- Email: [email protected]
Duodenostomy
REVIEWS
Duodenostomy
Sotiris Prigouris, MD, Athens, Greece Pan Michas, MD, Athens, Greece
The incidence of leakage from a duodenal stump after gastric resection for duodenal ulcer is 1.5 to 2.5 per cent; however, the mortality has been reported to approach 50 per cent [l-6]. Thus, when leakage occurs it is a major and life-threatening complication. A number of different surgical procedures have been recommended to prevent or manage this problem. Historically, the McKittrick two-stage gastric resection [7], the Devine [8] and Bancroft [9-Z?] antral exclusion techniques, and the sleeve resection of Wangensteen [13] have been used to prevent leakage from the duodenal stump. In addition, several methods of closure of the duodenum after gastric resection have been proposed. The most common procedures are Nissen’s [14-161, Graham’s [17], Basteh’s [18], Slattery’s [19], Cooper’s [20,21], and duodenostomy. In a review of the surgical literature, Neumann [22] in 1909 was the first surgeon to introduce a catheter through the opening of a large perforated duodenal ulcer because he could not close the perforation without causing stenosis (Figure 1A). By this means he created a temporary duodenal fistula. Neumann is therefore considered the pioneer of duodenostomy. In 1936, Friedmann 1.231(Figure 1B) used drainage of the duodenum for a patient with an insecurely closed duodenal stump. However, acceptance of prophylactic duodenostomy as an operative procedure is attributed to Welch [24] and Welch and Rodkey [25], who in 1949 applied and described the From the First Surgical Division, Evangelismos Hospital, Athens; Greece. Reprint requests should be addressed to Sotiris Prigouris, MD, First Surgical Unit, Evangelismos Hospital, 45 lpsilantou Street, Athens, Greece 140.
696
technical aspects of duodenostomy. Welch used a soft rubber Pezzer catheter that was introduced into the second portion of the duodenum and brought out through the abdominal wall to prevent possible rupture of the duodenal stump. The catheter could be introduced into the duodenum through the opened duodenal stump (Figure 2A), or through a lateral opening in the wall of the second portion of the duodenum. Rodkey and Welch [26] suggested this modification in 1960 (Figure 2B). In addition to the duodenal catheter, Welch suggested a double jejunostomy with one catheter going up to the stomach through the anastomosis to decompress the stomach; a second catheter proceeded distally into the jejunum, for feeding purposes and transfer of duodenal secretions (Figure 2C). Duodenostomy without jejunostomy has been used by many surgeons [27-351. It is curious, however, that despite the satisfactory results achieved by duodenostomy, surgeons do not perform the operation as extensively as would be expected for patients with an insecure duodenal stump. Material and Methods
Table I lists the number of patients and types of operations performed for duodenal ulcer at the First Surgical Division, Evangelismos Wospital, during the past 12 years. The operations have been divided into two groups: those performed from 1965 to 1971 and those performed from 1971 to 1977. In the first group, truncal vagotomy and antrectomy was performed in 16.9 per cent of the patients; in the second group this procedure was performed in 39.5 per cent. In 1971 we began to study and apply duodenostomy to patients with difficult duodenal stumps; we performed it 71 times in 230 patients after antrectomy, or in approximately 30 per cent of the patients. Twenty-one of these 71
The American Journal of Surgery
Duodenostomy
patients were operated on because of massive bleeding not controllable by conservative means. Forty-one of the 71 patients had a history of repeated bleeding episodes. In 9 of the 71 patients, the indication for antrectomy was intractability or large and penetrating ulcers. The technique of duodenostomy that we have used is as follows. A fine, elastic, soft catheter, Pezzer (French) no. 14 (Figure 3a), is introduced through the stump of the duodenum to a depth of about 4 to 5 cm. Before introducing the catheter, we trim the tip transversely (Figure 3b) and cut the stump in three places at 2, 6, and 10 o’clock (Figure 3c) so that removal of the catheter will be as non-
TABLE I
Operations for Duodenal Ulcer in 977 Patients at Evangelismos Hospital From 1965 to 1977
Operation
1965-1971 % No.
