusual Anastomotic Failure in Patients with COVID-19: A Case Report of 2 Patients

Introduction: A newly appeared challenge for the healthcare system is the variety of clinical symptoms of COVID-19. In this research, we report 2 cases admitted to Modarres Hospital with unusual postoperative anastomotic failure. Case Presentation: In a 72-year-old man with a perforated peptic ulcer in D2 and signs of leakage after the first operation and during the second operation due to massive unexpected hemorrhage, we found fully disrupted anastomosis on the second part of the duodenum. Accordingly, the suture ligature of the bleeding ulcer with the closure of the duodenal stump and loop gastrojejunostomy and tube duodenostomy were performed. During the postoperative period, he developed dyspnea, and the diagnostic test of SARS-CoV-2 confirmed him as a case of COVID-19. Unfortunately, 1 week after the second surgery, evidence of anastomotic leakage appeared again by bile discharge from drains; although it was managed conservatively, he died because of respiratory failure. In another case, a 65-year-old woman was admitted to the emergency ward with closed-loop small bowel obstruction. After emergency laparotomy, resection of ischemic bowel with primary anastomosis was performed. The same as the previous case, she developed dyspnea, and the diagnostic test resulted positive for COVID-19. After 2 weeks, she was admitted to the hospital with signs of anastomotic leakage that was subsequently confirmed by abdominal computed tomography (CT); although it was managed conservatively, she died because of respiratory failure due to COVID-19. Conclusions: These cases were unique in that intestinal microangiopathies can cause very severe problems, weaken the body, and eventually death, as we have seen in these 2 cases.

A NEW SURGICAL TECHNIQUE FOR PREVENTION OF LEAKAGE AFTER DUODENAL REPAIRS

Background: Duodenal injuries, due to their retroperitoneal location, are a diagnostic challenge to the surgeon; for this reason, they are identified in a late stage, and thus associated with increased morbidity and mortality. The diagnosis of duodenal injury requires a high level of suspicion. Delayed diagnosis and management of these injuries results in increased morbidity and mortality rates. It must be remembered that the retroperitoneal location of the duodenum usually precludes early detection of injury by physical examination, which is characterised by minimal findings. Signs of defence, abdominal rigidity and absence of bowel sounds indicate intra-abdominal injury and lead to a surgical procedure. There are many different surgical procedures based on injury complexity, one of which is the tube duodenostomy technique. Despite the advances in surgical technique, duodenal lesions are still associated with high morbidity and mortality rates. Purpose: The purpose of this presentation is to describe a new surgical technique in the management of duodenal injuries. Surgical Technique: The technique was performed on a patient, presented with Crohn’s disease together with intestinal tuberculosis, in the management of duodenal injury secondary to duodenocolic fistula and abscess during the postoperative follow-up. The patient was operated on due to invagination, intra-abdominal abscess and general condition deterioration. The second operation was performed because of contrast extravasation from the duodenum. Especially the third part of the technique, application of negative pressure through a tube enterostomy in order to prevent the accumulation of secretions and pressure increase in the duodenum, minimized the intra-duodenal pressure and decreased the risk of anastomotic dehiscence and fistula formation (Figure 1). For this purpose, continuous negative aspiration was performed with an aspiration cannula extended through the enterostomy tube during the first 14 days. The patient was recovered without any complications. Conclusion: The authors concluded that this new technique of “pyloric exclusion, the repair of the mucosal layer of the primary wound in the duodenum with a stapler and of serosa with vicryl, minimizing intra-duodenal pressure by applying negative pressure with the enterostomy tube” can be considered to be an alternative solution for duodenal injuries.

A rare case of D2 perforation in blunt injury abdomen

A 47-year-old female brought by attenders to casualty with alleged history of accidental injury, struck against iron rail in bus 1 day before sustained injury in abdomen. Presented with complaints of abdominal pain, vomiting for 2 days. Previous history of duodenal ulcer - Gastric outlet Obstruction & undergone bilateral truncal vagotomy with posterior Gastrojejunostomy 1year before. She was dehydrated, hemodynamically unstable bp not recordable, pulse feeble, with upper midline healed laparotomy scar in abdomen and tenderness in upper abdomen, diffuse swelling progressively increasing in size noted in epigastric region, guarding present. Patient was resuscitated. Supine Xray abdomen showed dilated bowel loops. CT abdomen showed pneumoperitoneum, free fluid in pelvis, no solid organ injury. Patient was taken for emergency laprotomy. Intraoperatively Omental adhesions to previous scar and about 300ml of turbid fluid noted, Status postoperative posterior Gastrojejunostomy. Colon-free from injuries. Diffuse saponification noted in omentum. Bile staining present. D2 perforation of size 2×2cm noted in anterolateral aspect. Pyloric exclusion, primary closure of duodenal injury and Tube duodenostomy done. Ryles tube passed through distal limb of GJ for feeding purposes postoperatively.

