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Ntongwetape N, Weledji EP, Mokake DMN. Failed primary repair of blunt duodenal injury managed by tube duodenostomy, gastrojejunostomy and a feeding jejunostomy: a case report. Surg Case Rep 2024; 10:194. [PMID: 39177833 PMCID: PMC11343951 DOI: 10.1186/s40792-024-01998-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 08/14/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND The 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 PRESENTATION We 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. CONCLUSIONS Detailed 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.
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Affiliation(s)
- Ngwane Ntongwetape
- Department of Surgery, Faculty of Health Sciences, University of Buea, S.W. Region, Buea, Cameroon
| | - Elroy Patrick Weledji
- Department of Surgery, Faculty of Health Sciences, University of Buea, S.W. Region, Buea, Cameroon.
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2
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Leppäniemi A, Tolonen M, Mentula P. Complex duodenal fistulae: a surgical nightmare. World J Emerg Surg 2023; 18:35. [PMID: 37208716 DOI: 10.1186/s13017-023-00503-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/22/2022] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION A common feature of external duodenal fistulae is the devastating effect of the duodenal content rich in bile and pancreatic juice on nearby tissues with therapy-resistant local and systemic complications. This study analyzes the results of different management options with emphasis on successful fistula closure rates. METHODS A retrospective single academic center study of adult patients treated for complex duodenal fistulas over a 17-year period with descriptive and univariate analyses was performed. RESULTS Fifty patients were identified. First line treatment was surgical in 38 (76%) cases and consisted of resuture or resection with anastomosis combined with duodenal decompression and periduodenal drainage in 36 cases, rectus muscle patch, and surgical decompression with T-tube in one each. Fistula closure rate was 29/38 (76%). In 12 cases, the initial management was nonoperative with or without percutaneous drainage. The fistula was closed without surgery in 5/6 patients (1 patient died with persistent fistula). Among the remaining 6 patients eventually operated, fistula closure was achieved in 4 cases. There was no difference in successful fistula closure rates among initially operatively versus nonoperatively managed patients (29/38 vs. 9/12, p = 1.000). However, when considering eventually failed nonoperative management in 7/12 patients, there was a significant difference in the fistula closure rate (29/38 vs. 5/12, p = 0.036). The overall in-hospital mortality rate was 20/50 (40%). CONCLUSIONS Surgical closure combined with duodenal decompression in complex duodenal leaks offers the best chance of successful outcome. In selected cases, nonoperative management can be tried, accepting that some patients may require surgery later.
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Affiliation(s)
- Ari Leppäniemi
- Abdominal Center, Division of Emergency Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
- Meilahti Tower Hospital, Haartmaninkatu 4, 00029, Helsinki, Finland.
| | - Matti Tolonen
- Abdominal Center, Division of Emergency Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Panu Mentula
- Abdominal Center, Division of Emergency Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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3
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Reddavid R, Ballauri E, Aguilar HAR, Cardile M, Marchiori G, Sbuelz F, Degiuli M. Iatrogenic Duodenal Perforation After Surgery: a Systematic Review. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03718-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Abstract
Duodenal perforation consequent to prior surgery is a rare but severe complication carrying serious consequences if not promptly managed. This study aims to identify the best treatment pathway available to date. This is a systematic review registered to PROSPERO. The literature research was conducted on Ovid Medline, Embase, and Cochrane up to February 2022 to identify all papers reporting surgical-related duodenal perforations. Twelve articles were included. Most of these studies were case reports or case series. The most common cause of perforation was laparoscopic cholecystectomy (72.7%). The median time to symptom appearance was 2 days. Most of these perforations were severe injuries located in the first portion of the duodenum. Only one patient was treated with a non-interventional conservative management, which failed. Five patients were managed with interventional non-surgical treatments: 4 with endoscopy (50% failure) and one with a percutaneous occluder. Different surgical treatments were reported: direct suture (100% failure), direct suture and T-tube duodenostomy (75% failure), simple abdominal drainage, and suture with pyloric exclusion. Further extensive surgeries were also reported. The overall mortality rate was 13.6%, with a median hospital stay of 38.5 days. This review shows a wide spectrum of managements for patients with duodenal perforation related to prior surgery. The decision on which treatment to adopt must consider patient’s clinical setting and duodenal defect characteristics (size, site, and time to diagnosis). A tentative treatment flowchart is provided, although larger sample size studies are needed to obtain a treatment pathway based on evidence.
