Duodenojejunostomy, an Old Technique but Novel Solution for Giant Duodenal Perforations - A Report of Four Cases and Review of Literature

Abstract

Background: Despite advances in the medical management of peptic ulcer disease, duodenal ulcer (DU) perforation remains a common surgical emergency. Most DU perforations are small and can be managed with omental patch repair. However, occasionally the surgeon may encounter a giant perforation not amenable to this. Giant DU perforations are defined as > 2cm. They are associated with high leak rates and mortality. Prognosis in elderly patients are particularly poor because of advanced age and comorbidities. Furthermore, there are no specific recommendations for their management despite a variety of repair techniques being described. Here, we aim to describe a novel technique used to treat such patients, especially those of advanced age, in our institution and to review the current literature. Case presentation: Four patients with giant DU perforation underwent emergency laparotomy and repair with our duodenojejunostomy technique at our hospital. Post-operatively, patients were monitored clinically and radiologically and discharged when well and tolerating diet. The mean age of the patients was 67 years with an equal gender distribution. The average Charlson Comorbidity Index (CCI) score was 3 (moderately severe). All presented with peritonitis and two had concomitant bleeding. There were two anterior and two posterior ulcers. One was a revision repair after a leak post laparoscopic omental patch repair for the initial perforation. In all cases, the duodenojejunostomy repair technique was used. Post-operative recovery was uneventful for all except one who developed pneumonia. In particular; there were no anastomotic leaks, intra-abdominal collections, gastric outlet obstructions or mortalities. Conclusion: Giant DU perforation remains a challenge to the general surgeon, particularly so in elderly patients with multiple comorbids. A review of the current literature suggests a myriad of surgical techniques but no perfect solution. Some suggested techniques include omental patch with pyloric exclusion, controlled tube duodenostomy, jejunal pedicled graft or serosal patch, gastric disconnection and partial gastrectomy. Here, we propose that isolated duodenojejunostomy can be a quick, safe and novel solution that ensures definitive repair of giant ulcer perforation in a single setting in the high-risk patient.

Duodenal ulcer perforation: A systematic literature review and narrative description of surgical techniques used to treat large duodenal defects

“…Subsequently, a loop of jejunum is brought up in retrocolic fashion and a hand-sewn side-to-side duodenojejunostomy performed. In a small case series of four patients, Gan et al 18 report no mortalities and one case of postoperative pneumonia, with an average length of stay of 11 days. The main appeal of this technique is its relative simplicity and in theory use of a single anastomosis.…”

“…This figure illustrates four of the techniques used to close large duodenal defects. ( A ) In the triple tube technique, 18 the duodenal defect is closed primarily and three tubes are placed. A gastrostomy to reduce secretion load passing into the duodenum, a retrograde duodenostomy to take tension off the repair, and a jejunostomy for feeding purposes.…”

“…Two articles 18,19 describe the use of a duodenojejunostomy in the repair of giant duodenal perforations. In this technique, the perforation site is identified and extended into the pylorus to minimize risk of subsequent gastric outlet obstruction.…”

Progress in the hemostasis of traumatic liver rupture during interventional embolization

“…Due to its biodegradability, good biocompatibility and membranformation, gelatin is also widely used in the pharmaceutical field. Gelatin material is used for clinical vascular interventional embolization technique for hemostasis [14] The risk is low, but because of its high instability, so the red blood ball, white blood ball, blood board and other pull ability is not strong, is also its shortcomings [2].…”