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.

Pedicled Falciform Ligament Flap repair in a Recurrent peptic ulcer perforation: case report and review of literature

Cellan Jones omentopexy technique is the mainstay of emergency surgical repair of perforated gastric/duodenal ulcers. Falciform ligament pedicle repair is a feasible alternative technique for peptic ulcer perforation repair when omentopexy is not possible, such as previous abdominal surgeries, partial gastrectomy, colectomy, severely malnourished individuals and absence of omentum as developmental anomaly. Other methods like jejunal patch repair, partial gastrectomy, Roux-en-Y duodenojejunostomy, tube duodenostomy and pyloric exclusion have also been used but they are associated with significant post-operative morbidity and failure rates and involve great deal of technicality. Recurrent peptic ulcers are those ulcers that reappear after healing. We report a case of recurrent peptic ulcer perforation treated by utilising pedicled falciform ligament flap to repair the perforation, with no postoperative and one-month follow-up complications. An omental flap was not available in this case because of dense adhesions and inflammation at the site of previous omentopexy.

Duodenal Leakage—Damage Control Using Modified Tube Duodenostomy

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

Comparison of operative procedures for re-leaks duodenal perforation: a cross-sectional analysis from a tertiary care hospital in a developing country

Background: Re-leaks following surgical closure of duodenal perforations is a well known entity. Considering the paucity of data on patients with re-leak from Indian population, the present study was carried out. Methods: The present study is a prospective audit of patients diagnosed with duodenal re-leak and surgical procedures for arresting the leak was done. Hospital indoor case records were reviewed from 2005 to 2010. Following details were collected: demographic details (age and sex); presenting complaints; success of the surgical procedures to arrest re-leak and overall survival of patients. Conservative measures, 3 tubes method, jejunal patch, T tube duodenostomy and rohondia’s cholecystoduodenoplasty were the type of procedures routinely performed for such patients. Descriptive statistics was used to represent various variables-mean (SD) for continuous and proportions (percentages) for categorical variables. Results: A total of 41 patients with duodenal re-leak requiring intervention were identified with mean (range) of age in years of 45 (25-65).The following types of procedures were carried out to arrest duodenal re-leaks: 3 tubes method (4/41, 9.8%), jejunal patch (7/41, 17.1%), T tube duodenostomy (1/41, 2.4%) and Rohondia’s cholecystoduodenoplasty (16/41, 39%) and conservative (13/41, 31.7%). A total of 75% (12/16) success in stopping the leak was observed with Rohondia’s cholecystoduodenoplasty followed by 1/4 (25%) with 3 tubes duodenostomy, one each with jejunal patch (14.3%) and conservative techniques (7.7%) and none with T- tube duodenostomy (P-0.1; not significant). A total of 32/41 (78%) patients died following the surgery for duodenal re-leak of which nearly four-fifths of them (26/32, 81%) died due to septicaemia, 5/33 (15.2%) had pulmonary complications and 1/33 (3%) due to perforation. Conclusions: To conclude, the present study gives baseline data on patients who have undergone various surgical procedures for arresting duodenal perforation but had re-leaks, in a tertiary care hospital of a developing country. The better outcomes associated with Rohondia’s cholecystoduodenoplasty was found in comparison to other surgical and conservative measures.

Outcomes of Non-Operative Treatment for Duodenal Stump Leakage after Gastrectomy in Patients with Gastric Cancer.

PurposeWe evaluated the clinical outcomes of the non-operative management of post-gastrectomy duodenal stump leakage in patients with gastric cancer.Materials and MethodsA total of 1,230 patients underwent gastrectomy at our institution between 2010 and 2014. Duodenal stump leakage was diagnosed in 19 patients (1.5%), and these patients were included in this study. The management options varied with patient condition; patients were managed conservatively, with a pigtail catheter drain, or by tube duodenostomy via a Foley catheter. The patients' clinical outcomes were analyzed.ResultsDuodenal stump leakage was diagnosed in all 19 patients within a median of 10 days (range, 1~20 days). The conservative group comprised of 5 patients (26.3%), the pigtail catheter group of 11 patients (57.9%), and the Foley catheter group of 3 patients (15.8%). All 3 management modalities were successful; none of the patients needed further operative intervention. The median hospital stay was 18, 33, and 42 days, respectively.ConclusionsNon-operative management of duodenal stump leakage for selected groups of patients with gastric cancer was effective for control of intra-abdominal sepsis. This management modality can help obviate the need for surgical intervention.