Vagotomy and drainage Vagotomy and antrectomy Duodenostomy
328 67 0
Total
395
83.1 16.9
1971-1977 No. % 352 230 71
60.5 39.5 ...
582
Figure 1. A, introduction of a catheter into a perforated duodenal ulcer, as reported by yeumann in 1909. B, catheter drainage of a duodenal stump, as reported by Friedmann in 1936.
Figure 3, left. Preparation of the Pezzer catheter before its introduction into the duodenal stump. (See text for explanation. )
traumatic as possible, preventing widening of the opening in the duodenal stump. The catheter is placed in that portion of the suture line with the least tissue and where there is the greatest difficulty in closing the stump watertight (Figure 4). The stump is closed around the catheter in two layers, using 3-O chromic catgut to invert the mucosa and interrupted 4-O silk for the outer row of sutures (Figure 5, A and B). The catheter is then brought out through the abdominal wall, just below the right costal margin, and secured to the skin. We try to make this opening in the abdominal wall slightly lower than the duodenal stump and as close to it as possible in order to make the intraperitoneal portion of the catheter as short as possible. An effort is made not to stretch the catheter between its fixation points, both at the stump and at the skin, to protect it from coming out during
Figure 2. Catheter drainage of (A) duodenal stump, (B) lateral duodenum, or ( C) jejunum retrograde through the gastrojejunostomy, as described by Welch in 1949 and Welch and Rodkey in 1954 and 1960.
a
Figure 4, right. Placement Of the catheter into the duodenal stump.
Volume 138. November 1979
699
Prigouris and Michas
I
4 5 2 3 DAYS POST-OPERATIVE
6
7
Figure 6. lntraduodenal pressure measured postoperalively in 10 patients after catheter duodenostomy.
Figure 5. Closure of the duodenal stump around a catheter in f wo layers.
coughing, increased abdominal distention, or during deep breathing. It is our experience that the catheter should remain in place for 10 to 12 days. When the catheter is removed, the opening into the duodenal stump closes spontaneously, as occurs after a T tube is removed from the common bile duct. Infrequently we have observed a small drainage of bile, which stops after a few hours or, rarely, after 24 hours. Comments
In the surgical management of duodenal ulcer, we believe that the surgeon should vary the operative procedures, depending on the different parameters encountered, such as the age and sex of the patient, bleeding, intractability, perforation of the ulcer, obesity, or other medical problems. These concepts about the surgical management of duodenal ulcer are not original or new, but have been strengthened by observations during the past few years. Several years ago we considered truncal vagotomy combined with drainage of the stomach the preferred surgical treatment in most of our patients with duodenal ulcer. Our results, we believe, depended on whether the vagotomy was complete and whether the
700
drainage was technically perfect and well-functioning. These two factors explain why the recurrence rate is so different in statistics reported in the international literature [36-411. During recent years we have compared our results of vagotomy with drainage to those of vagotomy with antrectomy. With the former method, we observed less mortality and fewer cases with dumping, but an increased recurrence rate of 10 per cent in 328 patients 5 years after surgical treatment. The increased recurrence rate, combined with our personal belief that in cases of bleeding ulcers the most suitable method is resection of the ulcer, have led us to perform more resections. In an effort to manage very deep ulcers of the posterior duodenal wall that penetrate into the pancreas and frequently bleed, we experienced great difficulty in securing the duodenal stump. This encouraged us to think, study, and consequently apply duodenostomy as a means of managing the difficult duodenal stump, thus avoiding serious and perhaps catastrophic complications. After performing duodenostomy in 71 patients, we conclude that it is a simple, effective, and safe method to prevent rupture of an insecure duodenal stump. No complications occurred in these patients, most of whom had very difficult stumps. One patient died from cardiac arrest that occurred immediately after the operation and was not related to the duodenostomy.
