Cautious and patient pushandpull movements with intermittent abdominal compression were needed to finally reach the papilla in a strictly tangential position fig. The esophagus enters the diaphragmatic hiatus at the level of t8. Duodenal diverticulum is a rare disease that can be easily missed. Single pursestring suture for reinforcement of duodenal. Esomeprazole 40 mgd was prescribed daily for 6 months. Russell martin, md, houston, texas leakage from the duodenal stump has been the most feared complication of the biuroth ii recon struction following gastric resection.
We tested whether duodenal tube feeding effectively improves the clinical symptoms and body weight gain in children with congenital heart disease chd and gastroesophageal reflux ger. Mar 21, 2017 i already introduced a technique of laparoscopic reinforcement suture lars on stapleline of duodenal stump using barbed suture for prevention of duodenal stump leakage. Duodenal stump leakage after gastrectomy is one of serious complications related to severe morbidity or mortality. Pdf a technique to prevent duodenal blowout after difficult. Non operative management of perforated duodenal ulcers. Recanalization of the jejunum at enterically closed site was investigated endoscopically or fluoroscopically. Leakage of the duodenal or antral stump complicating gastric resection. Safe answers section 4 gastric and duodenum flashcards. To avoid retained antrum syndrome, it is advisable histologically to verify the presence of duodenal brunner glands at the distal margin of resection by frozen section after antrectomy, particularly if scarring or active inflammation makes clear identification of the pylorus difficult. Complications immediate bleeding gastric retention dysphagia leakage of duodenal stump obstruction of the stoma acute pancreatitis late dumping syndrome diarrhoea steatorhoea enterogastric reflux recurrent ulceration iron deficiency anaemia risk of colorectal and gastric tumours. The effluent ducts of the pancreas and liver open into the duodenal cavity through a common aperture.
A vertical incision through the anterior wall of the antral cuff and pyloric ring permits a useful modification of the bancroft procedure for management of the difficult duodenal stump. Management of the difficult duodenal stump, the american journal of surgery 162, p. Duodenal perforation is a rare, life threatening injury associated with nonaccidental blunt abdominal trauma. Therefore, a prospective phase ii study was designed for safety of this technique. Early rupture of an ultralow duodenal stump after extended surgery for gastric cancer with duodenal invasion managed by tube duodenostomy and cholangiostomy. Leakage from the duodenal stump has been the most feared complication of the. Yes there is an acute form that can present early post operatively and mimic duodenal stump rupture and appears as a large fluid filled mass in ruq on ct needs also immediate surgery and jejunojejunostomy and rarely resection if the loop is gangrenous. Duodenal ulcer is a bacterial infection caused by bacteria helicobacter pylori h. Postoperative insufficiency of duodenal stump sutures caused by ascaris lumbricoides, magyar sebeszet. Herein, we introduced a new and simple surgical technique to reduce duodenal stump leakage during laparoscopic gastrectomy for gastric cancer. The present study reports a case of an early duodenal stump rupture after subtotal gastrectomy with resection of the.
Postgastrectomy duodenal leak, sometimes referred to as duodenal stump blowout, is an infrequent but potentially devastating complication of gastric surgery. The incidence of duodenal diverticulum diagnosed by upper gi study is approximately 5%. However, rupture of an ultralow duodenal stump necessitates advanced surgical skills and close postoperative observation. Gastroenterology that part of the stomach that remains after partial resection. Most commonly presenting in the early postoperative period, there is significant variation in the surgical management of the difficult duodenal stump due to complexity. Although the rygbp is effective in longterm weight reduction and prevention of obesityrelated complications, the short and longterm complications are now appearing in. It is suggested that lateral ttube duodenostomy may serve as an alternative to prolonged nasogastric intubation, obviating several of the complications associated with the latter. Duodenal stump leaks often lead to significant morbidity and mortality. Double contrast computed tomography is the most sensitive investigation to confirm clinical suspicion. Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. Jul 07, 20 anatomy of duodenum, duodenum structure, ppt of duodenum, power point presentation duodenum 1. The six patients underwent seven laparoscopic operative procedures to treat their duodenal disease table 4. Our experience suggests that retrograde bladder and duodenal stump opacification should be a routine part of the ct evaluation performed to detect leakage from the urinary bladder or duodenal stump after pancreas transplantation. Download fulltext pdf duodenal stump leak following a duodenal switch.