Duodenal injury post laparoscopic cholecystectomy: Incidence, mechanism, management and outcome.

To study the etiopathogenesis, management and outcome of duodenal injury post laparoscopic cholecystectomy (LC). A Medline search was carried out for all articles in English, on duodenal injury post LC, using the search word duodenal injury and LC. The cross references in these articles were further searched, for potential articles on duodenal injury, which when found was studied. Inclusion criteria included, case reports, case series, and reviews. Articles even with lack of details with some of the parameters studied, were also analyzed. The study period included all the cases published till January 2015. The data extracted were demographic details, the nature and day of presentation, potential cause for duodenal injury, site of duodenal injury, investigations, management and outcome. The model (fixed or random effect) for meta analyses was selected, based on Q and I (2) statistics. STATA software was used to draw the forest plot and to compute the overall estimate and the 95%CI for the time of detection of injury and its outcome on mortality. The association between time of detection of injury and mortality was estimated using χ (2) test with Yate's correction. Based on Kaplan Meier survival curve concept, the cumulative survival probabilities at various days of injury was estimated. Literature review detected 74 cases of duodenal injury, post LC. The mean age of the patients was 58 years (23-80 years) with 46% of them being males. The cause of injury was due to cautery (46%), dissection (39%) and due to retraction (14%). The injury was noted on table in 46% of the cases. The common site of injury was to the 2(nd) part of the duodenum with 46% above the papilla and 15% below papilla and in 31% to the 1(st) part of duodenum. Duodenorapphy (primary closure) was the predominant surgical intervention in 63% with 21% of these being carried out laparoscopically. Other procedures included, percutaneous drainage, tube duodenostomy, gastric resection, Whipple resection and pyloric exclusion. The day of detection among those who survived was a mean of 1.6 d (including those detected on table), compared to 4.25 d in those who died. Based on the random effect model, the overall mean duration of detection of injury was 1.6 (1.0-2.2) d (95%CI). Based on the fixed effect model, the overall mortality rate from these studies was 10% (0%-25%). On application of the Kaplan Meier survival probabilities, the cumulative probability of survival was 94%, if the injury was detected on day 1 and 80% if detected on day 2. In those that were detected later, the survival probabilities dropped steeply. Duodenal injuries are caused by thermal burns or by dissection during LC and require prompt treatment. Delay in repair could negatively influence the outcome.

Early Rupture of an Ultralow Duodenal Stump after Extended Surgery for Gastric Cancer with Duodenal Invasion Managed by Tube Duodenostomy and Cholangiostomy

When dealing with gastric cancer with duodenal invasion, gastrectomy with distal resection of the duodenum is necessary to achieve negative distal margin. However, rupture of an ultralow duodenal stump necessitates advanced surgical skills and close postoperative observation. The present study reports a case of an early duodenal stump rupture after subtotal gastrectomy with resection of the whole first part of the duodenum, complete omentectomy, bursectomy, and D2+ lymphadenectomy performed for a pT3pN2pM1 (+ number 13 lymph nodes) adenocarcinoma of the antrum. Duodenal stump rupture was managed successfully by end tube duodenostomy, without omental patching, and tube cholangiostomy. Close assessment of clinical, physical, and radiological signs, output volume, and enzyme concentration of the tube duodenostomy, T-tube, and closed suction drain, which was placed near the tube duodenostomy site to drain the leak around the catheter, dictated postoperative management of the external duodenal fistula.

The successful use of simple tube duodenostomy in large duodenal perforations from varied etiologies

INTRODUCTIONTube decompression of the duodenum is an old but underutilized technique known to decrease morbidity and mortality in patients with difficult to manage duodenal injuries. Broad arrays of techniques have been described in the literature and are reviewed, but most are complex procedures not appropriate for the management of an unstable patient. PRESENTATION OF CASEIn this paper we describe the technique of tube duodenostomy and the successful application in three cases of large defects (>3cm) which two of these cases had failed previous repair attempts. The defects were caused by very different etiologies, including blunt trauma, peptic ulcer disease and erosion from cancer. All were finally managed by application of tube duodenostomy with success. DISCUSSIONPatients with “difficult to manage duodenum” usually present with hemodynamic instability with hostile abdomen. Complex procedures in an unstable patient are associated with adverse outcomes. In patients with significant comorbidities and instability the damage control principle of trauma surgery is gaining popularity. Tube duodenostomy technique described in this paper fits in well with that principle. CONCLUSIONApplication of tube duodenostomy instead of a complex procedure in an unstable patient provides an opportunity to stabilize the patient, converting an impending catastrophe to a future scheduled surgery.