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Muacevic A, Adler JR, Pinnola AD. T-tube Duodenostomy for the Difficult Duodenum. Cureus 2022; 14:e32965. [PMID: 36712727 PMCID: PMC9876386 DOI: 10.7759/cureus.32965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2022] [Indexed: 12/27/2022] Open
Abstract
Tube duodenostomy has been described as a useful technique in the management of difficult duodenum arising from a variety of pathologies. In addition, the use of a t-tube for the duodenostomy presents a resourceful option in the event of Malecot or other such catheter unavailability. The aim of our study is to describe the technique and outcomes associated with this approach. During a six-month period in 2020, t-tube duodenostomies were performed in three patients for duodenal stump perforation: the first case involved a patient with Roux-en-Y esophagojejunostomy anatomy; the second involved duodenal stump closure security following Billroth II gastrectomy for peptic ulcer disease; and the third involved decompression following primary closure of duodenal perforation. All duodenostomies were performed with a t-tube that was trimmed with the back wall divided and then secured via the Witzel approach. The t-tube duodenostomies were performed during the index operations of all patients. No patient required additional operations. There was no mortality. All patients were closely monitored postoperatively with duodenostomies kept in place for six weeks. One patient developed a small leak after a trial of tube clamping, which was managed with continued tube drainage and antibiotics prior to definitive removal. The mean length of stay was 20.3 days with two patients being discharged to rehab. T-tube duodenostomy is a simple technique that helps avoid the blowout of the vulnerable duodenal stump in situations of biliopancreatic limb pathology, ulcerative disease, or injury.
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Pizarro E, Vallejos R, Norero E, Diaz A, Ceroni M. Two-stage esophagojejunal anastomosis: An alternative reconstruction in emergency gastrectomy for high-risk gastric cancer patients. SAGE Open Med Case Rep 2022; 10:2050313X211066226. [PMID: 35237440 PMCID: PMC8883396 DOI: 10.1177/2050313x211066226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/24/2021] [Indexed: 12/02/2022] Open
Abstract
Emergency total gastrectomy for patients with gastric cancer who are in shock carries a high risk of esophagojejunal anastomosis leakage. No alternatives have been reported to reduce this risk. This study reports two patients with gastric cancer who were in shock and underwent emergency gastrectomy and two-stage esophagojejunal anastomosis with good results. In the first stage, immediately after gastrectomy, the esophagus was attached to a Roux-en-Y jejunal loop that prevented retraction of the esophagus into the mediastinum. In the second stage, in a second surgery, the esophagojejunal anastomosis was completed under better clinical conditions.
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Affiliation(s)
- Eduardo Pizarro
- Esophagogastric Team, Sótero del Río Hospital, Pontifical Catholic University of Chile, Santiago, Chile
| | - Rodrigo Vallejos
- San Borja Arriarán and Carmen de Maipú Hospital, Santiago, Chile
| | - Enrique Norero
- Esophagogastric Team, Sótero del Río Hospital, Pontifical Catholic University of Chile, Santiago, Chile
| | - Alfonso Diaz
- Esophagogastric Team, Sótero del Río Hospital, Pontifical Catholic University of Chile, Santiago, Chile
| | - Marco Ceroni
- Esophagogastric Team, Sótero del Río Hospital, Pontifical Catholic University of Chile, Santiago, Chile
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Po Chu Patricia Y, Ka Fai Kevin W, Fong Yee L, Kiu Jing F, Kylie S, Siu Kee L. Duodenal stump leakage. Lessons to learn from a large-scale 15-year cohort study. Am J Surg 2020; 220:976-981. [PMID: 32171473 DOI: 10.1016/j.amjsurg.2020.02.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/14/2020] [Accepted: 02/20/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Duodenal stump leakage is a challenging condition causing significant morbidity and mortality. The aim of this study is to identify the risk factors associated with duodenal leak and advocate modification to prevent the incident. METHODS A retrospective cohort study was performed to include patients who had gastrectomy with excluded duodenum in a single surgical centre in the period of Jan 2003-March 2017. Analysis of associated factors was performed. Patients with duodenal leak were further analyzed and the treatment strategy was reviewed. RESULTS During the study period, 678 patients had gastrectomy with excluded duodenum. 502 patients had elective gastrectomy and 176 patients had emergency gastrectomy. 52 patients had subsequent duodenal stump leakage (7.7%). The existence of duodenal ulcer, intra-operative contamination, lower pre-operative haemoglobin and duodenostomy were the independent associated factors for duodenal leak. CONCLUSION This is the largest cohort in studying associated factors regarding duodenal leak in both emergency and elective gastrectomy. The independent associated factors were identified. We advocate a conservative approach for duodenal leak with adequate drainage, nutrition and antibiotics.