Scribd is the worlds largest social reading and publishing site. In the retrospective analysis of 17 consecutive children with chd who were treated with duodenal tube feeding for symptomatic ger, we found that clinical symptoms of persistent emesis or respiratory wheezing. A total of 1,230 patients underwent gastrectomy at our institution between 2010 and 2014. Duplication cysts are spherical and tubular structures covered by esophageal epithelium and with smooth muscle in their walls. The surgical treatment of morbid obesity using the rouxeny gastric bypass rygbp technique is being performed at an increasing rate, with more than 100,000 operations being performed each year in the united states alone. Postoperative anatomic and pathologic findings at ct. The entire duodenal stump proved diffusely strictured, such that we switched to a capfitted gastroscope to limit perforation risks. Duodenal stump rupture was managed successfully by end tube.
Jun 28, 2016 while lateral ttube catheter drainage of the duodenal stump has been described and used with success, contemporary approaches to tube duodenostomy typically involve introduction of a foley, pezzer, or straight catheter via the stump of the duodenum to approximately 5 cm see fig. Management of the difficult duodenal stump sciencedirect. The thoracic esophagus passes behind the right mainstem bronchus and the pericardium. Management of the difficult duodenal stump the american journal. Although the authors did not specifically state that the method they described to manage a difficult duodenal stump was original with them, in glancing over their reference list, there was. A total of 183 patients harboring gastric adenocarcinoma following laparoscopic radical gastrectomy with. The course of the efferent limb open arrows is more complex and difficult to follow. Multiple surgical modalities are available for dealing with this pathology.
Detection of pancreatic fluid and urine leakage after. The thoracic esophagus enters the posterior mediastinum anterior to the aortic arch. Congenital duodenal web leading to partial obstruction. A technique to prevent duodenal blowout after difficult. Full text full text is available as a scanned copy of the original print version.
Early rupture of an ultralow duodenal stump after extended. A duodenal stump fistula is one of the most severe complications after gastrectomy for gastric cancer. We report three cases, all with other features typical of nonaccidental injury. Burch jm1, cox cl, feliciano dv, richardson rj, martin rr. Management of the difficult duodenal stump ncbi nih. Distal gastrectomy with b1, b2 anastomsis or free download as powerpoint presentation. Perfect duodenal stump management has been the obsession of general abdominal surgeons for a long time and debates on the best methods of securing a safe stump have not really settled 3. Difficult closures of the duodenal stump jama surgery jama. Until now, no prospective clinical trial for duodenal stump leakage after laparoscopic or open gastrectomy for gastric cancer patients has been conducted. Duodenal injuries are uncommon, but not so rare as to preclude a comprehensive understanding of treatment strategies by general surgeons.
Know more about the symptoms, causes and treatment with this article. Mean operation time was 160 minutes, and the mean time for lars was 8 minutes. The overall incidence of duodenal stump fistula dsf or duodenal stump leakage is reportedly between 1. Duodenal ulcer is a open sore or lesion in the inner lining of the stomach or duodenum.
Uptodate, electronic clinical resource tool for physicians and patients that provides information on adult primary care and internal medicine, allergy and immunology, cardiovascular medicine, emergency medicine, endocrinology and diabetes, family medicine, gastroenterology and hepatology, hematology, infectious diseases, nephrology and. Aug 14, 20 these are rare nets of another part of the small bowel. Shortest, dilated and most fixed proximal part of small intestine. We aimed to analyze the risk factors for this problem, and to identify the methods used for its prevention and management. Classical technique of closing a difficult duodenal stump nissenbsteh has, up to now, not been compared with duodenojejunostomy dj in larger patient sets. Pdf early rupture of an ultralow duodenal stump after. Stump blowout, or duodenal blowout, is the leakage of the blind end of the duodenum. Delayed duodenal stump blowout following total gastrectomy for. Duodenal injuries challenges in management by habiba gad on prezi.
Modified bancroft procedure for the difficult duodenal stump. A good meditoon first establishes the normal anatomy and function, and then shows the development of the disease process. Autopsy results show that 22% of the population have duodenum diverticulum. It occurs as a complication of billroth ii gastrectomy, usually on the fourth or fifth day after surgery. C shaped curvature curved around head of pancreas lies above umbilicus opp. Duodenal injuries are uncommon duodenal injuries are both difficult to diagnose and repair due to its retroperitoneal location mortality is high in duodenal injuries 3. In the wall of the upper portion of the duodenum are the socalled brunners glands, which, in structure and in the composition of the juice they secrete, are closely related to the glands of the pyloric portion of the stomach. An empty stomach is roughly the size of an open hand and when distended with food, can fill much of. Primary closure of the duodenal stump following gastric resection for peptic ulcer disease usually poses no problem. Schwartz, management of the difficult duodenum, in. Additionally, this procedure enables decompression of the difficult duodenal stump. Get a printable copy pdf file of the complete article 1. In technically difficult duodenal stump closures, additional coverage of the stump with the back wall of the stomach can be obtained.
