Triple-ostomy: management of perforations to the second part of the duodenum in patients unfit for definitive surgery

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. case HistoryA 57-year-old man was admitted with right sided chest pain and increasing shortness of breath. He was commenced on treatment for right middle lobe pneumonia. Twenty-four hours into admission he deteriorated and suffered increasing abdominal pain and so a surgical opinion was sought.The patient had been discharged three weeks prior to this admission following a stroke. During that previous admission he had developed pneumonia and was therefore discharged on antibiotics. Past medical history included bronchiectasis and osteoarthritis, for which he was taking diclofenac. On examination, the patient looked cachetic and unwell and had cool clammy peripheries. His pulse was 90 beats/min and regular, his blood pressure 90/50mmHg, respiratory rate 25 breaths/min, oxygen saturation 93% on 35% O 2 and he had a temperature of 37.5 o C. There was generalised abdominal tenderness with guarding and rebound. A digital rectal examination was normal.A full blood count showed a white cell count of 26.7 x 10 9