The American Journal of Surgery
Duodenostomy
The choice of the site for introduction of the catheter, either through the duodenal stump or the lateral wall of the duodenum, is of great importance in duodenostomy. Duodenostomy through the lateral duodenal wall is probably the technique preferred by most surgeons [42-451. Hermann [42] believes that after duodenostomy through the duodenal stump, continued bleeding from the ulcer bed can follow a leak from the duodenum around the catheter, with intraperitoneal bleeding. He believes that this complication can be avoided by suturing the duodenal stump completely and performing a lateral duodenostomy, using a T tube. We believe that introducing the catheter through the stump of the duodenum is preferable. We arrived at that conclusion after our experience with two consecutive patients in whom, despite lateral duodenostomy, the stumps ruptured, leading to prolonged hospitalizations of 32 and 36 days. We therefore measured the intraduodenal pressure in 10 patients after duodenostomy by connecting the intraduodenal catheter to a saline-filled manometer and a fluid source. From this study it became apparent that duodenostomy does not lead to a significant decrease in intraduodenal pressure. We observed that from the first to the seventh postoperative days the pressure in the duodenum gradually decreased (Figure 6). The decrease in intraduodenal pressure appears to be the result of the resumption of intestinal peristalsis after the operation and not a result of the duodenostomy. Furthermore, we know that intraduodenal pressure may suddenly increase to 25 cm [45] as a result of a sudden increase in intraabdominal pressure, as occurs during coughing, independent of the existence of the duodenostomy. Therefore, one cannot absolutely rely on duodenostomy to protect an insecure duodenal stump by decompressing the duodenum. Conclusions
It may be that the two types of duodenostomy differ in the means employed to attain a common goal, the avoidance of any complications that might occur from rupture of the duodenal stump. Side duodenostomy aims to protect an insecure duodenal stump by decompressing the duodenum. This operative stratagem is based on the same logic as is prophylactic colostomy in low anterior resection in cases of insecure anastomosis. We prefer stump duodenostomy, which is totally different. In stump duodenostomy the surgeon establishes a kind of exteriorization of the duodenal stump by creating a fistula in the duodenum using a catheter. In our opinion,
Volume 138, November 1979
this fistula can be established safely in any difficult stump above the ampulla of Vater, regardless of the condition of the tissues around it. Finally, we emphasize again that we believe duodenostomy with the insertion of a catheter through the end of the duodenal stump is a safe and effective method to use in the resection of a difficult duodenal ulcer. Summary
The methods of managing a difficult duodenal stump after gastric resection are reviewed. One of two methods of catheter drainage of the duodenum can be used: end-stump catheterization or lateral tube drainage. A series of cases managed by end-stump duodenostomy is reviewed. The rationale for this technique and its advantages are presented. References 1. Sanford CE: The difficult duodenal stump. US Armed Forces Med J 7: 336, 1956. 2. Avola FA. Ellis DH: Leakage of the duodenal or antral stump complicating gastric resection. Surg Gyflecol O&ret 99: 359, 1954. 3. Barnett WO, Tucker FH: Management of the difficult duodenal stump. Ann Surg 159: 794, 1964. 4. Larson BB, Foreman RC: Syndrome of the leaking duodenal stump. Arch Surg 63: 480, 195 1. 5. Jones SA, Gregory G, Smith U. Saito S, Joergenson EJ: Surgical management of the difficult and perforated duodenal stump. Am J Surg 108: 257, 1964. 6. Smith EB: Duodenal stump problems. JNatl MedAssoc 65: 68, 1973. 7. McKittrick LS, Moore FD, Warren R: The complications and mortality in subtotal gastrectomy for duodenal ulcer. Report on 2-stage procedure. Ann Surg 120: 531, 1944. 6. Devine J: Gastric exclusion. Surg Gynecol Obstet 47: 239, 1928. 9. Bancroft FW: A modification of the Devine operation of pyloric exclusion for duodenal ulcer. Am J Surg 16: 223, 1932. 10. Bennett JM: Modified Bancroft procedure for the difficult duodenal stump. Arch Surg 104: 219, 1972. 11. Harvey DH: Safety in performing partial gastrectomy for peptic ulcer. Ann Surg 153: 256, 1961. 12. Makkas M, Maragos G: The surgical treatment of non-resectable duodenal ulcer: antral exclusion operation (Bancroft-Plenk modification). Br J Surg 37: 206, 1949. 13. Wangensteen OH: Segmental gastric resection for peptic ulcer; method permitting restoration of anatomic continuity. JAMA 149: 18, 1952. 14. Nissen R: Zur resektion des tiefsitzenden duodenalgschwuts. Zentralbl Chir 60: 483, 1933. 15. Ginzburg L: Management of the difficult duodenal stump. Surg Clin North Am 34: 473, 1954. 16. Welch CE: Surgery of the Stomach and Duodenum. Chicago, Year Book Medical, 1966. 17. Graham RR: Surgical therapy in lesions of the stomach and duodenum. Operative Surgery (Bancroft FW, ed). New York, Appleton-Century Crafts, 1941. 16. Basteh 0: Technik der resektion tiefsitzender duodenal ulcer. Arch K/in Chir 175: 114, 1933. 19. Slattery LR: Intramural dissection and staggered closure of the duodenal stump. Surg Gynecol Obsfet 110: 253, 1960. 20. Cooper P: Duodenal closure after gastrectomy for duodenal ulcer. Surgery 50: 425, 1961.