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Affiliation(s)
| | | | - Lam Fong Yee
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
| | - Fung Kiu Jing
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
| | - Szeto Kylie
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
| | - Leung Siu Kee
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
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7
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Agarwal N, Malviya NK, Gupta N, Singh I, Gupta S. Triple tube drainage for "difficult" gastroduodenal perforations: A prospective study. World J Gastrointest Surg 2017; 9:19-24. [PMID: 28138365 PMCID: PMC5237819 DOI: 10.4240/wjgs.v9.i1.19] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/07/2016] [Accepted: 11/01/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To prospectively study the outcome of difficult gastroduodenal perforations (GDPs) treated by triple tube drainage (TTD) in order to standardize the procedure. METHODS Patients presenting to a single surgical unit of a tertiary hospital with difficult GDPs (large, unfavourable local and systemic factors) were treated with TTD (gastrostomy, duodenostomy and feeding jejunostomy). Postoperative parameters were observed like time to return of bowel sounds, time to start enteral feeds, time to start oral feeds, daily output of all drains, time to clamping/removal of all drains, time for skin to heal, complications, hospital stay, and, mortality. Descriptive statistics were used. RESULTS Between December 2013 and April 2015, 20 patients undergoing TTD for GDP were included, with mean age of 44.6 ± 19.8 years and male:female ratio of 17:3. Mean pre-operative APACHE II scores were 10.85 ± 3.55; most GDPs were prepyloric (9/20; 45%) or proximal duodenal (8/20; 40%) and mean size was 1.83 ± 0.59 cm (largest 2.5 cm). Median times of resumption of enteral feeding, removal of gastrostomy, removal of duodenostomy, removal of feeding jejunostomy and oral feeding were 4 d (4-5 IQR), 13 (12-16.5 IQR), 16 (16.25-22.25 IQR), 18 (16.5-24 IQR) and 12 d (10.75-18.5 IQR) respectively. Median hospital stay was 22 d (19-26 IQR) while mortality was 4/20 (20%). CONCLUSION TTD for difficult GDP is feasible, easy in the emergency, and patients recover in two-three weeks. It obviates the need for technically demanding and riskier procedures.
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8
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Serrano OK, Solsky I, Sandoval E, Berlin A, Bellemare S. Draining T-Tube Jejunostomy: A Technique to Get Out of Trouble. Am Surg 2016. [DOI: 10.1177/000313481608200613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A perforated viscus in the postpancreaticoduodenectomy setting is a rare phenomenon and a devastating complication. In this situation, adherence to damage-control principles demands minimizing the operative intervention while addressing the intestinal perforation as a way to mitigate the injurious effects on a complex gastrointestinal reconstruction. Herein, we describe our intraoperative decision-making with an unconventional approach in the management of a perforated viscus in the postpancreaticoduodenectomy setting using a draining T-tube jejunostomy. Our patient recovered remarkably well from this and was discharged from the hospital in six days with a controlled draining T-tube jejunostomy, which was subsequently removed on postoperative day 35. Our case illustrates an important option when dealing with a perforated viscus in the complex gastrointestinal surgery patient that has minimal morbidity, adequate source control, and the potential for an excellent clinical outcome. As surgical care continues to be delivered in a specialty-driven manner, a draining T-tube jejunostomy presents the ideal technique to get out of trouble for the general surgeon practicing in the community who may not be as experienced with complex gastrointestinal surgery.
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Affiliation(s)
- Oscar K. Serrano
- Montefiore Center for Cancer Care, Montefiore Medical Center, New York, New York
- Department of Surgery, Albert Einstein College of Medicine, New York, New York
| | - Ian Solsky
- Montefiore Center for Cancer Care, Montefiore Medical Center, New York, New York
- Department of Surgery, Albert Einstein College of Medicine, New York, New York
| | - Eduardo Sandoval
- Montefiore Center for Cancer Care, Montefiore Medical Center, New York, New York
- Department of Surgery, Albert Einstein College of Medicine, New York, New York
| | - Arnold Berlin
- Montefiore Center for Cancer Care, Montefiore Medical Center, New York, New York
- Department of Surgery, Albert Einstein College of Medicine, New York, New York
| | - Sarah Bellemare
- Montefiore Center for Cancer Care, Montefiore Medical Center, New York, New York
- Department of Surgery, Albert Einstein College of Medicine, New York, New York
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9
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Ali BI, Park CH, Song KY. Outcomes of Non-Operative Treatment for Duodenal Stump Leakage after Gastrectomy in Patients with Gastric Cancer. J Gastric Cancer 2016; 16:28-33. [PMID: 27104024 PMCID: PMC4834618 DOI: 10.5230/jgc.2016.16.1.28] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/06/2016] [Accepted: 03/09/2016] [Indexed: 11/20/2022] Open
Abstract
Purpose We evaluated the clinical outcomes of the non-operative management of post-gastrectomy duodenal stump leakage in patients with gastric cancer. Materials and Methods A 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. Results Duodenal 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. Conclusions Non-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.
