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182 Atlas of Gastrointestinal Surgery: The Duodenum
A new ileocolic anastomosis is performed in the
standard fashion with an inner continuous layer of 3-
0 synthetic absorbable suture material and an outer
interrupted layer of 3-0 silk Lembert sutures. This
places the anastomosis well away from the site of the prior
duodenal fistula. A Roux-en-Y jejunal loop is constructed
from proximal jejunum and should measure 60 cm; it will be
used to close the duodenal fistula. Enteric continuity is
reestablished with an end-to-side jejunoje-
junostomy performed with an
Stomach
inner layer of continuous 3-0
synthetic absorbable suture
material and an outer layer
of interrupted 3-0 silk (5).
Duodenum
Roux-en-Y
jejunal loop
Colon
Fistula
Ileum
New
ileocolostomy
5
Mesentery
End-to-side
jejunojejunostomy
Duodenum
Outer layer of
posterior row
Closure of Lateral Wall Duodenal Fistula 183
The Roux-en-Y loop is used to close the fistula by perform-
ing a side-to-side anastomosis. I have found this to be more
successful in closing enteric fistulas than using the Roux-en-
Y as a serosal patch. If the tissue surrounding the fistula is
reasonably compliant and healthy, a standard two-layer
anastomosis is performed. The outer layer of the posteri-
or row is placed using interrupted 3-0 silk Lembert
6
Roux-en-Y
jejunal loop
sutures (6). The inner layer of the posterior row consists
of a continuous locking suture of 3-0 synthetic
absorbable suture (7) brought around anteriorly in a
Connell stitch (8). The outer layer of the anterior row
consists of interrupted 3-0 silk Lembert sutures (9).
Inner layer of
posterior row
Fistula
Jejunotomy
7
8 9
Inner layer of
anterior row
Outer layer
of anterior
row
184 Atlas of Gastrointestinal Surgery: The Duodenum
Closing the duodenal fistula in this fashion results in
a short circuiting of the distal duodenum (top inset,
10). If the Roux-en-Y loop is constructed
from proximal jejunum, we have
Jejunum
Duodenum
Stomach
Ileum
Colon
found this to present no problem.
However, an alternative and
perhaps more frequently per-
formed procedure is to use the
Roux-en-Y loop as a serosal
patch. When this procedure is
performed, generally the fistula is
closed with a single layer of interrupt-
ed silk sutures (11, 12, and bottom
inset). I have had recurrences using this tech-
nique and have had better success when the Roux-
en-Y loop is actually anastomosed to the fistula site.
Alternative
10
Mesentery
Single layer
anterior row
Jejunum
Patch
Duodenum
Single layer
posterior row
11
Alternative
12
Jejunum
Management of Duodenal Diverticula
Operative Indications
Duodenal diverticula occur with a surprisingly high frequency. They are usually found incidentally when barium studies of
the upper gastrointestinal tract, or CT scans with oral contrast, are done for unrelated conditions. They also may be seen
incidentally in patients undergoing upper endoscopy. Finally, during endoscopic retrograde cholangiopancreatography
(ERCP), they also may be detected as incidental findings and not directly related to the reason for the diagnostic study.
Duodenal diverticula may occur anywhere along the length of the duodenum, and they may be multiple. However, the
majority of diverticula occur around the ampulla of Vater (1). They are pseudodiverticula in that they are outpouchings of
mucosa through a muscular defect in the duodenal wall, most frequently where the bile and pancreatic ducts penetrate
through the muscular layer of the duodenum. Diverticulitis with perforation may occur, massive bleeding may result from
inflammation with erosion into an adjacent vessel, and duodenal obstruction may
occur secondary to inflammation in the diverticulum. These complications,
however, are exceedingly rare. In the majority of instances when symp-
toms are present, they relate to partial intermittent obstruction of the
pancreatic and/or biliary ductal systems. The incidence of gallstones
is higher in individuals with perivaterian diverticula than in a control
population without diverticula. In addition, patients may present
with abdominal pain and transaminase elevations. If no explanation
for the abnormalities is detected other than a perivaterian diverticu-
lum, it may by exclusion be considered the etiologic agent.
Intermittent abdominal pain with hyperamylasemia, in the absence of
other explanations, may also be attributed to partial intermittent obstruc-
tion of the pancreatic duct by the diverticulum. It is thought that a divertic-
ulum can intermittently become distended with food, directly impinge on the
Duodenum
Diverticulum
1
Ampulla
Mouth of
diverticulum
ampulla, and partially obstruct the biliary and/or pancreatic ducts.
186 Atlas of Gastrointestinal Surgery: The Duodenum
The vast majority of duodenal diverticula are asymptomatic and require no treatment. However, occasionally, with any
of the above symptoms and when no other etiologic explanations are possible, one may attribute symptoms to the diver-
ticulum. In the past a variety of alternative procedures, including sphincteroplasty and choledochoduodenostomy, were per-
formed to treat these lesions. However, in most instances today the diverticulum can be either excised or inverted.
