Management of the difficult duodenal stump

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Burch JM, Cox CL, Feliciano DV, Richardson RJ, Martin RR. Management of the difficult duodenal stump. Am J Surg. 1991 Dec;162(6):522-6.

Full-text for Emory users.

Abstract: 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.

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Surgical Treatment of Enterocutaneous Fistula

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“Enterocutaneous Fistula (ECF) is defined as an abnormal connection between the gastrointestinal tract and the skin, and it requires labor-intensive medical management and surgical expertise. Complex wound management, severe malnutrition, frequent infectious complications, chronic pain, and depression require significant investment of health care resources and make the short-term and long-term care of these patients difficult.”

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Predictors of Short-Term Readmission After Pancreaticoduodenectomy

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“Readmissions are a common complication after pancreaticoduodenectomy and are increasingly being used as a performance metric affecting quality assessment, public reporting, and reimbursement. This study aims to identify general and pancreatectomy-specific factors contributing to 30-day readmission after pancreaticoduodenectomy, and determine the additive value of incorporating pancreatectomy-specific factors into a large national dataset.”
“Large registry analyses of pancreatectomy outcomes are markedly improved by the incorporation of granular procedure-specific data. These data emphasize the need for prevention and careful management of perioperative infectious complications, fluid management, thromboprophylaxis, and pancreatic fistulae.”

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Clinical Practice Update on Management of Ostomies

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“Enteral ostomies are common in the management of patients with gastrointestinal conditions, including colorectal cancer (CRC), inflammatory bowel disease (IBD), diverticular disease, intestinal trauma, and intestinal perforation. An estimated 750,000 Americans live with an ostomy and 130,000 new ostomy surgeries occur in the United States annually. People with ostomies often face postsurgical complications and challenges to daily self-care. Studies have suggested that adequate stomal care improves clinical outcomes and reduces hospitalizations. However, little guidance exists to support clinicians in managing patients with an ostomy beyond the immediate perioperative period.”

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2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

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“Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).”
“CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted. With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.”

“Conclusions: grey areas and opportunities for improvements

We found some limitations within the present guidelines:

– They fail to cover all the possible abdominal scenarios when colon cancer occurs as an
emergency: for example, associated resections were not taken into considerations, neither we discussed about therapeutic strategies in case of evidence of peritoneal carcinomatosis.
– Despite our attempts to underline suggestions in case of low technical resources, the present guidelines are generally oriented toward hospitals with high level of resources.

On the other side, in our opinion, the current guidelines suggest some stimuli for doctors involved in this field:

– To review the approach to patient suffering from abdominal pain by introducing and promoting the use of bedside abdominal US.
– To bear in mind that the emergency surgeon should have a strong oncologic background or that the specialised colorectal surgeon should have a strong background of surgical pathophysiology, emergency surgery and damage control philosophy.
– To promote the use of clinical pathways within singular Hospitals”

Pisano M, et al 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg. 2018 Aug 13;13:36. Free Full Text

Incisional negative pressure wound therapy for the prevention of surgical site infection

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“The evidence on prophylactic use of negative pressure wound therapy on primary closed incisional wounds (iNPWT) for the prevention of surgical site infections (SSI) is confusing and ambiguous. Implementation in daily practice is impaired by inconsistent recommendations in current international guidelines and published meta-analyses. More recently, multiple new randomised controlled trials (RCTs) have been published. This study aimed to provide an overview of all meta-analyses and their characteristics; to conduct a new and up-to-date systematic review and meta-analysis and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment; and to explore the additive value of new RCTs with a trial sequential analysis (TSA).”

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Is it time to abandon routine operative drain use?

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“Postoperative pancreatic fistula (POPF) is a potentially devastating complication after pancreatic resection, seen in 5% to 30% of patients. Depending on severity, POPF may be associated with infectious complications, reoperation, increased length of hospital stay, readmission, and even death. Historically, surgeons placed drains routinely for many abdominal procedures to control potential leaks from various anastomoses. However, this practice has been abandoned by many surgeons over the last 2 decades because no benefit to routine abdominal drainage has been observed from several randomized controlled trials for resections of the colon and rectum, gallbladder, and liver.”

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