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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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172 Atlas of Gastrointestinal Surgery: The Duodenum
Duodenal
mucosa
Biliary ductal
mucosa
9
Duodenal
mucosa
10
Once the orifices of the bile
Pancreatic
ductal
mucosa
duct and the pancreatic duct have
been increased in size, the reconstruction is
11
carried out by using 5-0 interrupted synthetic absorbable sutures. The
normal duodenal mucosa is approximated to the ductal mucosa of the biliary and
pancreatic ducts. This is performed by circumferentially traversing around the circumference
of the duodenal defect (9, 10, and 11, 12).
Because the circumference of the duodenal defect may be greater than the two enlarged ducts, a gap may be left over
at the inferior border, which can be closed (13).
12
13
Gap in duodenal
mucosa closed
vertically
Resection of Villous Adenoma of Ampulla of Vater 173
The duodenotomy is closed in two layers: an inner continuous layer of 3-0 synthetic absorbable material placed in a
Connell fashion (14) and an outer interrupted layer of 3-0 silk Lembert sutures (15). The biliary Fogarty catheter is
removed, the cystic duct divided and ligated, and the abdominal wound closed. A closed suction drain is left near the
duodenal closure.
14
Inner layer of
duodenotomy closure
Outer
layer
15
Closure of End Duodenal Stump Fistula
Operative Indications
One of the most catastrophic and life-threatening complications that can follow a Billroth II gastrectomy is leakage from the
duodenal stump. If the duodenal stump has been well drained, the complication initially may be less life threatening, but
the problem of management remains. If the duodenal stump has not been drained at the time of surgery, the resulting col-
lection may be drained percutaneously or may require laparotomy for drainage. Once the initial abscess formation and
resulting sepsis have been controlled, one is left with a duodenal stump fistula that in some instances may close sponta-
neously on intravenous hyperalimentation. However, some will require operative intervention. Timing of the repair of the
fistula is very important. Ideally it should be done only after the abscess and sepsis have been well controlled and the area
has been well drained. The nutrition of the patient should be maintained with the use of intravenous hyperalimentation,
and enough time allowed to elapse since the initial operative procedure and stump leakage, so that tissues can be handled
and dissected safely.
Operative Technique
The patient generally will have had the gastrectomy performed through an upper
midline incision. The old midline incision may be reopened, or a right subcostal
incision used. To avoid creating other enterotomies, great care should be taken
in dissecting the upper abdomen. This initial part of the dissection should pro-
ceed very carefully and meticulously (1).
Closure of End Duodenal Stump Fistula 175
Biliary tree
1
Transverse colon
Jejunum
Duodenal
stump
fistula
gastrojejunostomy
Pancreas
Stomach
Billroth II
After the anatomy has been well defined and the
duodenal stump leak identified, the stump should
be debrided so that healthy duodenal mucosa is
identified. A Roux-en-Y jejunal loop is con-
structed to use in the repair of the duodenal fis-
tula. At a comfortable distance from the gas-
trojejunostomy, the efferent limb is divided with
a GIA stapler (2).
Duodenum
Fistula
debrided
Pancreas
Transverse colon
Mesentery
Stomach
2
Efferent limb
of jejunum
divided
Afferent limb
of jejunum
divided
GIA stapler
176 Atlas of Gastrointestinal Surgery: The Duodenum
The distal jejunum from which the Roux-en-Y loop is
to be constructed is then brought up into the
right upper quadrant in a retrocolic
position (3). The end of the
Roux-en-Y loop is inverted
with a layer of interrupted
3-0 silk Lembert sutures.
The Roux-en-Y loop is used
as a serosal patch to close
the duodenal stump.
Jejunum brought up
through mesocolon
Duodenal
stump
3
This is carried out by placing a row of 3-0
silk sutures through and through full thickness of
the duodenal stump, and into the antimesenteric serosal surface of
the jejunal loop. This is carried out circumferentially around the
duodenal stump (4, 5).