701
Prigouris
21.
22.
23.
24. 25.
26. 27.
28.
29. 30.
31.
32. 33.
702
and Michas
Cooper P. Pecora VD: The problem of duodenal closure after gastrectomy for duodenal ulcer. Am J Surg 91: 231, 1956. Neumann A: Zur Verwertung der Netzplastik bei der Behandlung des perforierten Magen und duodenalgeschwuts. Deutsch Z Chir 100: 298, 1909. Friedemann M: Uber Hilfen und Sicherungen bei gefahrvollen und technisch schwierigen magenoperationen. Beitr K/in Chir 163: 293, 1936. Welch CE: Treatment of acute, massive gastroduodenal hemorrhage. JAMA 141: 1113, 1949. Welch CE, Rodkey GV: A method of management of the duodenal stump after gastrectomy. Surg Gyneco/ Obstet 98: 376, 1954. Rodkey GV, Welch CE: Duodenal decompression in gastrectomy. N Engl J Med 262: 498, 1960. Caudell WS, Garrison RL, Lee CM Jr: Use and complications of catheter duodenostomy in gastric resection. Surg Gynecol Obstet 100: 506, 1955. Priestly JT, Butler DB: Ducxfenostomy. Technic for management of duodenal stump in certain cases of partial gastrectomy for duodenal ulcer. Am J Surg 82: 163, 1951. Lippert KD, Coleman HV: Duodenostomy in gastric resection for duodenal ulcer. Am J Surg 95: 781, 1958. Pearson SC, MacKensie RJ, Ross T: The use of catheter duodenostomy in gastric resection for duodenal ulcer. Am J Surg 106: 194, 1963. Shires T, Jackson D, Williams J: Temporary duodenal decompression as an adjunct to gastric resection for duodenal ulcer. Am Surg 28: 709, 1962. McEachern CG, Sullivan ER, Arate EJ: Duodenostomy. Arch Surg 72: 942, 1956. Mayfield CR, Abramson DP: The use of catheter duodenostomy in subtotal gastrectomy. Am J Surg 90: 996, 1955.