Duodenal perforation following blunt abdominal trauma

Duodenal perforation following blunt abdominal trauma is an extremely rare and often overlooked injury leading to increased mortality and morbidity. We report two cases of isolated duodenal injury following blunt abdominal trauma and highlight the challenges associated with their management. In both these patients, the diagnosis of the duodenal injuries was delayed, leading to prolonged hospital stay. The first patient had two perforations, one on the anterior and the other on the posterior wall of the duodenum, of which the posterior perforation was missed at initial laparotomy. In the other patient, the duodenal injury was missed during the initial assessment in the emergency department. He returned to the emergency department 24 hours after discharge with abdominal pain and vomiting. During trauma related laparotomy, complete kocherization (mobilization) of the duodenum must be mandatory, even in the presence of obvious injury on its anterior wall. We emphasize on keeping the management protocol simple by a “triple tube decompression”, i.e. duodenorrhaphy (simple closure), tube gastrostomy, reverse tube duodenostomy and a feeding jejunostomy.

T‐tube Duodenocholangiostomy for the Management of Duodenal Fistulae

The tube decompression of the duodenum through an additional point of access of the duodenal wall or occasionally via the leak site decreases morbidity and mortality in patients with duodenal fistula. The objective of this paper is to present the detailed technique and clinical benefits of simplified duodenal and biliary decompression achieved by transampullary insertion of a T-tube with one-step duodenal closure for the prevention and/or treatment of duodenal leak. The duodenocholangiostomy using T-tube with laterally perforated long duodenal limb was performed preventively in 4 patients and as a secondary procedure for septic duodenal leak in another selected 12. The mean output from the fistula, length of hospital stay, incidence of pancreatitis, as well as any postoperative septic events was recorded. The nutritional schedule during the in early postoperative period also was analyzed. The outcome was favorable for all patients. The mean length of hospital stay was 19 days. Septic events, such as wound or urinary tract infections, were observed in 30% of patients. Serum amylase and lipase activity was increased in two patients without a clinical picture of pancreatitis. Mean volume of T-tube duodenocholangiostomy drainage was approximately 500 ml per day during the first postoperative week. Enteral feeding was commenced 10-52 (mean, 21) hours after surgery and was followed by the initiation of normal diet on average 5 days postoperatively. Duodenocholangiostomy performed for duodenal decompression may be a promising alternative to classical tube duodenostomy for selected patients; however, further studies should be made to evaluate fully its practical value.

Controlled tube duodenostomy in the management of giant duodenal ulcer perforation—a new technique for a surgically challenging condition

Background Giant duodenal ulcer (GDU) perforation remains an extremely uncommon but a rather challenging condition to manage wherein routine surgical procedures are fraught with an extremely high incidence of failure and mortality. It therefore follows that this condition must be identified and managed differently at laparotomy than are most duodenal perforations. We describe a method by which to deal with this condition using triple-tube-ostomy. Methods In a prospective setting, 20 patients underwent surgery using the technique described in the article. During the same period, 20 patients with GDU perforation, who were managed in the conventional manner, were evaluated. The outcomes of the 2 groups were compared. Results The success rate was 100% in the study group compared with 30% in the control patients. Conclusions Based on the ease of the technique and the high success of the procedure in our experience in this select group, we recommend this procedure for the management of GDU perforation as a safe, reliable, and easy technique to learn.

Port site herniation of the small bowel following laparoscopy-assisted distal gastrectomy: a case report

IntroductionPort-site herniation is a rare but potentially dangerous complication after laparoscopic surgery. Closure of port sites, especially those measuring 10 mm or more, has been recommended to avoid such an event.Case presentationWe herein report the only case of a port site hernia among a series 52 consecutive cases of laparoscopy-assisted distal gastrectomy (LADG) carried out by our unit between July 2002 and March 2007. In this case the small bowel herniated and incarcerated through the port site on day 4 after LADG despite closure of the fascia. Initial manifestations experienced by the patient, possibly due to obstruction, and including mild abdominal pain and nausea, occurred on the third day postoperatively. The definitive diagnosis was made on day 4 based on symptoms related to leakage from the duodenal stump, which was considered to have developed after severe obstruction of the bowel. Re-operation for reduction of the incarcerated bowel and tube duodenostomy with peritoneal drainage were required to manage this complication.ConclusionWe present this case report and review of literature to discuss further regarding methods of fascial closure after laparoscopic surgery.

A Life-saving but Inadequately Discussed Procedure: Tube Duodenostomy. Known and Unknown Aspects

A Life-saving but Inadequately Discussed Procedure: Tube Duodenostomy. Known and Unknown Aspects