Management of the Duodenal Stump
Matthias Peiper, Wolfram T. Knoefel
Introduction
One of the most serious complications in the postoperative period after gastrectomy is a leakage from the duodenal stump. Historically it has occurred most frequently in Billroth II resections following emergency surgery for duodenal ulcer perforating in the pancreatic head and less frequently after resections for gastric cancer. Causes of duodenal stump suture dehiscence are:
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Technical failure
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Postoperative pancreatitis
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Attempt to close a severely diseased and scarred, edematous duodenal stump
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Blood clots in the duodenal bed leading to infection
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Excessive use of sutures at the stump leading to necrosis
Indications and Contraindications
Indications
■Peritonitis
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Signs of sepsis
Contraindications
■No contraindications in case of emergency
Preoperative Investigations/Preparation for Procedure
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Analysis of abdominal secretion in the drain tube (bilirubin, amylasis, lipase)
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Physical examination
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Abdominal ultrasound
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CT
Procedure
Access
The abdominal cavity is opened through the previous incision.
STEP 1
If the dehiscence is small or barely visible, an omental flap is performed and the area well drained. For some patients, primary suture of the duodenum might be performed.
This is usually hand-sewn, though some surgeons prefer the stapler technique.
STEP 2
If technically feasible, an end-to-side duodenojejunostomy may be performed using single-layered sutures (Vicryl 3-0).
282 SECTION 2 Esophagus, Stomach and Duodenum
STEP 3
If the duodenum is opened widely and its walls edematous, a primary closure is usually unsuccessful since the sutures will not last. Here it is suggested to insert a Foley catheter into the leak, which may be fixated using a purse-string suture. The catheter shall be completely covered by the greater omentum and externalized using a separate incision.
Most fistulas will close spontaneously after 3–4weeks. An alternative is to cover of the leak by a jejunal loop using the Roux-Y technique.
STEP 4
Late suture dehiscences will present usually 2weeks after (distal) gastrectomy. This course is less dramatic, since postsurgical adhesions lead to a compartmentation of the abdominal cavity. If the drainage is already removed, duodenal juice might drain via the former drainage incision. By using total parenteral nutrition as well as antibiotics, the fistula will close spontaneously. An alternative is the interventional placement of a drainage, such as a Sonnenberg catheter, for optimized drainage of the duodenal fluid.
Management of the Duodenal Stump 283
Standard Postoperative Investigations
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Daily check of the abdominal drainage
Postoperative Complications
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Recurrent insufficiency
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Insufficiency of the duodenojejunostomy
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Peritonitis
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Sepsis
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Pancreatitis
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Fistula formation
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Wound infection
Tricks of the Senior Surgeon
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Tissue should not be too edematous. Therefore, the indication for relaparotomy should immediately be established once duodenal stump insufficiency has been diagnosed.
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