34. Hoerr SO, Perryman GR: Catheter duodenostomy: safeguard in gastric resection. Report of 11 cases. C/eve Clin 0 19: 49, 1952. 35. Austen WG, Baue AE: Catheter duodenostomy for the difficult duodenum. Ann Surg 160: 781, 1964. 36. Ochsner A, Zehnder RP, Trammal WS: The surgical treatment of peptic ulcer. A critical analysis of results from subtotal gastrectomy and from vagotomy plus partial gastrectomy. Surgery67: 1017, 1970. 37. Nobles ER Jr: Vagotomy and gastroenterostomy: 15 year follow-up of 175 patients. Am Surg 32: 117, 1966. 38. Rhea WG Jr, Killen DA, Scott HW Jr: Long-term results of partial gastric resection without vagotomy in duodenal ulcer disease. Surg Gynecol Obstet 120: 970, 1965. 39. Tanner NC: Management of peptic ulcer. Ann R Co// Surg Engl 37: 150, 1965. 40. Zahn RL, Stemmer EA. Horn LW, Cowndley JE: Delayed recurrence of gastric ulcer following vagotomy and drainage procedure. Am Surg 34: 757, 1968. 41. Jordan HP, Condon ER: A prospective evaluation of vagotomy-pyloroplasty and vagotomy-antrectomy for treatment of duodenal ulcer. Ann Surg 172: 541, 1970. 42. Hermann RE: T-tube catheter drainage of the duodenal stump. Am J Surg 125: 364, 1973. 43. Jones RC, McClelland RN, Zedlitz WH: Difficult closures of the duodenal stump. Arch Surg 94: 696, 1967. 44. Hodgson PE, Hunter DC: Protection of a duodenal stump closure. Surg C/in North Am 41: 1323, 1961. 45. Dardik I, Dardik H, Shumofsky E, Gliedman ML: Lateral T-tube duodenostomy. Duodenal stump management and manometrics. Arch Surg 7: 89, 1973. 46. Gingrich GW, Haynes CD, Thoroughman JC: Use of the T-tube in difficult duodenal stump closures. Am Surg 29: 603, 1963.
The American Journal 01 Surgery
Duodenostomy
Sotiris Prigouris, MD, Athens, Greece Pan Michas, MD, Athens, Greece
The incidence of leakage from a duodenal stump after gastric resection for duodenal ulcer is 1.5 to 2.5 per cent; however, the mortality has been reported to approach 50 per cent [l-6]. Thus, when leakage occurs it is a major and life-threatening complication. A number of different surgical procedures have been recommended to prevent or manage this problem. Historically, the McKittrick two-stage gastric resection [7], the Devine [8] and Bancroft [9-Z?] antral exclusion techniques, and the sleeve resection of Wangensteen [13] have been used to prevent leakage from the duodenal stump. In addition, several methods of closure of the duodenum after gastric resection have been proposed. The most common procedures are Nissen’s [14-161, Graham’s [17], Basteh’s [18], Slattery’s [19], Cooper’s [20,21], and duodenostomy. In a review of the surgical literature, Neumann [22] in 1909 was the first surgeon to introduce a catheter through the opening of a large perforated duodenal ulcer because he could not close the perforation without causing stenosis (Figure 1A). By this means he created a temporary duodenal fistula. Neumann is therefore considered the pioneer of duodenostomy. In 1936, Friedmann 1.231(Figure 1B) used drainage of the duodenum for a patient with an insecurely closed duodenal stump. However, acceptance of prophylactic duodenostomy as an operative procedure is attributed to Welch [24] and Welch and Rodkey [25], who in 1949 applied and described the From the First Surgical Division, Evangelismos Hospital, Athens; Greece. Reprint requests should be addressed to Sotiris Prigouris, MD, First Surgical Unit, Evangelismos Hospital, 45 lpsilantou Street, Athens, Greece 140.
696
technical aspects of duodenostomy. Welch used a soft rubber Pezzer catheter that was introduced into the second portion of the duodenum and brought out through the abdominal wall to prevent possible rupture of the duodenal stump. The catheter could be introduced into the duodenum through the opened duodenal stump (Figure 2A), or through a lateral opening in the wall of the second portion of the duodenum. Rodkey and Welch [26] suggested this modification in 1960 (Figure 2B). In addition to the duodenal catheter, Welch suggested a double jejunostomy with one catheter going up to the stomach through the anastomosis to decompress the stomach; a second catheter proceeded distally into the jejunum, for feeding purposes and transfer of duodenal secretions (Figure 2C). Duodenostomy without jejunostomy has been used by many surgeons [27-351. It is curious, however, that despite the satisfactory results achieved by duodenostomy, surgeons do not perform the operation as extensively as would be expected for patients with an insecure duodenal stump. Material and Methods
Table I lists the number of patients and types of operations performed for duodenal ulcer at the First Surgical Division, Evangelismos Wospital, during the past 12 years. The operations have been divided into two groups: those performed from 1965 to 1971 and those performed from 1971 to 1977. In the first group, truncal vagotomy and antrectomy was performed in 16.9 per cent of the patients; in the second group this procedure was performed in 39.5 per cent. In 1971 we began to study and apply duodenostomy to patients with difficult duodenal stumps; we performed it 71 times in 230 patients after antrectomy, or in approximately 30 per cent of the patients. Twenty-one of these 71
The American Journal of Surgery
Duodenostomy
patients were operated on because of massive bleeding not controllable by conservative means. Forty-one of the 71 patients had a history of repeated bleeding episodes. In 9 of the 71 patients, the indication for antrectomy was intractability or large and penetrating ulcers. The technique of duodenostomy that we have used is as follows. A fine, elastic, soft catheter, Pezzer (French) no. 14 (Figure 3a), is introduced through the stump of the duodenum to a depth of about 4 to 5 cm. Before introducing the catheter, we trim the tip transversely (Figure 3b) and cut the stump in three places at 2, 6, and 10 o’clock (Figure 3c) so that removal of the catheter will be as non-
TABLE I
Operations for Duodenal Ulcer in 977 Patients at Evangelismos Hospital From 1965 to 1977
Operation
1965-1971 % No.
