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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1841_Библиотеки_им_академика_М_И_Перельмана.pdf
TRAUMA
93
The distal bowel can be either used as a free limb or a Roux-en-Y can be
constructed and anastomosed to the second part of the duodenum ( Fig. 2.4 ).
This avoids risk of anastomotic breakdown at the site of injury, provides a
postpyloric drainage of the duodenum, and allows anastomosis to a non-
traumatized segment of bowel (Rickard et al ., 2005 ). Biliary decompression is
not necessary in this situation but a feeding jejunostomy is recommended.
Fig. 2.4 Traumatized area is resected and healthy tissue identified. The proximal end
is oversewn and the distal end can be brought through and anastomosed to the
second part of the duodenum.
DUODENUM
94
Delayed presentation
Delayed presentation of injuries to the third and fourth part of the duodenum
may also require only drainage and stabilization. If the patient’s condition
permits, a Roux-en-Y anastomosis to the second part of the duodenum may
help manage the fistula output and obviate the need for a second operation.
Duodenal bleeding
Surgery for duodenal bleeding from peptic ulcer disease has dramatically
decreased in recent years. Peptic ulcer, refractory to pharmacological or endo-
scopic treatments such as heater probe, injection, clips, or argon beam coagula-
tion, still present to the surgeon on a regular but less frequent basis. Other causes
of bleeding such as duodenitis, angiodysplasia, and polyps may also occur and
can be difficult due to their intermittent nature. In all cases, endoscopy needs to
be performed to define the lesion present and exclude non-operable causes of
duodenal bleeding such as malignant pancreatic invasion of the duodenal wall
with diffuse duodenitis. The use of radiological embolization in the case of
duodenal bleeding is rarely successful and probably should only be attempted
in those unfit for surgical intervention. When all other methods have failed to
gain control of the duodenal bleeding, then surgery should be considered.
Benign bleeding
The guidelines regarding second bleeds in elderly patients or massive transfu-
sion requirements necessitate a coordinated team approach between physi-
cians, surgeons, and the intensivists to optimize timing of the surgical
intervention. Prior to any surgery for alleged duodenal bleeding the surgeon
must either perform an upper GI endoscopy him/herself or view the procedure
to confirm not only the site but also the nature of the pathology. All endo-
scopists are not created equal and a surgeon’s view of the site of bleeding may
be different from that of a non-surgical colleague. Such an endoscopy can be
conducted in the operating room but must be performed prior to any laparot-
omy being commenced. Surgical access will be by a midline laparotomy and
the duodenum mobilized prior to a longitudinal duodenotomy being per-
formed. This allows extension along the duodenum or across the pylorus. The
bleeding vessel once identified as that seen at endoscopy is then oversewn in an
‘X’ pattern using an absorbable 3/0 PDS suture ( Fig. 2.5 ).
The ampulla can usually be palpated digitally. If unable to be confidently
located, cannulation of the cystic duct with a 5-French feeding tube is a
less desirable but possible option. A cholecystectomy will be required at the
same time. Closure of the duodenotomy is usually achieved by longitudinal
continuous suture with 3/0 PDS.
DUODENAL BLEEDING
95
Malignant bleeding
This occurs most often with pancreatic cancer eroding through the wall of the
duodenum leading to bleeding ( Fig. 2.6 ).
The situation should be addressed by endoscopy if possible. Argon coagula-
tion may help in control. Embolization by radiological means is unlikely
to help due to the diffuse nature of the bleeding surface, but as a desperate
Fig. 2.5 An ‘X’ stitch is
inserted across the bleeding
vessel in the base of the
ulcer and repeated as
needed to achieve
haemostasis.
Fig. 2.6 Pancreatic
adenocarcinoma in its
advanced stages can
erode into the duodenal
wall producing bleeding
that can be very difficult
to control.
DUODENUM
96
measure can be attempted. Surgery has no role in the management of this situa-
tion; although not published, one regimen that may be of value in trying to
gain control with pharmacological means which is used by the authors is to
treat patients with propranolol 40mg bd intravenously, octreotide 100mg tds
intravenously, glutamine 10g tds orally. The results in this desperate situation
have been surprisingly successful.
Perforated duodenal ulcer
For an uncomplicated perforated duodenal ulcer, either an open or laparo-
scopic approach can be considered. The principle of irrigation to clean the
peritoneal cavity is important with both techniques. Small perforations may be
repaired primarily with an omental plug placed over the repair for additional
support. Some ulcers, however, are much larger and indurated making direct
closure impossible.
In this situation, the use of a large omental plug to cover the defect may be
attempted ( Fig. 2.7 ). If this is not a realistic option then a Roux-en-Y loop can
be used to cover the defect in a similar fashion to that described for repair of
major duodenal trauma (see Fig. 2.2 ).
Fig. 2.7 An omental plug can be used to cover a duodenal defect or reinforce a
primary closure (at either open or laparoscopic repairs).
DUODENAL TUMOURS
97
Duodenal tumours
Benign tumours
Tumours within the duodenum can be either located on the mucosa or
submucosally (Schottenfeld et al ., 2009 ). Endoscopic techniques may permit a
mucosal lesion to be excised. However, this is not always possible and it may
therefore be necessary to perform a laparotomy. Again the principle of having
performed or observed the endoscopy is essential. A clear understanding of the
location and nature of the lesion prior to surgery will remove unnecessary
surprises at the time of operation. A longitudinal duodenotomy over the site of
the lesion is recommended. When present in the first or second part of the
duodenum, removal is relatively straightforward, particularly on the free edge
of the duodenum. Closure should be performed transversely to reduce the
chance of stricture, although duodenal stricture from a longitudinal closure is
a rare sequelae. If, however, the tumour is large and the defect wide and long
then a Roux-en-Y loop to cover the defect is the safe option (see ‘Duodenal
trauma’).
