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13 Case on Leakage of the Duodenal Stump Following Gastrectomy
https://t.me/med1917
Fig. 13.2 After operative
drainage and treatment of the
leakage of the duodenal
stump (Foley’s catheter and
drain)
75
Illustration 13.1 ( a , b )
Surgical treatment of
duodenal leakage after
gastrectomy included a
duodenostomy for control of
the leakage, wrapping of the
omentum, abdominal rinsing,
and abdominal drainage
a
Leakage
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J.L.G. Sabrido and W.V. Jimenez
Illustration 13.1
(continued)
b
b
progressive decrease of drain production. At the 24th postoperative day radiological
control with gastrographin through the Foley catheter did not show any leakage; the
catheter was removed subsequently. Twenty-four hours later, the vacuum drainage
also was retired.
Discussion
The main cause of peritonitis following gastrectomy is the leakage of duodenal
stump. In the past, surgeons learned how to deal with a diffi cult duodenum during
the surgery of complicated peptic ulcers. Many ingenious ways have been
described to deal with this problem, but none will completely prevent a signifi cant
incidence of stump leakage. Nowadays, this kind of surgery is incidental. While
treating gastric cancer, the duodenum has no infl ammation, fi brosis, or cancer. The
patient, here described, shows how to deal with a diffi cult duodenal stump during
treatment of a complicated duodenal ulcer, in order to prevent the leakage.
Moreover, invasive gastric cancer is generally treated by neoadjuvant chemotherapy, and immunosuppression may increase the rate of duodenal stump leakage
after gastrectomy [ 1 ].
The closure of the duodenal stump has to be safe; it is usually performed with
linear stapler. Reinforcement of the stump by sutures is not recommended, because
the duodenal wall is thick but weak. In those cases where the stump closure is
13 Case on Leakage of the Duodenal Stump Following Gastrectomy
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77
considered unsafe, a lateral duodenotomy is recommended; this creates duodenal
decompression, which can also be achieved with the placement of a nasogastric/
transjejunal tube up to the end of the duodenal stump. Lateral duodenotomy implies
the introduction of a Foley-like tube through a purse string suture, being exteriorized and sealed by wrapping omentum around it. The lateral duodenotomy will
emerge through the upper-right abdominal wall, above the level of the duodenum,
to assure adequate drainage [ 2 , 3 ]. The tube should remain for 3 or 4 weeks before
removal, in order to assure a good canalized fi stula and thereby reducing the possibility of a peritoneal leakage. Adequate use of the external drains left in subhepatic
area is also important.
In the infrequent case of gastrectomy used because of a complicated peptic ulcer,
we specify two manoeuvres that are useful for the closure of a diffi cult stump: the
Nissen closure is performed in those cases with a diffi cult to manage duodenum in
which the duodenal stump is closed by means of separated stitches of the anterior
wall of the duodenum with the fi brotic posterior wall plus omentoplasty, or the
Finsterer-Bancroft-Plenk closure is a good alternative to the Nissen closure. It consists of three steps: the division of the antrum 6-cm from the pylorus, keeping its
irrigation from the pyloric and gastroepiploic arteries; the mucosa cuff being
resected following the submucous layer up to the pylorus, which is closed with
stitches that take the pyloric muscular layer, and to attach the anterior and posterior
antrum walls with stitches and a second continuous suture layer.
This complication occurs postoperatively rather early, usually between the fourth
and seventh postoperative days. The most important signs and symptoms are fever,
abdominal pain, tachycardia, and (if a drain is still in situ) the presence of biliary
and duodenal leakage through it.
At physical exploration, the patient may appear as septic, hemodynamically
unstable, dyspnoic, and the abdomen may show signs of distension and peritonitis.
Patient should then be admitted to the Medium Care or Intensive Care department
for initial resuscitation.
The CT scan of the abdomen with double contrast will show not only the duodenal leakage but also signs of local or general peritonitis, such as free air and fl uid
collections.
The leakage of the duodenal stump appears in 1–3 % of gastric resections.
Nowadays, the mortality associated with this complication is, due to improvements
in postoperative critical care, between 0 and 12 %.