Vagotomy and drainage Vagotomy and antrectomy Duodenostomy
328 67 0
Total
395
83.1 16.9
1971-1977 No. % 352 230 71
60.5 39.5 ...
582
Figure 1. A, introduction of a catheter into a perforated duodenal ulcer, as reported by yeumann in 1909. B, catheter drainage of a duodenal stump, as reported by Friedmann in 1936.
Figure 3, left. Preparation of the Pezzer catheter before its introduction into the duodenal stump. (See text for explanation. )
traumatic as possible, preventing widening of the opening in the duodenal stump. The catheter is placed in that portion of the suture line with the least tissue and where there is the greatest difficulty in closing the stump watertight (Figure 4). The stump is closed around the catheter in two layers, using 3-O chromic catgut to invert the mucosa and interrupted 4-O silk for the outer row of sutures (Figure 5, A and B). The catheter is then brought out through the abdominal wall, just below the right costal margin, and secured to the skin. We try to make this opening in the abdominal wall slightly lower than the duodenal stump and as close to it as possible in order to make the intraperitoneal portion of the catheter as short as possible. An effort is made not to stretch the catheter between its fixation points, both at the stump and at the skin, to protect it from coming out during
Figure 2. Catheter drainage of (A) duodenal stump, (B) lateral duodenum, or ( C) jejunum retrograde through the gastrojejunostomy, as described by Welch in 1949 and Welch and Rodkey in 1954 and 1960.
a
Figure 4, right. Placement Of the catheter into the duodenal stump.
Volume 138. November 1979
699
Prigouris and Michas
I
4 5 2 3 DAYS POST-OPERATIVE
6
7
Figure 6. lntraduodenal pressure measured postoperalively in 10 patients after catheter duodenostomy.
Figure 5. Closure of the duodenal stump around a catheter in f wo layers.
coughing, increased abdominal distention, or during deep breathing. It is our experience that the catheter should remain in place for 10 to 12 days. When the catheter is removed, the opening into the duodenal stump closes spontaneously, as occurs after a T tube is removed from the common bile duct. Infrequently we have observed a small drainage of bile, which stops after a few hours or, rarely, after 24 hours. Comments
In the surgical management of duodenal ulcer, we believe that the surgeon should vary the operative procedures, depending on the different parameters encountered, such as the age and sex of the patient, bleeding, intractability, perforation of the ulcer, obesity, or other medical problems. These concepts about the surgical management of duodenal ulcer are not original or new, but have been strengthened by observations during the past few years. Several years ago we considered truncal vagotomy combined with drainage of the stomach the preferred surgical treatment in most of our patients with duodenal ulcer. Our results, we believe, depended on whether the vagotomy was complete and whether the
700
drainage was technically perfect and well-functioning. These two factors explain why the recurrence rate is so different in statistics reported in the international literature [36-411. During recent years we have compared our results of vagotomy with drainage to those of vagotomy with antrectomy. With the former method, we observed less mortality and fewer cases with dumping, but an increased recurrence rate of 10 per cent in 328 patients 5 years after surgical treatment. The increased recurrence rate, combined with our personal belief that in cases of bleeding ulcers the most suitable method is resection of the ulcer, have led us to perform more resections. In an effort to manage very deep ulcers of the posterior duodenal wall that penetrate into the pancreas and frequently bleed, we experienced great difficulty in securing the duodenal stump. This encouraged us to think, study, and consequently apply duodenostomy as a means of managing the difficult duodenal stump, thus avoiding serious and perhaps catastrophic complications. After performing duodenostomy in 71 patients, we conclude that it is a simple, effective, and safe method to prevent rupture of an insecure duodenal stump. No complications occurred in these patients, most of whom had very difficult stumps. One patient died from cardiac arrest that occurred immediately after the operation and was not related to the duodenostomy.
