Duodenostomy

DUODENOSTOMY TECHNIC

FOR MANAGEMENT OF DUODENAL STUMP IN CERTAIN OF PARTIAL GASTRECTOMY FOR DUODENAL ULCER JAMES

T.

PRIESTLEY, M.D.

AND DONALD

Division of Surgery, Mayo Clinic

,Lfinnesota

I

N past years leakage from the duodenal stump has been a prominent source of serious complication after partia1 gastrectomy of the Billroth II type. At the present time successful closure of the duodenum still constitutes an important factor in maintaining the current low mortality rate after partiaI resection of the stomach. Dehiscence of the suture line in the duodenum may lead to generahzed peritonitis with subsequent fatality, localized peritonitis and subhepatic abscess, or duodenal fistula with resuItant loss of fluid and electrolytes and consequent debilitation of the patient. OF

THE

DUODENAL

STCMP

IN

ORDINARY

CASES

In performing partial gastrectomy of the Billroth II type the lower level of resection may be in one of four general locations in reference to the duodenal ulcer and the pylorus. (Fig. I .) Ideally, if circumstances permit, the surgeon prefers to sever the duodenum distal to the ulcer and close the duodenal stump in a suitable manner of his preference. (Fig. I.) This may be accomplished in most cases if the ulcer is not of excessive size, if the duodenum is relatively accessible, if the ulcer is not located at an appreciable distance from the pylorus and if the distance between the pylorus and amp& of Vater has not been significantly shortened by recurring ulceration and healing. Under these circumstances the duodenal tissues at the site of closure are relatively normal and mobile, and satisfactory suture of the duodenum can be accompIished without too much difficulty. In other cases in which there is an active, perforating uIcer on the posterior walI of the duodenum and a reIatively short distance between the ulcer and the ampulla of Vater one may sever the duodenum at the level of the uIcer, leaving the crater of the lesion on the pancreas. (Fig. I .) In this instance the posterior

July, 1951

BUTLER, M.D.

Fellow in Surgery, Mayo Foundation

Kochester,

CLOSURE

B.

CASES

waI1 of the duodenum is carefulIy mobilized for a short distance beyond the crater of the ulcer. Ordinarily the anterior wail of the duodenum is severed at a level somewhat closer to the pylorus than the posterior waI1 in order to preserve an adequate amount of freely movable anterior \\-a11 to roll over to the posterior wall to permit satisfactory closure without tension. In some cases as the posterior duodenal wall is mobilized it forms a V-shaped edge, with the deep converging Iimbs of the V directed downward in the mid-portion of the posterior wall. This is especially true if the crater of the ulcer has been situated in the mid-part of the posterior duodenal wall. Under these circumstances the line of closure of the duodenal stump may advantageousIy be directed from the most dependent level posteriorly to the anterior wall. This is in contrast with the usual direction of the suture line from the inferior to the superior border of the duodenum. Closure of the “open duodenal stump” rather than closure with the aid of a clamp of some type placed across the duodenum is helpful in avoiding excessive mobilization of the duodenum. Under other circumstances a duodenal uIccr may be situated at a considerable distance from the pylorus (4 cm. or more). In this type of case if there is no bleeding and acute perforation of the uIcer does not appear imminent, the surgeon may elect to sever the duodenum immediately distal to the pylorus and close the duodenal stump proxima1 to the ulcer. (Fig. I .) Several words of caution might be offered regarding the use of this procedure. In the first place a greater length of duodenum proxima1 to the ulcer is necessary for satisfactory cIosure of the stump than might appear if a suture Iine without tension is to be obtained. As the region of the ulcer is approached, the duodena1 wall becomes fixed, perhaps edematous, and does not Iend itseIf to compIeteIy satisfactory mobilization as the sutures are inserted.

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PriestIey,

ButIer

Secondly, if the uIcer is to be left in pIace, one shouId refrain from freeing the tissues around it or appIying much traction on the invoIved duodenum in order to decrease the chance of Ieakage from the region of the uIcer during the early postoperative period.

FIG. I. Various distal levels at which gastrectomy for duodenal ulcer.

In certain selected cases (few in our practice) one may elect to sever the stomach a few centimeters proximal to the pylorus, excise the remaining prepyloric gastric mucosa and cIose the stump after the method described by Bancroft. (Fig. I.) This procedure may be empIoyed in the presence of an active duodenal ulcer of such magnitude and position that no through the duodenum type of resection appears to he safe or wise. In our opinion it should not be performed if the ulcer is bleeding or causing an advanced degree of obstruction. Certain technica points are of course important in obtaining satisfactory closure of the duodena1 stump. A number of methods and procedures have been suggested and empIoyed in closure of the duodenum. M’ithout discussing technical details certain genera1 principles might be mentioned. First, it probabl!, goes without saying that satisfactory inversion of the cut end of the duodenum is essential. It is our practice to use at least three rows of sutures, a11 but the first being silk. The suture into tfle adjacent panline is then “rolled” creas. Second, there must be no tension on the

of

-Duodenostomy suture Iine. Third, adequate bIood suppIy of the duodenal waI1 must be maintained. Fourth, and we believe this point has been inadequately stressed, attention must be directed toward prevention of any increase in the normal intraIumina1 pressure of the duodenum during

resection

may

be performed

in partial

the postoperative period. This, of course, means that there must be no degree of obstruction in the proximal loop of the jejunum. We are inclined to beIieve that increased pressure within the duodenum has been responsible for Ieakage from more than one duodena1 stump. It is our belief that use of a truly short proximal Ioop of jejunum in estabIishing the anastomosis is heIpfu1 in this regard when a posterior type of gastrojejuna1 anastomosis is made. DUODENOSTOMY

