Article of interest: Management of the difficult duodenal stump in penetrating duodenal ulcer disease: a comparative analysis of duodenojejunostomy with “classical” stump closure (Nissen-Bsteh)

Vashist YK, et al. Management of the difficult duodenal stump in penetrating duodenal ulcer disease: a comparative analysis of duodenojejunostomy with “classical” stump closure (Nissen-Bsteh). Langenbecks Arch Surg. 2012 Dec;397(8):1243-9.

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Table 4. Multivariable Analysis for Perioperative Mortality and Leakage in All 124 Patients

Background: Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. “Classical” technique of closing a difficult duodenal stump (Nissen-Bsteh) has, up to now, not been compared with duodenojejunostomy (DJ) in larger patient sets. This also refers to the potential benefit of a gastric and biliary diversion under such conditions. The aim of the present study was to compare classical duodenal closure (CC) with DJ and to evaluate the impact of gastric and biliary diversion on postoperative outcome after surgery for penetrating, high-risk duodenal ulcer in a matched control study.

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Article of interest: Management of the difficult duodenal stump.

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.

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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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Choosing the appropriate patch repair based on the duodenal perforation size

Poris S, et al. Routine versus selective upper gastrointestinal contrast series after omental patch repair for gastric or duodenal perforation. Surg Endosc. 2018 Jan; 32(1):400-404.

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“Age greater than 60 years (p-0.0470, CI-0.76-31.54), pulse rate greater than 110/minute (p-0.0217, CI-1.04-34.48), systolic blood pressure less than 90 mm Hg (p-0.0016, CI-2.04-71.9), haemoglobin level less than 10 g/dl (p-0.0009, CI-2.25-135.02), serum albumin less than 2.5 grams/dl (p-0.0145, CI-1.21-38.31), total lymphocyte count less than 1800 cells/mm-3 (p-0.0003, CI-8.9-42.2), size of perforation greater than 5 mm (p-0.0011, CI-1.09-36.13) were identified as risk factors for releak. Serum albumin, hemoglobin and size of perforation were independent risk factors for prediction of releak on multivariate analysis. The anthropometric parameters namely mean triceps skin fold thickness, mean mid arm circumference and mean body mass index were all significantly less in cases as compared to controls. Releak was found to be a significant cause of death in patients with perforated duodenal ulcer. A total of 8 patients died in both the groups. The mortality rate in the releak group was 55.6% (5 out of 9 patients) compared to 2.7% (3 out of 110 patients) in the control group [p-0.0001].”

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The management of perforated duodenal ulcers: operative vs non-operative?

Chung KT, Shelat VG. Perforated peptic ulcer – an update. World J Gastrointest Surg. 2017 Jan 27;9(1):1-12. doi: 10.4240/wjgs.v9.i1.1.

Mortality is a serious complication in PPU. As we mentioned before, PPU carries a mortality ranging from 1.3% to 20%[9,10]. Other studies have also reported 30-d mortality rate reaching 20% and 90-d mortality rate of up to 30%[11,12].

Significant risk factors that lead to death are presence of shock at admission, co-morbidities, resection surgery, female, elderly patients, a delay presentation of more than 24 h, metabolic acidosis, acute renal failure, hypoalbuminemia, being underweight and smokers[11,127-131]. The mortality rate is as high as 12%-47% in elderly patients undergoing PPU surgery[132-134]. Patients older than 65 year-old were associated with higher mortality rate when compared to younger patients (37.7% vs 1.4%)[131]. A study involving 96 patients with PPU also showed that there was a ninefold increase in postoperative complications in patients with comorbidities[119]. In another large population study, patients with diabetes had significantly increased 30-day mortality from PPU[135]. (Chung, 2017, p. 8)

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