Duodenal varices were first described by alberti,15 and visualised endoscopically in 1973 by kunisaki et al. However, definite surgical method for duodenal stump leakage is not established. Surgical exposure surgical options cattellbraasch maneuver closure of the perforation primary repair duodenorrhaphy mucosal or serosal patch. The management of large perforations of duodenal ulcers. Laparoscopic reinforcement suture lars of duodenal stump. Leakage from the duodenal stump has been the most feared complication of the billroth ii.
The esophagus deviates anteriorly and to the left as it enters the abdomen. Delayed perforation of the defunctionalized stomach after. A duodenal web, diaphragm or intraluminal diverticulum refers to a complete or incomplete obstruction at the duodenum due to a membranous web or intraluminal diverticulum. Download fulltext pdf duodenal stump leak followi ng a duodenal switch. Laparoscopic reinforcement suture lars of duodenal stump a. I already introduced a technique of laparoscopic reinforcement suture lars on stapleline of duodenal stump using barbed suture for prevention of duodenal stump leakage. Historically duodenal leak has been a potentially devastating complication after billroth ii resections following emergency surgery for duodenal ulcer perforation. The duodenal stump, the blind end of the afferent limb solid arrow in c, is noted in the right subhepatic space. It is due to improper closure of duodenal stump, especially when the duodenum is inflamed and oedematous. Duodenal stump disruption is not a surgical anachronism, because it still.
High % of h pylori infections reported with perforated duodenal ulcers. In most instances of partial gastric resection of the billroth ii type performed for duodenal ulcer, management of the duodenal stump presents no unusual proble. Get a printable copy pdf file of the complete article. Links to pubmed are also available for selected references. This also refers to the potential benefit of a gastric and biliary diversion under such conditions. Despite the fact that the number of gastric cancer encounters with a difficult. While lateral ttube catheter drainage of the duodenal stump has been described and used with success, contemporary approaches to tube duodenostomy typically involve introduction of a foley, pezzer, or straight catheter via the stump of the duodenum to approximately 5 cm see fig. The approach allows completion of subtotal gastrectomy or hemigastrectomy and vagotomy for duodenal ulcer without.
Duodenal stump blowout is a feared complication of billroth ii reconstruction after gastrectomy. Several tiny duodenal sessile polyps are noted on the anterior wall of bulb figure a. Two years later, she underwent egd for recurred acid regurgitation. Management of the difficult duodenal stump in penetrating. We report two cases of giant duodenal ulcer perforation after neurosurgery for brainstem tumors that needed reoperation for.
Necrotizing fasciitis complicated by duodenal stump. Emergency exploration was performed for suspected necrotizing fasciitis nf of the abdominal wall with or without peritonitis. A duodenal ulcer is a raw area or open sore ulcer that develops when there is a break in the lining of the duodenum, the upper part of the small intestine which is connected to the stomach. There is usually a small aperture at the center differentiating this from duodenal atresia. Despite the efficacy of pharmacotherapy for gastrointestinal ulcers, severe cases of bleeding or perforation due to gastrointestinal ulcers still occur. Here, we report a highly unusual case of a delayed duodenal stump perforation secondary to a golfball sized enterolith without. Anatomy of duodenum, duodenum structure, ppt of duodenum. These included a gastroenterostomy that was fashioned as a loop n 5 or in a rouxeny configuration n 1, and a pancreaspreserving distal duodenectomy 3 with a duodenojejunal anastomosis n 1. Duodenal article about duodenal by the free dictionary.
Ng et al reported 80% 58 of 73 case of pdu were infected. Leakage from the duodenal stump has been the most feared complication of the billroth ii reconstruction following gastric resection. These are rare nets of another part of the small bowel. However, when there is intense scarring or active ulceration with marked edema and inflammation, the closure and management of this difficult.
When food passes from your mouth, it moves through the esophagus and into your stomach. Diagnostic delay is common, as the true history is concealed and signs may be minimal. Risk factors for duodenal stump leakage after gastrectomy for. When dealing with gastric cancer with duodenal invasion, gastrectomy with distal resection of the duodenum is necessary to achieve negative distal margin. The goal of this study was to elucidate the risk factors for duodenal stump leakage after gastrectomy for gastric cancer. A technique to prevent duodenal blowout after difficult gastrectomies. Duodenal stump leakage dsl is a serious surgical complication after radical gastrectomy with rouxeny or billrothii reconstruction. Duodenal diverticular perforation after small bowel. However, complications like inflammation, perforation with retroperitoneal abscess.