Duodenum
Jejunum
4
Duodenum
5
Jejunum
Closure of End Duodenal Stump Fistula 177
When this has been completed, the end of the duodenum has been closed with a serosal patch from the Roux-en-Y
loop. The Roux-en-Y is tacked to the rent in the transverse mesocolon with interrupted 3-0 silk. Enteric continuity is reestab-
lished with an end-to-side jejunojejunostomy performed with an inner continuous layer of 3-0 synthetic absorbable suture
material, and an outer interrupted layer of 3-0 silk Lembert sutures, 60 cm from the end of the Roux-en-Y loop (6).
Patch
Duodenum
Jejunum
6
178 Atlas of Gastrointestinal Surgery: The Duodenum
Alternative
Jejunal anastomosis
Outer
layer
Jejunum
7 8
Duodenum
The alternative to using the Roux-en-Y as a serosal
Inner
layer
patch is to actually anastomose the Roux-en-Y loop to
the opening in the duodenal stump. When this is per-
formed, it is done, if possible, in the standard fashion for
a small bowel anastomosis, with an outer interrupted
layer of 3-0 silk Lembert sutures and an inner continu-
ous layer of synthetic absorbable sutures (7, 8). If
the duodenal stump is so edematous and inflamed
that it will not allow a standard two-layer anas-
tomosis, then a one-layer interrupted silk
anastomosis is performed. We have actually
had better success anastomosing the Roux-
en-Y loop to the duodenal stump, rather
than using it as a serosal patch. Perhaps the
decompression of the end of the duodenum
achieved with the anastomosis technique
Duodenojejunostomy
Duodenum
Duodenum
Jejunum
9
favors healing (9). Either way, the anastomosis
should be well drained with closed suction drains
before the abdomen is closed.
Closure of Lateral Wall Duodenal Fistula
Operative Indications
Lateral wall duodenal fistulas can be seen in a variety of settings. They may be seen as a complication of endoscopic papil-
lotomy, perhaps today its most frequent cause. In addition, either blunt or penetrating trauma with injury to the second
portion of the duodenum may result in a lateral wall fistula. Crohn’s disease involving the ascending colon may also pro-
duce a duodenal fistula at the site where the ascending colon and second portion of the duodenum are in close approxi-
mation. As depicted here, a fistula between the ascending colon and distal second portion and the proximal third portion
of the duodenum had occurred secondary to Crohn’s disease; it was closed at an initial operation in which the patient
underwent resection of the distal ileum and right colon. An ileotransverse colostomy was performed. Several years later a
recurrent fistula developed between the ileocolic anastomosis and the old site of the duodenal fistula.
Operative Technique
The patient initially had been operated on through a midline abdominal inci-
sion, and this incision is reopened. The adhesions are carefully dissected, and
the area of the ileocolic anastomosis is identified.
180 Atlas of Gastrointestinal Surgery: The Duodenum
The second portion of the duodenum is dissected free, and the ileocolic anastomosis is found to be densely adherent to
the duodenum at the junction between the second and third portions (1). Barium studies and endoscopy preoperatively
had identified a sizable fistula between the duodenum and the ileocolic anastomosis (inset).
Once the anatomy is clearly defined, the omentum is taken off a long segment of transverse colon. Even though the
transverse colon is normal, a substantial segment will be resected so that the resulting ileocolic anastomosis will be well
away from the site of the duodenal closure. The ileum is divided with a GIA stapler just proximal to the old anastomosis.
Ileocolic
fistula
into
duodenum
Ileum
Colon
Stomach
Duodenum
Fistula
1
Ileum
(cross section)
Colon
Closure of Lateral Wall Duodenal Fistula 181
The colon is divided with a GIA stapler approximately 25 cm distal to the anastomosis (2). The site of the duodenal fis-
tula is then dissected and opened as the specimen is dissected free to be removed from the operative field (3). The result-
ing duodenal fistula is approximately 5 cm in length. The surrounding duodenal wall and mucosa are healthy (4). Recurrent
Crohn’s disease is restricted to the immediate area of the old ileocolic anastomosis.
Stomach
Pancreas
Dudenal
fistula
2
GIA
stapler
Ileum
Transverse colon
Mesentery
Fistula
Mesocolon
Jejunum
Transverse colon
4
Fistula
Ileum
3
Transverse mesocolon (cut)
Colon
Ileum
Jejunum
Mesentery
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