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17 Case on Leakage After Closure of a Perforated Duodenal Diverticulum
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Fig. 17.2 ( a , b ) CT scan
showing paracolic abscess
a
b
97
Postoperative Course: Identifi cation and Treatment
of the Complication
On the Intensive Care Unit (ICU) she was treated for septic shock, with mechanical
ventilation, fl uid resuscitation, inotropes, and intravenously applied broad-spectrum
antibiotics. After 3 days, mechanical ventilation was terminated, but on the seventh
postoperative day her clinical condition deteriorated. She had abdominal pain and
the surgical drain produced intestinal contents. She experienced a tachycardia of
117 beats/min with a normal blood pressure and fever of 39.2 °C. A CT scan showed
important free fl uid and air in the retroperitoneal space around the duodenum
extending to the right paracolic space (Fig. 17.2a, b ). This fl uid was drained
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Fig. 17.3 Fistulogram
showing the fi stula’s tracks
R. Gorter and J.W. Oosterhuis
percutaneously, revealing a mixture of bile and bowel contents. After drainage, the
patient entered a severe septic shock, and a relaparotomy was performed.
At the reoperation, two defects in the duodenal suture line were detected and
sutured. Additionally, necrosis around the head of the pancreas was removed.
Furthermore, the T-drain seemed to be dislocated, hence it was replaced. After
extensive lavage, two drains were left, one right paracolic and one at the level of the
duodenum, and she was admitted to the ICU. Cultures of the intra-abdominal fl uid
revealed an Enterococcus faecalis . Patient recovered from the septic situation,
and on the 7th day after the second operation, she was discharged from the ICU and
admitted to the surgical ward.
She was treated with total parenteral nutrition, a nasogastric tube, and intravenous
antibiotics. Her condition improved and oral feeding was started on her 10th postoperative day.
After the second operation, she had seven episodes of high fever and right
abdominal pain. After exclusion of pneumonia or urinary tract infection, a CT scan
with double contrast showed one or two abscesses located at the right paracolic
space in communication with the duodenum. Analysis of the drained fl uid revealed
organic fi bers and an amylase of 30.000 U/L. A contrast medium administered
through the drains showed persistent leakage of the duodenal defect and an extensive fi stula complex in the retroperitoneal space (Fig. 17.3 , Illustration 17.1b ). New
and old drains were draining pus and intestinal contents up to the 18th postoperative
day when the drains were progressively mobilized and fi nally removed. After a visit
to the hairdressing saloon and normal oral intake she could be discharged. On the
outpatient policlinic, she was doing well and she was dismissed from surveillance.
17 Case on Leakage After Closure of a Perforated Duodenal Diverticulum
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Illustration 17.1 ( a , b )
Perforation of a duodenal
diverticulum should be
treated by resection after
papilla of Vater control.
Leakages should be treated
by percutaneous drainage
a
b
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Discussion
Leakage after closure of a perforated duodenal diverticulum is a rare but serious
complication. In literature not much is known about its optimal treatment strategy.
Duodenal diverticula are common with an estimated incidence between 5 and
1 , 2 ]. They are usually located at the second part of the duodenum at the
22 % [
mesenteric or pancreatic border [ 3 ]. Most are asymptomatic, although in about 5 %
of cases, complications occur such as bleeding, infl ammation, or even perforation
(with a mortality rate up to 30 %) [ 1 – 3 ]. As the location is in the second part of the
duodenum, perforation usually leads to leakage of duodenal contents in the retroperitoneal and peritoneal spaces, leading to abscess formation or generalized peritonitis and sepsis. Due to its rarity, there are no equivocal guidelines concerning the
initial management. Several authors consider nonoperative management (parenteral
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R. Gorter and J.W. Oosterhuis
feeding, percutaneous drainage of abscesses, and intravenous antibiotics) in stable
and non-septic patients as the treatment strategy of choice although in literature, the
resection of the diverticulum is still considered to be the golden standard [ 1 – 3 ].
However, in up to 41 % of patients treated by diverticulectomy such complications
may occur as bile duct injury, leakage with fi stula formation (20 %), intra- abdominal
abscess formation, pancreatitis, persistent leakage, and sepsis [ 2 , 3 ].
Not much is known about the optimal treatment strategy in especially those
patients with recurrent fi stulas and abscesses. In our patient in view, a reoperation
was not an option, but repeated percutaneous drainages were performed. In her case,
an extensive resection (e.g., Whipple procedure) was one of the considered options.
However, she would not have survived such an operation due to her poor clinical
condition, grade of infl ammation, and the amount of affected tissue. Although it
meant a long admission in this case, her problem has been solved; her condition has
now signifi cantly improved as well as her quality of life.
References
1. Duarte B, Nagy KK, Cintron J. Perforated duodenal diverticulum. Br J Surg. 1992;79:
877–81.
2. Bergman S, Koumanis J, Stein LA, et al. Duodenal diverticulum with retroperitoneal
perforation. Can J Surg. 2005;48:332–4.