Esophagogastroduodenoscopy egd revealed reflux esophagitis. Succession of duodenal polypoid lesion gastroenterology. Delayed duodenal stump blowout following total gastrectomy. Distal gastrectomy with b1, b2 anastomsis or stomach. Pdf a simple technique of decompressing the duodenum following difficult gastrectomies is described which can be applied across the country to. The open end of the duodenum is then gently secured in place around the tube using a pursestring 3. A 27yearold woman presented to the clinic with acid regurgitation of 3 years duration. Duodenal stump leakage free download as powerpoint presentation. Although most staplers would produce at least two or three rows of staples, burying this line with a second layer using monofilament sutures placed. Gastric stump definition of gastric stump by medical dictionary. Most patients with duodenal diverticulum are asymptomatic.
After cutting of duodenal stump, lars commenced with continuous invagination method or interrupted method using barbed suture. This may not be the complete list of references from this article. Dsf is a rare complication but is associated with a high morbidity and mortality rate. Duodenal stump fistula after gastrectomy for gastric. Free stl 3d models for download, files in stl with low poly, animated, rigged, game, and vr options.
High prevalence of helicobacter pylori infection in duodenal ulcer perforations not caused by nonsteroidal antiinflammatory drugs. Duodenal stump leakage was diagnosed in 19 patients 1. The value of duodenal tube decompression for postgastrectomy management of the duodenal stump was demonstrated for the first time in 1954. Duodenal ulcer perforations are a common surgical emergency, but literature is silent on the exact definition, incidence, management and complications of large perforations of duodenal ulcers. Giant duodenal ulcers after neurosurgery for brainstem. Subcutaneous infiltration with emphysema around the drain site and mesenteric fat haziness with air densities around the duodenal stump site were observed figures 1a, b on computed tomography ct.
Risk factors for duodenal stump leakage after gastrectomy. We evaluated the clinical outcomes of the nonoperative management of postgastrectomy duodenal stump leakage in patients with gastric cancer. Duodenal stump fistula after gastrectomy for gastric cancer. Historically it has occurred most frequently in billroth ii resections following emergency surgery for duodenal ulcer perforating in the pancreatic head and less frequently after resections for gastric cancer. This study was designed to evaluate the effectiveness of laparoscopic single pursestring suture for reinforcement of duodenal stump. Duodenal stump blowout, while much less common than in previous decades due to a marked reduction in the number of gastrectomies performed, continues to be one of the most dreaded complications following gastric resection. Difficult closures of the duodenal stump jama surgery.
Introduction the epitome of an organ poorly designed to withstand the ravages of trauma. Pdf duodenal stump leak following a duodenal switch. One of the most serious complications after gastrectomy is leakage from the duodenal stump. Sixty patients underwent distal gastrectomy with bii, and two patients had total gastrectomy. Duodenal stump closure carries a leak rate of % and a mortality rate of 02% in recent series. Giant duodenal ulcer perforation is an uncommon but difficult tomanage pathology with a high mortality rate. In the era of gastrectomy for peptic ulcer disease, duodenal leak occurred after gastric surgery in 1 to 3 percent of patients 2,3.
One of the most serious complications in the postoperative period after gastrectomy is a leakage from the duodenal stump. The stomach is distensible and on a free mesentery, therefore, the size, shape, and position may vary with posture and content. Full text is available as a scanned copy of the original print version. Total parenteral nutrition, when added to prompt and adequate surgical drainage, has sharply reduced mortality and in many cases will eliminate the need for further operative intervention. A case report article pdf available in international journal of surgery case reports 14c. Morbidity was observed in three patients aspiration pneumonia, delayed gastric emptying with nausea and vomiting, and leakage of the duodenal stump. Laparoscopic reinforcement suture of duodenal stump using. Outcomes of nonoperative treatment for duodenal stump. Inadequate duodenal stump ds closure, inappropriate usage of cautery, excessive dissection skeletonization for more than 2 cm of the first part of the duodenum or overzealous suturing of the ds resulting in ischemia and necrosis, submucosal hematoma in the resection line of the ds, local pancreatitis, incorrect drain position, and acute. This is the first part of the bowel after the stomach.
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