Tube Duodenostomy Research Articles

The veiled right kidney sign

The “veiled right kidney sign” is an uncommon entity in which the right kidney is masked by the collection of air around it in the retroperitoneum.1,2 A 20 year-old male presented with vomiting and distension of the abdomen following an accidental fall on a rock, sustaining a blunt injury over his abdomen. Hematological and routine blood biochemistry tests did not reveal any abnormalities. A plain skiagram of the abdomen (an anteroposterior (AP) view) showed the presence of air in the right perinephric region masking the right kidney. Contrast computed tomography of the abdomen revealed the presence of air in the right perinephric space and a moderate amount of fluid in the peritoneum [Fig. 1]. Laporotomy showed an injury in the third part of the duodenum. Closure of the duodenal laceration, gastrojejunostomy, and a decompression tube duodenostomy were performed after which the patient was discharged on recovery. Fig. 1 Contrast-enhanced computed tomography axial section at the level of the lower pole of the kidneys showing evidence of foci of air in the mesentery and air collection around the right kidney Traumatic blunt duodenal injury is associated with about 12% mortality. Morbidity and mortality from duodenal wounds may be reduced by early hospitalization, early diagnosis, and consequently, earlier surgical repair.3 The presence of air in the right perinephric region—“the veiled right kidney sign” —helps in this situation as an invaluable pointer towards appropriate management.1,2

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

The most successful method of managing the difficult duodenum, including the stump leakage, has been the tube duodenostomy technique, but it has not gained wide acceptance and is rarely used. The purpose of this study is to describe the details of the procedure for indication, technical approach, and postoperative care. During the period from 1998 to 2006, a tube duodenostomy was performed in 31 patients for possible insecure duodenal stump closure during gastric resection, postoperative duodenal stump leakage, duodenal leak after primary closure of duodenum for perforation or injury, or anostomotic leak after choledochoduodenostomy. All of the tube duodenostomies were performed through the open end of the duodenum. We also inserted a T-tube into the common bile duct in 19 of 31 patients (61.2 %) with tube duodenostomy. A tube duodenostomy was performed in the primary operation in 15 of 31 patients. None of those 15 patients required a second operation, and there were no leaks and no deaths. Among the larger group (31 patients), there was one (3.2 %) duodenal stump leak after tube duodenostomy, and it ceased spontaneously; one patient had a subhepatic collection after removal of the duodenostomy tube, and three patients had associated incisional infections. Two patients died; one after a myocardial infarction and the other from irreversible sepsis. The mean length of hospital stay was 26.9 days. We conclude that tube duodenostomy is a simple, effective, and safe method to prevent rupture of an insecure duodenal stump or to treat the leakage from the duodenal stump or primary repair on the duodenum.

A Life Saving but Inadequately Discussed Procedure: Tube Duodenostomy—So Far the Known and Unknown Aspects

This article, with its peculiar title, presents the authors’ experience with 31 patients treated with tube duodenostomy (TD). Like most such retrospective studies, this one is a ‘‘mix bag’’ that includes three main groups of patients: (1) those who underwent ‘‘primary’’ TD ‘‘for possible insecure duodenal stump’’ following gastrectomy for complicated duodenal ulcers; (2) patients in whom the TD was inserted into the duodenal stump during reoperation for duodenal leaks (which occurred following gastrectomy) or when the gastrectomy was added during reoperation; (3) gastric cancer patients undergoing ‘‘extended duodenal resection to achieve a free distal margin’’ or those undergoing ‘‘palliative’’ gastrectomy in whom ‘‘duodenal infiltration did not allow secure duodenal stump closure.’’ Tube duodenostomy is a maneuver well known to anyone experienced with the gastric surgery of the ‘‘old good peptic ulcer days.’’ The role of TD, when inserted into the end of the duodenal stump, is to produce a controlled ‘‘end’’ duodenal fistula that eventually closes spontaneously after removal of the TD. Surgical texts, particularly the older ones, usually mention TD in the context of the ‘‘difficult’’ duodenal stump. Numerous publications from around the world had reported experience with TD as well as other options to deal with the ‘‘difficult’’ duodenum. The raison d’etre of this article, according to the authors, is as follows: ‘‘It is surprising that despite the good results reported by many authors with TD, it has not gained wide acceptance and is rarely used.’’ As is usually the case, however, solutions for rare problems are rarely used and thus do not seem to gain wide acceptance and are rarely reported. Moreover, at least in my own surgical environment, a ‘‘difficult’’ duodenal stump, in need of a ‘‘life saving’’ TD, has become a pleasant memory from the remote past (the 1980s), when I was an aggressive young surgeon. How is it possible, then, that whereas we had an opportunity to insert only one TD in the last 10 years the authors could come up with such an impressive series of 31 cases? A closer look at the reported patients provides a few explanations. Elective surgery for duodenal ulcer is now history. Even complicated ulcers in need of surgical treatment have become a rarity in our H2 antagonistor proton pump inhibitor-fed population. Heliocobacter pylori eradication, accidental or purposeful, has nearly eliminated peptic ulcer disease in developed countries. The authors, on the other hand, are still blessed with operations for perforated, bleeding, and obstructed duodenal ulcer—whatever the reasons for it. This seems to be true for the developing world in general. I believe that gastrectomy is rarely indicated when operating for complicated ulcers. My good friend A. Hirshberg likes to say: ‘‘In the era of Helicobacter pylori, doing a gastrectomy for peptic ulcer is like doing a lobectomy for pneumonia’’ [1]. The alternatives to gastrectomy in these situations are feasible even in the presence of gross duodenal ulceration. Clearly, the best way to avoid a ‘‘difficult duodenum’’ (thus the need for TD) is to avoid an unnecessary gastrectomy. Even in the rare situations that mandate an emergency gastrectomy for perforated duodenal ulcer, such as a giant ulcer, it is our experience that a ‘‘difficult duodenal stump’’ can be avoided with a Billroth I reconstruction [2, 3]. M. Schein (&) Marshfield Clinic, 906 College Avenue West Ladysmith, WI 54848, USA e-mail: mschein1@mindspring.com