Operative Technique
The patient may be explored through either a midline or a right subcostal inci-
sion. I prefer the upper middle incision. If the gallbladder is still in place, it
should be mobilized and a biliary Fogarty catheter passed through a small open-
ing in the cystic duct, down through the ampulla, and into the duodenal lumen
(2). This allows one to palpate and determine the relationship of the diverticu-
lum to the distal common duct and ampulla. If the patient previously has under-
gone a cholecystectomy, preoperatively a biliary catheter can be inserted percu-
taneously and transhepatically into the biliary tree, through the ampulla, and into
the duodenum for the same purpose.
Biliary
Fogarty
catheter
Management of Duodenal Diverticula 187
Mobilized
gallbladder
Duodenum
Ampulla
Balloon tip
Cystic duct
Common
bile duct
Stomach
Mouth of
diverticulum
Once the biliary Fogarty catheter has
been passed into the duodenum, the
duodenum is extensively kocherized.
Generally the diverticulum can be
easily identified closely adherent to
the posterior aspect of the head of
the pancreas. It may be covered with
areolar tissue and initially appear to be
within pancreatic substance. This is
rarely the case, however, and almost always
is posterior to the head of the pancreas and
easily dissectable from it (3).
2
3
Kocherized
duodenum
Diverticulum
Pancreas
Retroperitoneum
188 Atlas of Gastrointestinal Surgery: The Duodenum
The diverticulum can be grasped with a small
Babcock clamp and dissected free down to where it
narrows at its neck (4). The diverticulum is a
pseudodiverticulum and consists of mucosa her-
niated through a defect in the muscular wall of
the duodenum (5). Thus, one has to handle
Catheter in
bile duct
the diverticulum very carefully or it will tear, or,
more frequently, mucosal hematomas will develop
and distort the anatomy. During the dissection of
the neck of the diverticulum, one can palpate
for the catheter in the common duct,
ampulla, and duodenum, and therefore be
aware of the exact relationships.
Stay
suture
Stay sutures
in neck of
diverticulum
Mouth of diverticulum
Diverticulum
Duodenal
mucosa
Duodenum
Pancreas
4
Mucosa herniated
through
seromuscular
layer of
duodenal wall
At this point the diverticulum is
excised. Stay sutures are place in the
mucosa at the diverticulum neck, and
5
Diverticulum
excised at neck
6
Pancreas
Retroperitoneum
Diverticulum
7
Alternative
the lesion excised with the electro-
cautery (6, 7). An alternative is to use
a TA stapler to close the neck of the
diverticulum before excision (8, 9).
TA stapler
9
Stapled
neck of
diverticulum
Head of
8
pancreas
The duodenal defect is closed in two layers. The mucosa
Management of Duodenal Diverticula 189
is closed with an interrupted layer of 3-0 synthetic
absorbable suture material (10, 11) or the stapler.
Closure of
duodenal
mucosa
10
11
12
Closure of
seromuscular
mucosa
A seromuscular layer is then placed with 3-0
silk Lembert sutures (12, 13).
13
190 Atlas of Gastrointestinal Surgery: The Duodenum
If there is any concern about narrowing
the distal common duct or ampulla during
duodenal wall closure, a duodenotomy
should be performed, and a sphinctero-
plasty carried out (14). The ampulla is
opened on top of the biliary catheter with
the electrocautery (15).
Ampulla
opened
Duodenotomy
14
Biliary
catheter
Closed mouth of
diverticulum
15
The ductal and duodenal mucosae are sutured together with
16
Duodenal
and
ductal
mucosae
17
a series of interrupted 5-0 synthetic absorbable sutures
(16). This will avoid any narrowing of the distal common
duct or ampulla that might have been caused by diverticulum
excision and duodenal wall closure (17).
Bile duct
Pancreatic
duct
Closed
mouth of
diverticulum
Occasionally diverticula not adjacent to the ampulla of
Vater will be symptomatic. In such instances one has the
option of merely inverting the diverticulum and closing the
duodenal wall without actually excising the lesion. This is a
Management of Duodenal Diverticula 191
Common bile and
pancreatic ducts
somewhat safer, simple procedure that can be quickly car-
ried out. In this instance the diverticulum is at the junction
of the second and third portions of the duodenum, well
distal to the ampulla of Vater (18).
Common
bile duct
Kocherized
duodenum
Pancreas
Ampullla
of Vater
Diverticulum
Duodenum
18
Mouth of
diverticulum
Diverticulum
mobilized and
inverted into
duodenum
The duodenum is kocherized (19), and the diverticulum can
then be easily inverted into the duodenal lumen (20, 21).
With a series of 3-0 silk sutures placed in a Lembert fash-
ion, the duodenal wall muscular defect is closed (22, 23).
19
Duodenum
Duodenum
Diverticulum
Duodenal
wall defect
closed
20 21 22 23
Inverted
diverticulum
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