Initial resuscitation by fl uid reposition and adequate antibiotic treatment is
important followed in the majority of cases by relaparotomy. The most commonly
used technique is the terminal duodenotomy. A 22 or a 24 French, Petzer or Foley
catheter is introduced through the duodenal leakage at the stump and a purse string
is made with nonabsorbable material. This procedure can be complemented with
wrapping and fi xation of the major omentum around the suture (Wu technique),
which contributes to closing it [ 2 , 3 ]. A Penrose and a sump drain are left subhe-
patic and in the Morrison pouch. A temporary gastrostomy for suction and a jejunostomy for feeding are created. Abdomen should be rinsed and drained. Skin
should be left open.
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J.L.G. Sabrido and W.V. Jimenez
The only option for conservative approach will be the situation in which the
duodenal leakage is fi stulized and drained totally through a drain. Moreover, the
patient should be hemodynamically stable and no intra-abdominal collections are
allowed to be present on the CT scan. But also in this situation, if the fl ow is persistent and higher than 500 mL/24 h (high-fl ow bilio-pancreatic fi stula), then surgical
exploration could be indicated. In this case, the high fl ow may be associated with
distal obstruction (afferent loop syndrome) or the presence of local abscess.
Total parenteral nutrition (TPN) through a central venous access should be initiated early after reoperation because these patients have an increased catabolism and
do not get enteral food for several days.
The use of octreotide or somatostatin analogues (e.g., Lanreotide ® ) has demonstrated the effi cacy of decreasing the fi stula production during the fi rst week; however, its share in the closure of the fi stula is still controversial.
References
1. Garcia Sabrido JL, Vasquez JW. How to prevent, early diagnose, and treat major postoperative
complications after gastric surgery. In: Cuesta MA, Bonjer HJ, editors. Treatment of complica-
tions after digestive surgery, chapter 9. London: Springer; 2013.
2. Tsuei BJ, Schwartz RW. Management of the diffi cult duodenum. Curr Surg. 2004;61:166–71.
3. Isik B, Yilmaz S, Kirimlioglu V, et al. A life-saving but inadequately discussed procedure: tube
duodenostomy. Known and unknown aspects. World J Surg. 2007;31:1616–24.
Chapter 14
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Case on Re-bleeding After Repair of Bleeding
Duodenal Ulcer
Jose L. Garcia Sabrido and Wenceslao Vasquez Jimenez
Keywords Duodenal ulcer • Hematemesis • Melena • Gastroscopy • Duodenotomy •
Peptic ulcer • Peptic ulcer bleeding
Diagnosis and Indication for Surgery
In view is a 35-year-old male patient, evaluated in the emergency room with
hematemesis and melena. The patient possessed a history of smoking, a duodenal
ulcer treated irregularly with proton pump inhibitors (PPIs), and a positive
Helicobacter pylori breathing test with irregular treatment. He was also taking
Diclophenac ® 75 mg orally for 2 days due to a traumatic lesion of the right leg. At
examination, the patient was in shock with signs of hypoperfusion, with a blood
pressure of 90/40 mmHg and a heart rate of 110/min.
Two peripheral intravenous 14F lines were placed in his upper limbs. The hemoglobin was 7 g/dL, platelets were 350,000, and coagulation times in normal range.
Two packed cell blood concentrates were transfused.
Gastroscopy summarily showed an ulcer of 2.5 cm in the posterior side of the
fi rst portion of the duodenum, classifi ed as Forrest IIb (bleeding with visible vessel)
(Fig. 14.1 ). Adrenaline was infi ltrated together with contact diathermia therapy and
the bleeding stopped. The patient was admitted to the ICU and received 80 mg
Omeprazol ® intravenously as a bolus and as a continuous perfusion afterwards. The
Helicobacter pylori test was positive.
Four hours after the fi rst procedure, the patient complained about abdominal
pain, hematemesis, and hypotension. A second endoscopic procedure was
J. L. G. Sabrido , M.D. (*) • W. V. Jimenez , M.D., Ph.D.
Department of Surgery , Gregorio Marañon Hospital , Madrid , Spain
e-mail: jlgsabrido@gmail.com, jlgsabrido@ciriii.hggm.es
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_14,
© Springer International Publishing Switzerland 2014
79
80
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Fig. 14.1 Gastroscopy
showing a bleeding
postpyloric ulcer at the
posterior side
J.L.G. Sabrido and W.V. Jimenez
performed with evidence of active bleeding in the ulcer; the bleeding could not be
controlled with adrenaline and clips.