Intra-peritoneal duodenal perforation caused by delayed migration of endobiliary stent: a case report

Endoscopic biliary stenting is an accepted modality of palliation of malignant biliary obstructions. Delayed stent migration causing intra-peritoneal perforation of duodenum, is a rare life threatening complication. Proximal adhesion of stent to the tumor is believed to increase the intensity of distal trauma produced by the intra-duodenal segment, preventing its adaptation to intestinal peristalsis and causing perforation. Low bacterial load and containment of leak by gut and omentum blunts the clinical features. Unexplained abdominal discomfort in stented patients should alert the clinician to its possibility, irrespective of the delay between stent placement and onset of symptoms. Early diagnosis and treatment is desirable but aggressive surgical management with gastro-biliary diversion, tube duodenostomy, antibiotics, bowel rest and parenteral alimentation followed by distal alimentation, may make up for the delay in those presenting late. A case of 7 days old intra-peritoneal duodenal perforation following delayed migration (3 months) of endobiliary stent presenting with atypical features is reported. Stent's distal end was protruding through the duodenum with its proximal end in CBD. Mortality, fistulization, abscesses and sepsis are known complications but were not observed in our case. Much of the management can be done minimally invasively, if recognized early.

Operative Approach in Traumatic Injuries of the Duodenum

Background: The management of duodenal traumas remains controversial. The experience of Ankara Numune Training and Research Hospital Emergency Surgery Department with duodena! injuries during a 10-year period was analyzed to identify trends in operative management and sources of duodenum-related morbidity and mortality. Methods and Results: Between 1994 and 2003, 1799 patients with blunt abdominal trauma were operated on and the incidence of duodenal trauma was 2.8% (50 patients). The injuries were penetrating in 31 (62%) patients and blunt in 19 (38%). Primary repair (PR) of injury was performed in 24 (48%) patients, primary repair and tube duodenostomy (PRTd) in 8 (16%) patients, complex repair (CR) in 11 (22%) patients, and exploration only without a duodenal procedure in 5 (10%) patients. Two of the patients died during laparotomy. The mortality rate was 12% and the incidence of duodenum-related morbidity was 12%. The overall morbidity rate was 40% (20 patients). The most commonly injured portion of the duodenum was DII (58%), and the most frequent cause of duodenum-related and overall morbidity in our series was Grade III duodenal injury.Conclusion: Our experience suggests that the use of primary repair in grade III injury may be associated with higher duodenum-related morbidity. Our recommendation is to use complex repair for grade III duodenal injuries.

Damage control: collective review.

Damage control: collective review.

Management of the difficult duodenal stump

Leakage from the duodenal stump has been the most feared complication of the Billroth II reconstruction following gastric resection. The purpose of our study was to evaluate four methods of duodenal stump closure in 200 patients. One hundred and forty-seven (74%) patients had duodenal ulcers; 28 (14%) had gastric ulcers; and 25 (13%) had a variety of other inflammatory conditions. The most common indication for operation was acute hemorrhage (51%), followed by perforation (24%), intractability (15%), and obstruction (10%). Conventional duodenal closures were performed in 160 (80%) patients, Nissen's closure in 25 (13%), Bancroft's closure in 6 (3%), and tube duodenostomy in 9 (5%). Duodenal leaks occurred in four (2.5%) patients with conventional closures and in three (33%) patients with tube duodenostomies. No leaks occurred in patients with Nissen's or Bancroft's closures. The hospital mortality rate for the series was 9.5%; however, no patient who developed a duodenal leak died. We conclude that Nissen's and Bancroft's closures were safe and effective, but that tube duodenostomy did not reliably prevent uncontrolled leakage.