The American Journal of Surgery
Duodenostomy
The choice of the site for introduction of the catheter, either through the duodenal stump or the lateral wall of the duodenum, is of great importance in duodenostomy. Duodenostomy through the lateral duodenal wall is probably the technique preferred by most surgeons [42-451. Hermann [42] believes that after duodenostomy through the duodenal stump, continued bleeding from the ulcer bed can follow a leak from the duodenum around the catheter, with intraperitoneal bleeding. He believes that this complication can be avoided by suturing the duodenal stump completely and performing a lateral duodenostomy, using a T tube. We believe that introducing the catheter through the stump of the duodenum is preferable. We arrived at that conclusion after our experience with two consecutive patients in whom, despite lateral duodenostomy, the stumps ruptured, leading to prolonged hospitalizations of 32 and 36 days. We therefore measured the intraduodenal pressure in 10 patients after duodenostomy by connecting the intraduodenal catheter to a saline-filled manometer and a fluid source. From this study it became apparent that duodenostomy does not lead to a significant decrease in intraduodenal pressure. We observed that from the first to the seventh postoperative days the pressure in the duodenum gradually decreased (Figure 6). The decrease in intraduodenal pressure appears to be the result of the resumption of intestinal peristalsis after the operation and not a result of the duodenostomy. Furthermore, we know that intraduodenal pressure may suddenly increase to 25 cm [45] as a result of a sudden increase in intraabdominal pressure, as occurs during coughing, independent of the existence of the duodenostomy. Therefore, one cannot absolutely rely on duodenostomy to protect an insecure duodenal stump by decompressing the duodenum. Conclusions
It may be that the two types of duodenostomy differ in the means employed to attain a common goal, the avoidance of any complications that might occur from rupture of the duodenal stump. Side duodenostomy aims to protect an insecure duodenal stump by decompressing the duodenum. This operative stratagem is based on the same logic as is prophylactic colostomy in low anterior resection in cases of insecure anastomosis. We prefer stump duodenostomy, which is totally different. In stump duodenostomy the surgeon establishes a kind of exteriorization of the duodenal stump by creating a fistula in the duodenum using a catheter. In our opinion,
Volume 138, November 1979
this fistula can be established safely in any difficult stump above the ampulla of Vater, regardless of the condition of the tissues around it. Finally, we emphasize again that we believe duodenostomy with the insertion of a catheter through the end of the duodenal stump is a safe and effective method to use in the resection of a difficult duodenal ulcer. Summary
The methods of managing a difficult duodenal stump after gastric resection are reviewed. One of two methods of catheter drainage of the duodenum can be used: end-stump catheterization or lateral tube drainage. A series of cases managed by end-stump duodenostomy is reviewed. The rationale for this technique and its advantages are presented. References 1. Sanford CE: The difficult duodenal stump. US Armed Forces Med J 7: 336, 1956. 2. Avola FA. Ellis DH: Leakage of the duodenal or antral stump complicating gastric resection. Surg Gyflecol O&ret 99: 359, 1954. 3. Barnett WO, Tucker FH: Management of the difficult duodenal stump. Ann Surg 159: 794, 1964. 