In certain unusual cases the surgeon may experience diffIcuIty in cIosing the duodenal stump by any of the conventiona methods. Such a situation may arise if for any reason the duodenum has been severed so far distaIIy that its satisfactory cIosure in an ordinary manner might encroach on the common biIe duct. In our opinion partial gastrectomy for duodena1 uIcer should never be pIanned in such a manner that reimplantation of the common bile duct into the duodenum is required. Occasionally, however, because of unexpected findings as the operation progresses or for other reasons one

American

Journal

of Surgery

PriestIey,

ButIer-Duodenostomy

may fmd that closure of the duodenal stump in a usual manner might result in undesirabIe encroachment on certain important adjacent structures. Under these circumstances management of the duodena1 stump by performance of duodenostomy may prove to be quite helpful. (Fig. 2.) This procedure consists simply of cIosing the open end of the duodenum around an appropriate catheter, perhaps a size 20 F straight latex type. That portion of the duodenum which can be sutured satisfactorily is closed and the catheter is permitted to remain where satisfactory closure is difficult or impossible without endangering adjacent structures or the wall of the duodenum by further mobilization. Purse-string sutures placed around the catheter may be heIpfu1. Nearf,fatty tissue may be sutured around the catheter if further protection of the closure appears advisable. The catheter is brought out of the abdominal waI1 through a stab wound. The cathether is anchored securely to the skin by a sturdy nonabsorbabIe suture. A Penrose-type drain may be Ieft near the end of the duodenum if one wishes and brought out a different tract through the abdominal wall. The catheter is connected with a bottle at the conclusion of the operation so that Buid which drains from the duodenum may be coIIected and measured. This, of course, is helpfu1 in judging the need for repIacement of Auid and electrolytes. There may be relatively little drainage from the duodenum. Ten or tw-elve days after operation the catheter may be clamped to observe any untoward effects that might result. In our limited experience with this procedure no such results have been observed. The catheter may be withdrawn twelve to fourteen days after operation. The sinus tract may be expected to heal quite promptIy. COMMENT

Duodenostomy is not a new procedure. Billroth (as quoted by WMer in 1881) considered the advisability of leaving a duodenal fistula in his descriptions of the first successful gastric resections. Neumann in 1909 used a rubber catheter or drain in two cases of perforated gastric ulcer in which the opening could not be cIosed by suture. Keynes in 1934 reintroduced Neumann’s method in England for the management of both perforated gastric and duodena1 ulcers. EIe inserted a mushroom

1%

type of catheter into the opening and cIosed the tissues around it with purse-string sutures. Other surgeons 3,4 have utilized this technic in certain cases of perforated uIcer in which they were aIso unabIe to obtain a satisfactory cIosure with sutures alone. Welch described the use of

FIG. Z. Technic of duodenostomy.

a catheter in the duodenal stump after gastric resection in several cases of bleeding duodenal ulcer. The technic described by us is in a11 essentials identical with the method that Welch used. It is not suggested that duodenostomy should ever be selected as the method of choice in managing the duodena1 stump but rather that it shouId be used as a method of eIedtion when other methods cannot be used with safety. The underIying surgica1 principle is similar to the use of a T tube in drainage of the common biIe duct after choIedochostomy. The method mav be of some value in the occasional case in which the surgeon believes that duo-

Priestley,

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denal Ieakage is probable or inevitabIe usua1 form of closure is used.

Butlerif a more

REFERENCES I. BANCROFT, F. W. A modification of the Devine operation of pyloric excIusion for duodenal ulcer. Am. J. Surg., 16: 223-230, 1932. 2. KEYNES, GEOFFREY. Surgical aphorisms. St. Barth. Hosp. J., 41: 64-65, 1934. 3. KIRSCHNER, MARTIN. Operative Surgery; the Abdomen and Rectum. (TransIated by I. S. Ravdin.) Philadelphia, 1933. J. B. Lippincott Co.

DuodenostornJ 4. MAINGOT, RODNEY. Post-graduate Surgery, vol. I. New York, 1936. AppIeton-Century Co. ALFRED. Zur Verwertung der Netz5. NEUMANN, plastik bei der Behandlung des perforierten Magen- und DuodenaIgeschwiirs. Deutsche Ztschr. f. Cbir., IOO: 298-305, Igog. 6. WELCH, C. E. Treatment of acute, massive gastroduodenal hemorrhage. J. A. M. A., 141: I I 131118,194g.

ANTON. Ueber die von Herrn Professor 7. W~LFLER, Billroth ausgefiihrten Resectionen des carcinomatiisen Pylorus. Vienna, I 88 I. W. Braumiiller.

American

Journal of Surgery