Conservative Management of Duodenal Trauma

The experience of eight trauma centers with duodenal injuries was analyzed to identify trends in operative management, sources of duodenal-related morbidity, and causes of mortality. During the 5-year period ending December 1988, 164 duodenal injuries were identified. Patient ages ranged from 5 to 78 years. There were 38 Class I, 70 Class II, 48 Class III, four Class IV, and four Class V injuries. Injury mechanism was penetrating in 102 (62%) patients and blunt in 62. Primary repair of the duodenal injury was performed in 117 (71%) patients, including 27 patients also managed with pyloric exclusion and 12 with tube duodenostomy. Duodenal resection with primary anastomosis was used in six (4%) patients and pancreatoduodenectomy was necessary in five (3%). There were 30 (18%) deaths. The cause of death was uncontrolled hemorrhage from severe hepatic or vascular injuries in 22 (73%) patients. In only two (1%) patients could death be attributed to the duodenal injury; each as the result of duodenal repair dehiscence and subsequent sepsis. Duodenal-related morbidity was documented in 29 (18%) patients, including 22 patients with intra-abdominal abscess, six with duodenal fistula, and five with frank duodenal dehiscence. In summary, this analysis demonstrated: 1) the great majority of duodenal injuries can be managed by simple repair; 2) tube duodenostomy is not a mandatory component of operative treatment; 3) pyloric exclusion is a useful adjunct for more complex injuries; 4) pancreatoduodenectomy is rarely necessary for civilian duodenal trauma; 5) morbidity following duodenal trauma is more dependent on associated intra-abdominal injuries than the extent of duodenal trauma; and 6) mortality following duodenal injuries is primarily related to associated vascular and hepatic trauma.

Acute peptic ulcer in childhood. Emergency surgical therapy in 39 cases.

Acute peptic ulcers occurred in 39 infants and children, 22 girls and 17 boys. Eleven patients were less than one year of age. Peptic ulcers were secondary to systemic disease or ulcerogenic medications in 34 cases. Hemorrhage occurred in 27 patients, perforation in 12. Endoscopy was the most useful diagnostic procedure for hemorrhage. Free air was seen on abdominal roentgenogram in all perforated patients. Ligation of the ulcer bed, vagotomy, and pyloroplasty were performed in 25 patients with bleeding. One patient required total gastrectomy. Simple plication was performed in nine patients with perforation. Plication was combined with pyloroplasty and tube duodenostomy in one patient each, and vagotomy and antrectomy were required in one patient. Operative mortality was 5.2%. There were two late deaths (Reye's syndrome and burn sepsis). No ulcer has recurred.

Factors influencing outcome after blunt duodenal injury.

Thirty-six patients with blunt duodenal injury have been treated at Detroit General Hospital since 1960. The majority of the patients were driving an automobile under the influence of alcohol and none were wearing seat restraints. Diagnosis was often delayed due to a failure to recognize the significant, but subtle, physical and roentgenographic findings of retro-peritoneal injury. Morbidity and mortality were related to a delay in operative intervention, the severity of duodenal injury, the presence and degree of associated pancreatic injury, and the choice of operative therapy. Patients with intramural hematoma or complete duodenal perforation without pancreatic injury did well with simple closure or evacuation of the hematoma. Patients with duodenal perforation and minor pancreatic injury did best after primary closure and pancreatic drainage if operation was performed within 24 hours; delay beyond 24 hours resulted in a high incidence of duodenal fistula after simple closure, and therefore is an indication for a bypass procedure, such as a distal gastrectomy, vagotomy, tube duodenostomy, and gastrojejunostomy. Patients with combined duodenal and major pancreatic disruption did best after a bypass procedure when the main pancreatic ductal system was intact, whereas pancreaticoduodenectomy was the best procedure when the main pancreatic duct was disrupted.

Duodenal “diverticulization” for duodenal and pancreatic injury

Duodenal “diverticulization” has been achieved in thirty-four cases of combined duodenal and pancreatic or severe duodenal or pancreatic injury. The operation consists of gastric antrectomy with end to side gastrojejunostomy, tube duodenostomy, closure of the duodenal perforation, and drainage. The combined mortality for these thirty-four cases and a previously reported series of sixteen cases is 16 per cent. Regional complications that developed after duodenal diverticulization were generally well tolerated and not lethal. All duodenal and pancreatic fistulas closed spontaneously.

Effects of Alteration of Biliary Pressure on Bile Composition—A Method for Study: Primate Biliary Physiology V.

A method for inducing, maintaining, and measuring different biliary tract pressures was established in rhesus monkeys. A T-tube was placed in the common bile duct and two limbs were exteriorized. All bile was diverted to the exterior via one limb and common bile duct pressure measured through the other limb by a pressure transducer. Interruption of the enterohepatic circulation was controlled by passing the diverted bile through a “stream splitter” which collected a predetermined percentage of the bile and returned the remainder to the animal via a tube duodenostomy. Pressures from —10 to + 25 cm of saline were induced in the common bile duct and each pressure was maintained within the range of respiratory fluctuation for several hours. For purposes of illustration, preliminary data from 1 animal on the effect of biliary pressure on bile flow and secretion of biliary lipids are presented.