4. Larson BB, Foreman RC: Syndrome of the leaking duodenal stump. Arch Surg 63: 480, 195 1. 5. Jones SA, Gregory G, Smith U. Saito S, Joergenson EJ: Surgical management of the difficult and perforated duodenal stump. Am J Surg 108: 257, 1964. 6. Smith EB: Duodenal stump problems. JNatl MedAssoc 65: 68, 1973. 7. McKittrick LS, Moore FD, Warren R: The complications and mortality in subtotal gastrectomy for duodenal ulcer. Report on 2-stage procedure. Ann Surg 120: 531, 1944. 6. Devine J: Gastric exclusion. Surg Gynecol Obstet 47: 239, 1928. 9. Bancroft FW: A modification of the Devine operation of pyloric exclusion for duodenal ulcer. Am J Surg 16: 223, 1932. 10. Bennett JM: Modified Bancroft procedure for the difficult duodenal stump. Arch Surg 104: 219, 1972. 11. Harvey DH: Safety in performing partial gastrectomy for peptic ulcer. Ann Surg 153: 256, 1961. 12. Makkas M, Maragos G: The surgical treatment of non-resectable duodenal ulcer: antral exclusion operation (Bancroft-Plenk modification). Br J Surg 37: 206, 1949. 13. Wangensteen OH: Segmental gastric resection for peptic ulcer; method permitting restoration of anatomic continuity. JAMA 149: 18, 1952. 14. Nissen R: Zur resektion des tiefsitzenden duodenalgschwuts. Zentralbl Chir 60: 483, 1933. 15. Ginzburg L: Management of the difficult duodenal stump. Surg Clin North Am 34: 473, 1954. 16. Welch CE: Surgery of the Stomach and Duodenum. Chicago, Year Book Medical, 1966. 17. Graham RR: Surgical therapy in lesions of the stomach and duodenum. Operative Surgery (Bancroft FW, ed). New York, Appleton-Century Crafts, 1941. 16. Basteh 0: Technik der resektion tiefsitzender duodenal ulcer. Arch K/in Chir 175: 114, 1933. 19. Slattery LR: Intramural dissection and staggered closure of the duodenal stump. Surg Gynecol Obsfet 110: 253, 1960. 20. Cooper P: Duodenal closure after gastrectomy for duodenal ulcer. Surgery 50: 425, 1961.
701
Prigouris
21.
22.
23.
24. 25.
26. 27.
28.
29. 30.
31.
32. 33.
702
and Michas
Cooper P. Pecora VD: The problem of duodenal closure after gastrectomy for duodenal ulcer. Am J Surg 91: 231, 1956. Neumann A: Zur Verwertung der Netzplastik bei der Behandlung des perforierten Magen und duodenalgeschwuts. Deutsch Z Chir 100: 298, 1909. Friedemann M: Uber Hilfen und Sicherungen bei gefahrvollen und technisch schwierigen magenoperationen. Beitr K/in Chir 163: 293, 1936. Welch CE: Treatment of acute, massive gastroduodenal hemorrhage. JAMA 141: 1113, 1949. Welch CE, Rodkey GV: A method of management of the duodenal stump after gastrectomy. Surg Gyneco/ Obstet 98: 376, 1954. Rodkey GV, Welch CE: Duodenal decompression in gastrectomy. N Engl J Med 262: 498, 1960. Caudell WS, Garrison RL, Lee CM Jr: Use and complications of catheter duodenostomy in gastric resection. Surg Gynecol Obstet 100: 506, 1955. Priestly JT, Butler DB: Ducxfenostomy. Technic for management of duodenal stump in certain cases of partial gastrectomy for duodenal ulcer. Am J Surg 82: 163, 1951. Lippert KD, Coleman HV: Duodenostomy in gastric resection for duodenal ulcer. Am J Surg 95: 781, 1958. Pearson SC, MacKensie RJ, Ross T: The use of catheter duodenostomy in gastric resection for duodenal ulcer. Am J Surg 106: 194, 1963. Shires T, Jackson D, Williams J: Temporary duodenal decompression as an adjunct to gastric resection for duodenal ulcer. Am Surg 28: 709, 1962. McEachern CG, Sullivan ER, Arate EJ: Duodenostomy. Arch Surg 72: 942, 1956. Mayfield CR, Abramson DP: The use of catheter duodenostomy in subtotal gastrectomy. Am J Surg 90: 996, 1955.
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