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Affiliation(s)
- Bandar Idrees Ali
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Cho Hyun Park
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyo Young Song
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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10
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Rudnicki Y, Shpitz B, White I, Wiener Y, Golani G, Avital S. The use of a T drain tube to treat anastomotic leaks. Tech Coloproctol 2016; 20:255-7. [PMID: 26886935 DOI: 10.1007/s10151-016-1439-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/15/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Y Rudnicki
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - B Shpitz
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - I White
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Y Wiener
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - G Golani
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S Avital
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel. .,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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11
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Cornejo MDLÁ, Priego P, Ramos D, Coll M, Ballestero A, Galindo J, García-Moreno F, Rodríguez G, Carda P, Lobo E. Duodenal fistula after gastrectomy: Retrospective study of 13 new cases. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:20-6. [PMID: 26765231 DOI: 10.17235/reed.2015.3928/2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Duodenal stump fistula (DSF) after gastrectomy has a low incidence but a high morbidity and mortality, and is therefore one of the most aggressive and feared complications of this procedure. MATERIAL AND METHODS We retrospectively evaluated all DSF occurred at our hospital after carrying out a gastrectomy for gastric cancer, between January 1997 and December 2014. We analyzed demographic, oncologic, and surgical variables, and the evolution in terms of morbidity, mortality and hospital stay. RESULTS In the period covered in this study, we performed 666 gastrectomies and observed DSF in 13 patients (1.95%). In 8 of the 13 patients (61.5%) surgery was the treatment of choice and in 5 cases (38.5%) conservative treatment was carried out. Postoperative mortality associated with DSF was 46.2% (6 cases). In the surgical group, 3 patients developed severe sepsis with multiple organ failure, 2 patients presented a major hematemesis which required endoscopic haemostasis, 1 patient had an evisceration and another presented a subphrenic abscess requiring percutaneous drainage. Six patients (75%) died despite surgery, with 3 deaths in the first 24 hours of postoperative care. The 2 patients who survived after the second surgical procedure had a hospital stay of 45 and 84 days respectively. In the conservative treatment group the cure rate was 100% with no significant complications and an average postoperative hospital stay of 39.5 days (range, 26-65 days). CONCLUSION FMD is an unusual complication but it is associated with a high morbidity and mortality. In our experience, conservative management has shown better results compared with surgical treatment.
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Affiliation(s)
| | - Pablo Priego
- Cirugía General y Digestivo, Hospital Ramón y Cajal, España
| | - Diego Ramos
- Hospital Universitario Ramón y Cajal. Madrid
| | | | | | | | | | | | - Pedro Carda
- Hospital Universitario Ramón y Cajal. Madrid
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12
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Cozzaglio L, Giovenzana M, Biffi R, Cobianchi L, Coniglio A, Framarini M, Gerard L, Gianotti L, Marchet A, Mazzaferro V, Morgagni P, Orsenigo E, Rausei S, Romano F, Rosa F, Rosati R, Roviello F, Sacchi M, Morenghi E, Quagliuolo V. Surgical management of duodenal stump fistula after elective gastrectomy for malignancy: an Italian retrospective multicenter study. Gastric Cancer 2016; 19:273-279. [PMID: 25491774 DOI: 10.1007/s10120-014-0445-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 11/17/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Duodenal stump fistula (DSF) is a severe complication of gastrectomy. Although nonsurgical therapy is preferred, surgery is still mandatory in one third of DSF patients. The aim of this article is to analyze the surgical management of DSF and factors related to its outcome. METHODS We performed a retrospective multicenter study using data from January 1990 to November 2011 in 16 Italian surgery centers. We collected 8,268 elective gastrectomies for malignancies, 7,987 by the laparotomic and 281 by the laparoscopic approach. Two hundred five patients developed a DSF, 75 of whom underwent surgery for DSF. We analyzed mortality and DSF healing time as well as the impact of clinical, oncological, and surgical characteristics. RESULTS The laparoscopic approach increased the risk of DSF development (odds ratio 5.6, 95% confidence interval 2.7-10.6, P < 0.001). The indication for first DSF surgery was intra-abdominal sepsis; the failure rate was over 30%, associated with the appearance of fistulas of neighboring organs, bleeding, and the need for reoperations. The mortality rate was 28% and was related to the presence of vascular disease (P = 0.04), more than one reoperation (P = 0.05), sepsis (P < 0.001), and renal failure (P < 0.001). Fifty-four patients recovered after a median of 39 days (interquartile range 22-68 days); the need to perform more reoperations (P < 0.01) and the presence of an abdominal abscess (P < 0.01) led to an increase in healing time. CONCLUSIONS Surgery for DSF has a poor prognosis. Our data will help to identify patients at risk of death, but unfortunately could not establish the best surgical procedure applicable to all cases of DSF.
