Original Articles
 

By Dr. Antonio Manenti , Dr. Erica Pavesi
Corresponding Author Dr. Antonio Manenti
Department Surgery, - Italy
Submitting Author Dr. Antonio Manenti
Other Authors Dr. Erica Pavesi
Department of surgery - University of Modena, - Italy

SURGICAL TECHNIQUE

Difficult Duodenal Stump, Duodeno-Jejunostomy, Roux-en-Y Jejunal Loop

Manenti A, Pavesi E. The "Ultra Low" Duodenal Stump and its Difficult Management: An Old Technique Revisited. WebmedCentral SURGICAL TECHNIQUE 2011;2(6):WMC001998
doi: 10.9754/journal.wmc.2011.001998
No
Submitted on: 20 Jun 2011 09:58:24 AM GMT
Published on: 21 Jun 2011 06:37:21 PM GMT

Abstract


After a subtotal gastrectomy with a concomitant resection to the whole first part of the duodenum, an “ultralow” duodenal stump is difficult to close. A safe and effective technical solution is proposed, based on the use of a Roux-en-Y jejunal loop, which permits an end-to-end duodeno-jejunal anastomosis.

Introduction


After resection of the first part of the duodenum, the management of the duodenal stump can present serious problems, requiring particular technical solutions (1, 2 ,3 ,4). In our experience, this occurred in case of chronic post- bulbar duodenal ulcer (3 cases), gastric lymphoma extending beyond the pylorus (2 cases), single big sessile duodenal polyp (2 cases). We performed a complete resection of the first part of the duodenum to ensure a negative histological margin, or to remove all the scarring tissue around an ulcer. The associated subtotal gastric resection advised against a gastro-duodenal direct anastomosis, and we preferred a safer procedure, that is reported later.

Methods


After a subtotal gastrectomy extended to the whole first part of the duodenum, the duodenal stump, which remains dorsally fixed on the pancreas, is circumferentially dissected, preserving the trunk of the gastro- duodenal artery, but dividing the other more peripheral (sopraduodenal, retroduodenale and infrapyloric) branches, and leaving the Vater’s papilla well beyond the line of transection. A concomitant Kocher’s manoeuvre facilitates the dissection. At this level the duodenal wall regains a normal thickness and remains well vascularised by the anterior and posterior pancreatico-duodenal arteries (5) (Fig.1). An extended perigastric lymphoadenectomy (D2) can be associated.
In order to reconstruct the alimentary tract, a Roux-en-Y jejunal loop, 70-80 cm long, prepared 20-30 cm from the Treitz ligament is placed up into the supra mesocolic compartment, in a retrocolic way. An end-to-end direct duodeno-jejunal anastomosis is realized with a single row of submucosal synthetic absorbable interrupted 3/0 stitches. Attention must be paid not to injury the lower part of the choledochus; for this purpose the surgeon can pass his left hand behind the duodeno-pancreatic block, and lift it in order to better expose the posterior duodenal wall. A properly prepared omental patch can be used to wrap the anastomosis.
Proximally 30 cm to this first anastomosis, on the same jejunal loop, a total, or subtotal, standard antiperistaltic gastro-enterostomy is performed, usually retrocolically (Fig.2). A naso- gastric aspiration tube can be useful in the post-operative period, as well as a feeding jejunostomy.

Discussion


A similar technique, just proposed by Fessler (6) and Nissen (7) with the use of en-omega-jejunal loop and a subsequent less easy end-to-side duodeno-jejunal anastomosis, was later improved by others (8,9), but with an experience limited to postbulbar duodenal ulcers. We have extended its indication to other similar conditions requiring resection of the whole first part of the duodenum, believing that a regular anastomosis is better than an uncertain closure, and always preferring a Roux-en- Y jejunal procedure, with a subsequent safer end-to-end duodeno-jejunostomy.
On the other hand, an extended resection of all the first part of the duodenum permits to dispose a well vascularized duodenal wall, and without signs of scarring fibrosis.
Fundamentally this solution is addressed to prevent major complications, at first leakage of the duodenal stump, which is followed, today still, by a high morbidity and mortality(10).
From a functional point of view, our post operative controls showed a prevalent gastric outlet through the efferent limb, rather than the afferent towards the duodenum. No symptoms of afferent loop nor dumping syndrome, nor endoscopic signs of alkaline reflux gastritis were observed at mid- or long-term distance.
The same treatment of the duodenal stump can be extended to cases after a total gastrectomy, where an esophago-jejunal, rather than a gastro-jejunal, anastomosis must be performed (11).

References


1. Guinier D., Heyd B., Mention G. Traitment chirurgical des ulcères duodénaux hémorragiques par antroduodénectomie sans excision de l’ulcère.  J Chir 2003;140:225-8.
2. Meyer Ch., Brigand C., Rohr S. traitment chirurgical de l’ulcère duodénal hémorragique par antroduodénectomie, avec exclusion de l’ulcère, et fermeture du duodénum par “dejantement”partiel. J.Chir. 2004;141:98-102.
3. Barnett W.O.,Tucker F.H. Management of the difficult duodenal stump. Ann Surg 1964;159:794-9.
4. Burch J.M., Cox C. L., Feliciano D.V. et al. Management of  the difficult duodenal stump. Am J Surg 1991;162:523-4.
5. Kimura W., Nagai H. Study of surgical anatomy for duodenum-preserving resection of the head of the pancreas.  Ann Surg 1995;221:359-63.
6. Fessler A. Beitrag zur  Versorgung des hurischeren Duodenal-stumples. Chirug 1964;35:219-23.
7. Nissen R. in  Brandt G.,Kunz H., Nissen R. Intra- und postoperative zwischenfalle. Band II Abdomen. G.Thieme Verlag-Stuttgart. 1969.
8. Androulakis J., Colborn G.L., Skandalakis  P.N. et al. Embryologic and anatomical basis of duodenal surgery.  Surg Clin North Am 2000;80:171-99.
9. Chung R.S.K., DenBesten L. Duodenojejunostomy in gastric operations for postbulbar duodenal ulcer. Arch Surg 1976; 111: 955-7.
10. Parc Y.,Frileux P., Vaillant J.C. et al. Post-operative peritonitis originating from the duodenum :operative management by intubation and continuous intraluminal irrigation.Br J Surg 1999 ;86 :1207-12.
11. Manenti A. Un procédé original de jéjunoplastie dans la gastrectomie totale. Nouv Presse Méd 1981 ;10 :1653-4

Source(s) of Funding


none

Competing Interests


none

Disclaimer


This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

Reviews
0 reviews posted so far

Comments
0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.

 

Author Comments
0 comments posted so far

 

What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
Where
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)