Operation
Due to his hemodynamic instability and failure of the endoscopic treatment, surgery
was indicated. A medial laparotomy was done, followed by a Kocher maneuver, a
longitudinal duodenostomy at the level of the pylorus, and identifi cation of the
ulcer. Hemostatic sutures were placed in the four quadrants of the ulcer with Prolene
®
3/0
. The bleeding was controlled. Peroperatively, the patient remained hypotensive, requiring inotropes and transfusion of eight packed cell units. The duodenotomy was closed in one layer with PDS 4/0. A nasogastric tube was placed in the
antrum, and he was readmitted to the ICU.
Postoperative Course
Twenty-four hours after surgery, hematemesis and hypotension recurred with a
hemoglobin of 7 g/dL. Blood and clots were removed by fl ushing saline through the
nasogastric tube. A new gastroscopy showed a recurrent ulcer bleeding; so again
clips were placed and bleeding partially became controlled. Additionally, an
14 Case on Re-bleeding After Repair of Bleeding Duodenal Ulcer
https://t.me/med1917
Fig. 14.2 Celiac trunk
angiography shows active
bleeding (blush) at the
gastroduodenal artery after
surgery
Fig. 14.3 Selective
embolization of
gastroduodenal artery by
means of coils
81
angiography was performed, showing a bleeding from the gastroduodenal artery
with a blush (Fig. 14.2 ) and consequently an embolization with coils was performed
(Fig. 14.3 ).
The patient evolved favorably leading to discharge at the 8th postoperative day
with Helicobacter pylori eradication therapy for 2 weeks. A second Helicobacter
pylori breath test was negative.
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Illustration 14.1 (a, b)
Selective angiography and
coiling of the gastroduodenal
artery
J.L.G. Sabrido and W.V. Jimenez
a
Aorta
b
Discussion
Acute bleeding is the most common complication of peptic ulcer disease and its mortality lies between 5 and 10 %. Endoscopic treatment solves bleeding in the majority of
patients; however 5–10 % of patients have re-bleeding and require surgery or embolization (Illustration 14.1a, b ). After surgery, the risk of re-bleeding is about 4 %. The
factors that increase the risk of re-bleeding are: an ulcer larger than 2 cm, localized in
the lesser curvature or posterior side of the duodenal bulb, and hypovolemic shock.
Chapter 15
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Case on Stenosis of a Side-to-Side
Gastrojejunostomy After a Laparoscopic
Subtotal Gastrectomy
Alfredo Alonso Poza and Francisco Nevarez Noboa
Keywords Stenosis • Gastrojejunostomy • Lymphadenectomy • Gastric cancer •
Laparoscopic gastrectomy
Diagnosis and Indication for Surgery
We view a 65-year-old male patient, known for having hypertension and Diabetes
mellitus type II, who had a stroke 3 years ago with left hemiparesia, and now he is
studied because of anemia. Through gastroscopy he was diagnosed having a gastric
adenocarcinoma in the antrum. Dissemination study by CT scan showed no metastatic disease. The tumor was staged as T3N1M0.
Operation
A subtotal laparoscopic gastrectomy with a D2 lymphadenectomy and spleen preservation was performed. A stapled side-to-side Roux-en-Y anastomosis in the
greater curvature was performed with closure of the insertion of de endostapler by
means of another mechanical stapler.
Postoperative Course and Identifi cation of the Complication
On the 5th postoperative day, a transit X-ray was performed for control showing a
slow passage of the contrast with gastric remnant dilatation, but no leakage (Fig. 15.1 ).
A. A. Poza , M.D., Ph.D. (*) • F. N. Noboa , M.D.
Department of Surgery , Hospital del Sureste , Madrid , Spain
e-mail: alfredo.alonsop@salud.madrid.org
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_15,
© Springer International Publishing Switzerland 2014
83
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Fig. 15.1 Stenosis
gastrojejunostomy
A.A. Poza and F.N. Noboa
Fig. 15.2 CT scan showing
the gastric dilatation
Patient, taking a semisolid diet, was discharged at the 10th postoperative day. He
was readmitted on the 14th postoperative day with upper left quadrant pain and
experiencing vomiting. A CT scan with oral contrast was performed showing a
marked dilatation of the gastric remnant with signifi cant stenosis of the anastomosis
(Fig. 15.2 and Illustration 15.1a, b ).
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