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Affiliation(s)
- Luca Cozzaglio
- Division of Surgical Oncology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy.
| | - Marco Giovenzana
- Division of Surgical Oncology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Roberto Biffi
- Division of Abdominal-Pelvic and Minimally Invasive Surgery, European Institute of Oncology, Milan, Italy
| | - Lorenzo Cobianchi
- Division of General Surgery 1, IRCCS Fondazione Policlinico S. Matteo, University of Pavia, Pavia, Italy
| | - Arianna Coniglio
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Massimo Framarini
- Division of Surgery and Advanced Oncological Therapies, G.B. Morgagni-L. Pierantoni Hospital, Forlì, Italy
| | | | - Luca Gianotti
- Unit of Hepatobiliopancreatic Surgery, Department of Surgery and Translational Medicine, S. Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Alberto Marchet
- Department of Surgical Science, University of Padua, Padua, Italy
| | - Vincenzo Mazzaferro
- Division of Gastrointestinal Surgery and Liver Transplantation, IRCCS Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
| | - Paolo Morgagni
- Division of Surgery, G.B. Morgagni-L.Pierantoni Hospital, Forlì, Italy
| | - Elena Orsenigo
- Department of Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Rausei
- Department of Surgical Science, Insubria University, Varese, Italy
| | - Fabrizio Romano
- Unit of Hepatobiliopancreatic Surgery, Department of Surgery and Translational Medicine, S. Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Fausto Rosa
- Division of Digestive Surgery, Department of Surgical Sciences, Policlinico A. Gemelli, Catholic University Sacro Cuore, Rome, Italy
| | - Riccardo Rosati
- Division of General and Minimally Invasive Surgery, Humanitas Clinical and Research Center, Rozzano, MI, Italy
| | - Francesco Roviello
- Division of Surgical Oncology, Department of Human Pathology and Oncology, University of Siena, Siena, Italy
| | - Matteo Sacchi
- Division of General Surgery, Humanitas Clinical and Research Center, University of Milan, Rozzano, MI, Italy
| | - Emanuela Morenghi
- Department of Biostatistics, Humanitas Clinical and Research Center, Rozzano, MI, Italy
| | - Vittorio Quagliuolo
- Division of Surgical Oncology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
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13
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Skipenko OG, Chekunov DA, Bedzhanyan AL, Bagmet NN. [External duodenal fistula]. Khirurgiia (Mosk) 2016. [PMID: 28635703 DOI: 10.17116/hirurgia2016886-88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- O G Skipenko
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - D A Chekunov
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - A L Bedzhanyan
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - N N Bagmet
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
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14
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Sartelli M, Griffiths EA, Nestori M. The challenge of post-operative peritonitis after gastrointestinal surgery. Updates Surg 2015; 67:373-81. [DOI: 10.1007/s13304-015-0324-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/11/2015] [Indexed: 12/13/2022]
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Vasiliadis K, Fortounis K, Kokarhidas A, Papavasiliou C, Nimer AA, Stratilati S, Makridis C. Delayed duodenal stump blow-out following total gastrectomy for cancer: Heightened awareness for the continued presence of the surgical past in the present is the key to a successful duodenal stump disruption management. A case report. Int J Surg Case Rep 2014; 5:1229-33. [PMID: 25437683 PMCID: PMC4275811 DOI: 10.1016/j.ijscr.2014.11.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 11/06/2014] [Accepted: 11/08/2014] [Indexed: 02/07/2023] Open
Abstract
Duodenal stump disruption is not a surgical anachronism, because it still remains one of the most dreadful postgastrectomy complications. Postgastrectomy duodenal stump disruption poses an overwhelming therapeutic challenge. Historical surgical sense and familiarity with the various well established methods for the treatment of duodenal stump disruption can provide to the surgical team the ability to successfully manage this devastating complication. INTRODUCTION Duodenal stump disruption remains one of the most dreadful postgastrectomy complications, posing an overwhelming therapeutic challenge. PRESENTATION OF CASE The present report describes the extremely rare occurrence of a delayed duodenal stump disruption following total gastrectomy with Roux-en-Y esophagojejunostomy for cancer, because of mechanical obstruction of the distal jejunum resulting in increased backpressure on afferent limp and duodenal stump. Surgical management included repair of distal jejunum obstruction, mobilization and re-stapling of the duodenum at the level of its intact second part and retrograde decompressing tube duodenostomy through the proximal jejunum. DISCUSSION Several strategies have been proposed for the successful management post-gastrectomy duodenal stump disruption however; its treatment planning is absolutely determined by the presence or not of generalized peritonitis and hemodynamic instability with hostile abdomen. In such scenario, urgent reoperation is mandatory and the damage control principle should govern the operative treatment. CONCLUSION Considering that scientific data about duodenal stump disruption have virtually disappeared from the current medical literature, this report by contradicting the anachronism of this complication aims to serve as a useful reminder for gastrointestinal surgeons to be familiar with the surgical techniques that provide the ability to properly manage this dreadful postoperative complication.