Tumours located in the third part of the duodenum are more difficult to
access. It is useful therefore to be confident that the lesion has been precisely
felt and localized prior to opening the duodenum. The endoscopic assessment
may have alerted the surgeon to a third-part tumour and, if necessary, should
be repeated intraoperatively to determine the exact position and extent of the
lesion. Mobilization of the third part of the duodenum is best performed prior
to opening into the lumen. If a third-part tumour is large, total resection of the
third part may be required and Roux-en-Y loop anastomosis to the second
part of the duodenum is needed.
Malignant tumours ( Fig. 2.8 )
Duodenal ampullary tumours ( Figs. 2.9 – 2.12 )
Endoscopic examination of the duodenum with biopsy may determine that
the ampulla is either malignant (adenocarcinoma) or is involved by adenoma-
tous change without dysplasia. Dysplasia or adenocarcinomas are best man-
aged with a Whipple’s procedure (Lowry, 2008 ) (see Section 1). In relatively
unfit or elderly patients, especially with mild or moderate dysplasia, a policy of
surveillance is justified. It is believed that:
◆
Progression between stages of dysplasia takes 18–36 months (O’Connell
et al ., 2008 )
◆
Dysplasia should always be assumed to be one grade higher than demon-
strated histologically.
DUODENUM
98
Symptomatic
Ulceration/pain
Bleeding
Anaemia
Acute
Resuscitate
Surgery if
required
Settles
Investigate and
assess
operability
Obstruction
Resectable Pancreaticoduodenectomy
Non-resectable
Dissemination
Surgery or stent
only if becomes
symptomatic
Local invasion
Investigate
• Laproscopy
• US
• EUS
Incidental
endoscopy or CT
Duodenal
tumour
Fig. 2.8 Management of duodenal tumour.
DUODENAL TUMOURS
99
Thus with mild or moderate dysplasia, we would offer these patients
6-monthly endoscopies and treat more aggressively only if clear progression
occurred. Other patients have either a benign process at the ampulla or are
simply not fit enough for a Whipple’s procedure and a local excision of the
tumour at the ampulla is required. The surgery requires a careful laparotomy
Fig. 2.10 Identification of the papilla by cannulation with a catheter from a
choledochotomy.
Fig. 2.9 Longitudinal
duodenotomy to
expose the periampullary
tumour.
DUODENUM
100
Fig. 2.11 Stay sutures inserted around the planned line of incision and schematic
representation of the duodenal wall and head of the pancreas to show the extent
of the local excision for an ampullary tumour.
DUODENAL TUMOURS
101
Fig. 2.12 Stepwise incision of the common bile duct while securing it with sutures
followed by reimplantation of the openings of the bile and pancreatic ducts into
the duodenal wall.
DUODENUM
102
to exclude dissemination into peri-portal or pancreatic lymph nodes. This is
determined by frozen section.
If involvement is demonstrated, a biliary bypass is all that is required. Once
the disease is confirmed to be localized to the ampulla, a duodenotomy is
made over it ( Fig. 2.9 ).
A 7-French infant feeding tube cannulates the bile duct after a cholecystec-
tomy. Previous ERCP may have determined the location of the pancreatic duct
but frequently this has proven impossible. Careful attempts to cannulate the
pancreatic duct should be made.
Once the ducts are cannulated the tumour should be excised with the
maximal possible clearance. Stay sutures or a small self-retaining retractor
can help provide access to the duodenal edges, which in practice can be very
difficult.
Once the proximal bile duct is identified, a 4/0 PDS mucosa-to-mucosa
suture is placed. This should be continued as the tumour is separated from the
bile duct. A similar process should occur as the pancreatic duct is identified.
It is always necessary to anastomose the pancreatic duct to the bile duct with
one or two sutures. The duodenum is closed longitudinally and a T-tube inserted
into the CBD to provide a safety valve for swelling within the duodenum.
Duodenal adenocarcinoma
Most cases of duodenal cancer of all types are best managed with a Whipple’s
resection, especially if they are large and involve the pancreatic portion of the
duodenum. Small tumours, if a margin can be achieved, respond to a local
resection (see the rest of this section). The position of familial adenomatous
polyposis (FAP) in the duodenum after colectomy and in the absence of other
GI tract involvement presents a difficult problem. Options include duodenal
resection only with re-anastomosis to the ampulla and pylorus via Roux-en-Y
loop ( Figs. 2.13 and 2.14 ) or a pancreaticoduodenectomy.
Duodenal invasion from external malignancy
Ongoing bleeding from a malignant process invading through the duodenal
wall is a distressing and frustrating problem. Maximal doses of PPIs aimed
at increasing the pH of gastric fluid entering the duodenum is the principal
strategy pursued. Endoscopic coagulation can be attempted. With modern
pharmacological strategies, duodenal exclusion operations, which can pro-
duce significant morbidity and are unlikely to provide survival advantage,
should not be used. This is a situation where surgery is unlikely to have a
useful role.