3. Martinez-Cecilia D, Arjano-Sanchez A, Gomez-Alvarez M, et al. Conservative management of
perforated duodenal diverticulum: a case report and review of the literature. World
J Gastroenterol. 2008;14:1949–51.
Chapter 18
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Case on An Acute Complication of the Wilkie
Syndrome
Miguel A. Cuesta and Donald L. van der Peet
Keywords Wilkie syndrome • Complications • Peritonitis • Pneumatosis
Diagnosis and Indication for Surgery
We now regard a 16-year-old female patient, a high school student without previous
complaints, who suddenly became ill, experiencing abdominal pain and vomiting.
The general practitioner observed her at home under an initial diagnosis of gastroenteritis. After 3 days, the complaints worsened and the patient was referred to our
surgical department. She appeared to be dehydrated, had a fever of 38.7 °C, tachycardia, and she displayed a poor general aspect. Physical examination of the abdomen showed upper abdominal pain with signs of local peritonitis. The laboratory
results showed a leukocytosis of 21,000/L and a CRP of 180 mg/L were found. A
CT scan with oral and IV contrast was performed. A gastric dilatation with pneumatosis in the stomach wall was found with dilatation of duodenum and possible compression of the horizontal part of the duodenum (Fig. 18.1 ). Differential diagnosis
was made between annular pancreas and duodenal web.
Operation
At emergency laparotomy, a clear compression of the horizontal part of duodenum
by the superior mesenteric vessels against the spine was seen. Moreover, gastric
dilatation with necrosis of the fundus was found (Fig 18.2 ).
M. A. Cuesta , M.D. () • D.L. van der Peet
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl; dl.vdpeet@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_18,
© Springer International Publishing Switzerland 2014
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Fig. 18.1 CT scan showing
gastric dilatation and
pneumatosis. Gas in the
portal veins
Fig. 18.2 Aspect of the
operation, stomach is dilated
and the greater curvature is
necrotic
M.A. Cuesta and D.L. van der Peet
A resection of the necrotic part of the gastric fundus along the greater curvature
was performed by means of staplers and a running suture over it. Moreover, to treat
the cause, a side-to-side duodenojejunostomy was performed in two layers
(Fig. 18.3 ).
18 Case on An Acute Complication of the Wilkie Syndrome
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Fig. 18.3 After resection of
the greater curvature and
duodenojejnunostomy
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Postoperative Course
Postoperatively, the patient recovered very quickly and could initiate oral feeding
progressively from the 3rd day on. At day 7 she went home and after a period of 4
weeks she could reinitiate her daily activities and studies.
Discussion
Wilkie’s syndrome is a rare cause of duodenal passage problems. It is produced by
compression of the superior mesenteric artery on the horizontal duodenal part.
Chronic complaints are typical with dilatation of the duodenum and stomach. Acute
complication is very rare and in this young patient led to gastric dilatation and
necrosis of the greater curvature.
Chapter 19
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Case on Distal Duodenal Perforation
After Double Balloon Endoscopy (DBE)
Marijn Poelman and Chris J.J. Mulder
Keywords Perforation • Double balloon endoscopy (DBE) • Celiac sprue •
Laparotomy • Proximal jejunum
Diagnosis and Indication for Surgery: Identifi cation
of the Complication
A 56-year-old female patient, known for having celiac sprue since 7 years, was
admitted at the surgical ward of a hospital because of vomiting and weight loss. The
CT scan with double contrast revealed a stenosis in the duodenojejunal junction
(Fig. 19.1 ). A gastroscopy done up to the distal part of the duodenum showed no
anomalies, and in order to investigate the distal part and jejunum, a double balloon
endoscopy (DBE) was performed (Illustration 19.1a ). Here, a tumor was seen and
localized in the horizontal part of the duodenum. Biopsies were taken for histological examination. The patient developed progressive abdominal pain after the procedure and on the X-ray of the abdomen free air was observed. A CT scan showed
signs of a perforation (Fig. 19.2 ) with pneumoperitoneum and free fl uid at the level
of the tumor in the ligament of Treitz and patient was operated on.
M. Poelman , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: mm.poelman@vumc.nl
C.J.J. Mulder
Department of Gastroenterology , VU University Medical Center , Amsterdam ,
The Netherlands
e-mail: cjmulder@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_19,
© Springer International Publishing Switzerland 2014
105
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Fig. 19.1 Thickness with
stenosis at horizontal part of
the duodenum (tumor) with
intraabdominal free air
M. Poelman and C.J.J. Mulder
Fig. 19.2 Perforation with
pneumoperitoneum and free
air and fl uid collection at the
level of Treitz ligament
19 Case on Distal Duodenal Perforation After Double Balloon Endoscopy (DBE)
https://t.me/med1917
Illustration 19.1 ( a ) Double
balloon endoscopy.
Perforation as complication.
( b ) Resection of tumor after
perforation
a
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Tumour
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