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Affiliation(s)
- K Vasiliadis
- First Surgical Department, General Hospital Papageorgiou, West Ring Road, Nea Efkarpia, GR-56 403 Thessaloniki, Greece.
| | - K Fortounis
- First Surgical Department, General Hospital Papageorgiou, West Ring Road, Nea Efkarpia, GR-56 403 Thessaloniki, Greece
| | - A Kokarhidas
- First Surgical Department, General Hospital Papageorgiou, West Ring Road, Nea Efkarpia, GR-56 403 Thessaloniki, Greece
| | - C Papavasiliou
- First Surgical Department, General Hospital Papageorgiou, West Ring Road, Nea Efkarpia, GR-56 403 Thessaloniki, Greece
| | - A Al Nimer
- First Surgical Department, General Hospital Papageorgiou, West Ring Road, Nea Efkarpia, GR-56 403 Thessaloniki, Greece
| | - S Stratilati
- Department of Radiology, General Hospital Papageorgiou, West Ring Road, Nea Efkarpia, GR-56 403 Thessaloniki, Greece
| | - C Makridis
- First Surgical Department, General Hospital Papageorgiou, West Ring Road, Nea Efkarpia, GR-56 403 Thessaloniki, Greece
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Cvetkovic AM, Milasinovic DZ, Peulic AS, Mijailovic NV, Filipovic ND, Zdravkovic ND. Numerical and experimental analysis of factors leading to suture dehiscence after Billroth II gastric resection. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2014; 117:71-79. [PMID: 25201585 DOI: 10.1016/j.cmpb.2014.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 08/07/2014] [Accepted: 08/18/2014] [Indexed: 06/03/2023]
Abstract
The main goal of this study was to numerically quantify risk of duodenal stump blowout after Billroth II (BII) gastric resection. Our hypothesis was that the geometry of the reconstructed tract after BII resection is one of the key factors that can lead to duodenal dehiscence. We used computational fluid dynamics (CFD) with finite element (FE) simulations of various models of BII reconstructed gastrointestinal (GI) tract, as well as non-perfused, ex vivo, porcine experimental models. As main geometrical parameters for FE postoperative models we have used duodenal stump length and inclination between gastric remnant and duodenal stump. Virtual gastric resection was performed on each of 3D FE models based on multislice Computer Tomography (CT) DICOM. According to our computer simulation the difference between maximal duodenal stump pressures for models with most and least preferable geometry of reconstructed GI tract is about 30%. We compared the resulting postoperative duodenal pressure from computer simulations with duodenal stump dehiscence pressure from the experiment. Pressure at duodenal stump after BII resection obtained by computer simulation is 4-5 times lower than the dehiscence pressure according to our experiment on isolated bowel segment. Our conclusion is that if the surgery is performed technically correct, geometry variations of the reconstructed GI tract by themselves are not sufficient to cause duodenal stump blowout. Pressure that develops in the duodenal stump after BII resection using omega loop, only in the conjunction with other risk factors can cause duodenal dehiscence. Increased duodenal pressure after BII resection is risk factor. Hence we recommend the routine use of Roux en Y anastomosis as a safer solution in terms of resulting intraluminal pressure. However, if the surgeon decides to perform BII reconstruction, results obtained with this methodology can be valuable.
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Affiliation(s)
- Aleksandar M Cvetkovic
- Faculty of Medical sciences, University in Kragujevac, Svetozara Markovica 69, 34000 Kragujevac, Serbia.
| | - Danko Z Milasinovic
- Faculty of Hotel Management and Tourism, Vojvodjanska bb, 36210 Vrnjacka Banja, Serbia; BioIRC, Bioengineering Research and Development Center, Prvoslava Stojanovica 6, 34000 Kragujevac, Serbia
| | - Aleksandar S Peulic
- Faculty of Engineering, University of Kragujevac, Sestre Janjic 6, 34000 Kragujevac, Serbia
| | - Nikola V Mijailovic
- BioIRC, Bioengineering Research and Development Center, Prvoslava Stojanovica 6, 34000 Kragujevac, Serbia; Faculty of Engineering, University of Kragujevac, Sestre Janjic 6, 34000 Kragujevac, Serbia
| | - Nenad D Filipovic
- BioIRC, Bioengineering Research and Development Center, Prvoslava Stojanovica 6, 34000 Kragujevac, Serbia; Faculty of Engineering, University of Kragujevac, Sestre Janjic 6, 34000 Kragujevac, Serbia
| | - Nebojsa D Zdravkovic
- Faculty of Medical sciences, University in Kragujevac, Svetozara Markovica 69, 34000 Kragujevac, Serbia
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Orsenigo E, Bissolati M, Socci C, Chiari D, Muffatti F, Nifosi J, Staudacher C. Duodenal stump fistula after gastric surgery for malignancies: a retrospective analysis of risk factors in a single centre experience. Gastric Cancer 2014; 17:733-44. [PMID: 24399492 DOI: 10.1007/s10120-013-0327-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 12/16/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Duodenal stump fistula (DSF) is the most severe surgical complication after gastrectomy. This study was designed to assess the incidence, to observe the consequences, and to identify the risk factors associated with DSF after gastrectomy. METHODS All procedures involving total or sub-total gastrectomy for cancer, performed between January 1987 and June 2012 in a single institution, were prospectively entered into a computerized database. Risk factors analysis was performed between DSF patients, patients with complete uneventful postoperative course and patients with other major surgical complications. RESULTS Over this 25 years period, 1287 gastrectomies were performed. DSF was present in 32 cases (2.5 %). Mean post-operative onset was 6.6 days. 19 patients were treated conservatively and 13 surgically. Mean DSF healing time was 31.2 and 45.2 days in the two groups, respectively. Mortality was registered in 3 cases (9.37 %), due to septic shock (2 cases) and bleeding (1 case). In monovariate analysis, heart disease (p < 0.001), pre-operative lymphocytes number (p = 0.003) and absence of manual reinforcement over duodenal stump (p < 0.001) were found to be DSF-specific risk factors, whereas liver cirrhosis (p = 0.002), pre-operative albumin levels (p < 0.001) and blood losses (p = 0.002) were found to be non-DSF-specific risk factors. In multivariate analysis heart disease (OR 5.18; p < 0.001), liver cirrhosis (OR 13.2; p < 0.001), bio-humoral nutritional status impairment (OR 2.29; p = 0.05), blood losses >300 mL (OR 4.47; p = 0.001) and absence of manual reinforcement over duodenal stump (OR 30.47; p < 0.001) were found to be independent risk factors for DSF development. CONCLUSIONS Duodenal stump fistula still remains a life-threatening complication after gastric surgery. Co-morbidity factors, nutritional status impairment and surgical technical difficulties should be considered as important risk factors in developing this awful complication.
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Affiliation(s)
- Elena Orsenigo
- Department of Surgery, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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Gupta V, Singh SP, Pandey A, Verma R. Study on the use of T-tube for patients with persistent duodenal fistula: is it useful? World J Surg 2013; 37:2542-2545. [PMID: 23982780 DOI: 10.1007/s00268-013-2196-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The commonest surgical treatment used for peptic ulcer perforation is omental patching. If, however, the perforation leaks, it rarely heals by itself due to persistence of duodenal fistula (DF). We present our experience with a T-tube placed into the DF for better outcome of the patients. METHODS All patients in our hospital with DF following failure of surgery for duodenal perforation were included in this study. After identification of the perforation, a size 16 French T-tube was put in place. The patients were analyzed on basis of duration of hospital stay, complications related to the T-tube and overall complications, start of oral feeds, and follow-up. RESULTS In this 3-year study, ten patients with DF were admitted. The mean age was 50 years. The T-tube was kept in place within the fistula for 20.5 days. The mean duration to start oral feeds was 8.8 days. The mean duration of hospital stay was 23.2 days, and the mean follow-up period was 6.3 months. The complications observed in the postoperative period were fever in four patients, wound dehiscence in four patients, and peritoneal collection in two patients, all of which were managed easily. There was no peritubal leakage and no failure of surgery as regards placement of a T-tube. There were no deaths in this study. CONCLUSIONS Placement of a T-tube into a DF appears to be very effective procedure for managing this complication of surgical repair of a perforated peptic ulcer with an omental patch. The technique appears to be simple and rewarding. Further use of this method by other workers will substantiate our efforts.
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Affiliation(s)
- Vipin Gupta
- Department of Surgery, UP Rural Institute of Medical Sciences & Research, Saifai, Etawah, 206130, Uttar Pradesh, India
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Early rupture of an ultralow duodenal stump after extended surgery for gastric cancer with duodenal invasion managed by tube duodenostomy and cholangiostomy. Case Rep Surg 2013; 2013:430295. [PMID: 24159410 PMCID: PMC3789440 DOI: 10.1155/2013/430295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 08/23/2013] [Indexed: 12/20/2022] Open
Abstract
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.
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20
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Kutlu OC, Garcia S, Dissanaike S. The successful use of simple tube duodenostomy in large duodenal perforations from varied etiologies. Int J Surg Case Rep 2012; 4:279-82. [PMID: 23357008 DOI: 10.1016/j.ijscr.2012.11.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 11/21/2012] [Accepted: 11/29/2012] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Tube 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 CASE In 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. DISCUSSION Patients 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. CONCLUSION Application 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.
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Affiliation(s)
- Onur C Kutlu
- Department of Surgery, Texas Tech University Health Sciences Center, United States
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Abstract
Injuries to the duodenum pose a diagnostic and therapeutic challenge to the surgeon. Due to the intra- and extra-peritoneal location of the duodenum, the presentation can be overt or occult, and delay in diagnosis is associated with an increased mortality rate. A range of interventions have been described and this article reviews the relevant literature, highlights the salient points and suggests a treatment algorithm.
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Affiliation(s)
- Mansoor A Khan
- Specialist Registrar, General Surgery, Doncaster Royal Infirmary, Doncaster, UK
| | - Jeff Garner
- Consultant Colorectal Surgeon, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Clive Kelty
- Consultant General and Upper GI Surgeon, Doncaster Royal Infirmary, Doncaster, UK
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Herrod PJJ, Kamali D, Pillai SCB. Triple-ostomy: management of perforations to the second part of the duodenum in patients unfit for definitive surgery. Ann R Coll Surg Engl 2011; 93:e122-4. [PMID: 22004618 DOI: 10.1308/147870811x602320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Peptic ulcers in the second part of the duodenum are a rare occurrence and present challenging management. Conventional surgical operations are associated with life threatening complications. We describe a case of a perforated duodenal ulcer in a medically unstable patient who was deemed unfit for lengthy definitive surgery. An emergency laparotomy and 'triple-ostomy' was performed. We recommend this procedure as an alternative for the emergency repair of D2 ulcers, especially in patients with multiple co-morbidities.
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Affiliation(s)
- P J J Herrod
- Department of General Surgery, Lincoln County Hospital, Lincoln, UK.
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Percutaneous transhepatic biliary drainage and occlusion balloon in the management of duodenal stump fistula. J Gastrointest Surg 2011; 15:1977-81. [PMID: 21913043 DOI: 10.1007/s11605-011-1668-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Accepted: 08/10/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Duodenal stump fistula (DSF) after gastrectomy is a complication with a high mortality rate. We report a series of patients with postoperative DSF treated with percutaneous transhepatic biliary drainage and occlusion balloon (PTBD-OB). The aim of this study is to explore the feasibility and efficacy of PTBD-OB in the treatment of DSF. PATIENTS AND METHODS Six patients developing DSF underwent PTBD-OB because of high DSF output and because medical and surgical management was unsuccessful. In these patients, an occlusion balloon was percutaneously inserted into the common bile duct and a biliary drain was positioned above the balloon to obtain external drainage of bile. RESULTS In all cases, percutaneous access to the biliary tree was achieved. Patients maintained the PTBD-OB for a median of 43 days. In all patients, DSF output decreased after PTBD-OB placement from a median of 500 to 100 ml/day (p = 0.02). The DSF resolved in three patients and three patients died of sepsis, but in two of them, death was related to other digestive fistulas that developed before PTBD-OB placement. CONCLUSIONS This paper presents the first published series on DSF management with PTBD-OB and shows that it is a feasible and safe procedure which reduces DSF output.
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Park SH, Mok YJ, Kim JH, Park SS, Kim SJ, Kim CS. Clinical significance of gastric outlet obstruction on the oncologic and surgical outcomes of radical surgery for carcinoma of the distal stomach. J Surg Oncol 2009; 100:215-21. [DOI: 10.1002/jso.21256] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Vereczkei A. [Gastric surgery]. Magy Seb 2008; 61:320-33. [PMID: 19073487 DOI: 10.1556/maseb.61.2008.6.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Zarzour JG, Christein JD, Drelichman ER, Oser RF, Hawn MT. Percutaneous transhepatic duodenal diversion for the management of duodenal fistulae. J Gastrointest Surg 2008; 12:1103-9. [PMID: 18172607 DOI: 10.1007/s11605-007-0456-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 11/29/2007] [Indexed: 01/31/2023]
Abstract
PURPOSE The aim of this study was to determine the success of the nonoperative management of persistent duodenal fistulae (DF) with percutaneous transhepatic duodenal diversion (PTDD). METHODS Retrospective chart review identified six patients with DF managed by PTDD from 2006 to 2007. Patient outcomes and complications were assessed. RESULTS The etiology of DF included pancreatic surgery (three patients), gastrectomy (two patients), and Crohn's disease (one patient). PTDD was performed by interventional radiology at a median time of 37 days after fistula recognition. After PTDD, fistula drainage decreased from 775 cc/day (range 200 to 2,525 cc/day) to <50 cc/day at a median of 8 days. Patients were discharged 32 days (median) after PTDD. One patient with Crohn's disease required definitive surgical treatment. Of the remaining five patients, the PTDD tube was capped at 27 days (median) after placement and was removed on an outpatient basis at 79 days (median) after placement. There was no mortality, no fistula recurrence, or complications associated with PTDD placement. CONCLUSIONS We present an algorithm for the nonoperative management of persistent postoperative DF. In this limited series, PTDD was highly effective at definitively treating DF, especially in the acute setting. PTDD should be considered by surgeons facing the management of postoperative DF.
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Affiliation(s)
- Jessica G Zarzour
- Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Paluszkiewicz P. Should the Tube Cholangiostomy be Performed as a Supplement Procedure to Duodenostomy for Treatment or Prevention of Duodenal Fistula? World J Surg 2008; 32:1905; author reply 1906. [DOI: 10.1007/s00268-008-9551-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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