Gastroduodenostomy

Gastroduodenostomy An Answer to the Difficult Duodenal

Stump

ERWIN J. FUERST, M.D., Elkins, West lrirginia

From the Department Elkins, West Virginia.

of Surgery,

The Golden

Clinic,

establishing physiologic conditions as closely as possible. If both phases, that is, vagotomy and resection, are performed properly, the mortality and recurrence rate are not higher than with other procedures [IO]. The present paper will be restricted to the technical aspects of dealing with the difficult duodenal stoma after completion of the resectional phase. Observing these details will result in a lower morbidity and mortality and thus will widen the application of the superior combined procedure of vagotomy and antrectomy or hemigastrectomy for the treatment of duodenal ulcer disease. Yet it is also emphasized that there is no place for rigidity in the management of this disease entity. Only when the proper operation is adapted to fit the needs of the individual patient under the prevailing circumstances will satisfactory results be yielded.

EPORTSof problems associated with closure of the duodenal stump and its complications after gastric resection appear periodically in the literature, both in the past and again quite recently [l-6]. Accordingly, perforations of the duodenal stump largely determine the morbidity and mortality, which tend to increase when the operation is carried out under emergency conditions, yielding a mortality as high as 66 per cent. These figures are rightly used as argument against employment of resective measures for the definite treatment of duodenal ulcer disease. One must concede that it leaves the patient and surgeon in a precarious position if the duodenum is closed in an unsatisfactory manner. Yet, there remains only one other choice: a catheter duodenostomy, which is by no means an innocuous procedure. Mortality with this procedure ranges from 10 to 80 per cent and difficult electrolyte disturbances are created [7-91. Indeed, the problematic duodenal stump appears to remain for many surgeons the most influential single factor in determining the choice of the combined procedure of vagotomy with resection of the antrum or distal half of the stomach, which is presently employed more and more. Its desired effects of eliminating the cephalic and gastric phase of acid stimulation while preserving the reservoir function of the stomach are well recognized. It is my belief that restoration of the gastrointestinal continuity by gastroduodenostomy eliminates the problems of the technically difficult duodenal stump to a high degree, as will be shown. It also adds the benefit of re-

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Vol.115,March1968

PROBLEMSIN CLOSURE OF THE DUODENALSTUMP The duodenal stump as depicted in surgical texts is seldom encountered in practice when one observes stringent criteria for surgical intervention in duodenal ulcer disease. More often one has to deal with a friable duodenal wall, especially in that area adjacent to the pancreas, or even with a defect in the wall at the site of a penetrating ulcer. Duodenitis with edema of the mucosa or that which affects the entire wall and periduodenitis with its plastic adhesive coverings decrease the tissue pliability. Therefore, in the course of closure of the duodenal stump an increased tension manifests itself when the wall is turned in. In the most dificult situation one is left additionally with a narrow cuff on the pancreatic side. (Fig. 1.) 287

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288

DUODENUM

FIG. 1. A typical difficult duodenal ulcer in the pancreas.

stump. Arrow points to base of resected

FIG. 2. X marks the area of compromised for closure.

A continued dissection in this plane carries the danger of opening the accessory pancreatic duct or undue trauma resulting in the dreaded and highly lethal pancreatitis. Also, there is the possibility of compromising the ampulla of Vater when closing the duodenal stoma after resection of a low lying ulcer. The usual methods of closure cannot be employed [11-131. Even the methods of Nissen require a fair pliability of the wall [14]. To “borrow” tissue by fashioning a “lid” projecting from and based on the antimesenteric semicircumference of the duodenum is dangerous. (Fig. 2.) It has been shown that the blood supply to and around the duodenum is abundant [15]. The study of the mural circulation reveals a chiefly circular arrangement with few longitudinal anastomoses. Any rise in intraluminal pressure jeopardizes its function [IS]. Therefore a later perforation can be expected. TECHNIC

Let us now consider the proposed technic. Any procedure on the pylorus and duodenum is greatly facilitated by incising the lateral attachment of the duodenum and rolling it medially until the inferior vena cava is exposed (Kocher maneuver). This applies equally for resective and nonresective procedures. The Kocher maneuver is therefore carried out after completion of the vagotomy and before any dissection of the stomach is started. Once a resective procedure and its extent are decided upon, this step is completed according to the individual surgeon’s technic, but at no time should tissuecrushing clamps be applied to the duodenal wall. After closure of the lesser curvature side of

blood supply when a “lid” is fashioned

the stomach in the customary manner, an opening on the greater curvature should remain equal to the duodenal stoma with all excessively bulging mucosa carefully trimmed. To assure accurate placement of all sutures, those of the outer posterior layer are left long and only tied after the last stitch has been placed. On the posterior stomach wall they are of the customary seromuscular variety. However, to deal with the difficult, short, stiff duodenal cuff all stitches of the posterior outer layer on the “duodenal site” take their bite in the thickened capsule of the pancreas with the needle emerging at the level where the duodenum touches upon the pancreas. (Fig. 3.) The posterior stomach wall is now brought into apposition with the duodenum and the sutures are tied. The posterior anastomotic line is completed with a tier of interrupted No. 3-O chromic catgut sutures which pass through the full thickness of the stomach and duodenum. (Fig. 4.) The advantage of this technic is obvious: a duodenal stump length of just the thickness of its wall is sufficient to accomplish a safe, solid posterior anastomotic suture line. The serosa of the stomach is in contact with the duodenal wall, which in this area is not covered by serosa. Having released the stomach from its fixed position at the esophageal hiatus during and with vagotomy and having brought the duodenum towards the midline with the Kocher maneuver beforehand, the surgeon will find no tension on the suture line. Rather, the stomach remains firmly anchored to the pancreatic capsule in complete apposition with the duodenum. The anastomosis is completed anteriorly with a through and through layer of interrupted chromic catgut American

Journal of Surgery

Gastroduodenostomy DUODENAL

289

STUMP

LCER BASE

FIG. 3. Key stitch of proposed technic. After passagethroughseromuscularcoat of the stomach,it entersthe pancreaticcapsule distal to the ulcer base and emerges where the duodenum touches upon the pancreas. FIG.4. The completedposterioranastomosis. Left arrow indicates outer layer of “gastroduodenal”sutureline. stitches with the knots tied intraluminally and a seromuscular tier of No. 3-O silk. Here again one need not be concerned with the condition of the duodenal wall. No matter what its pliability, the stomach wall can be folded over without difficulties. The customary “angle stitch” on the lesser curvature side is considered important. A modification of this technic is easily applicable in the execution of a routine Billroth I operation with a normal duodenal cti. Here the majority of the stitches of the outer posterior layer enter the duodenal wall to include the muscularis. A few “anchor stitches” taking a “bite” in the fibrosed pancreatic capsule protect the suture line. (Fig. 5.) The foregoing technic was used during the past several years when a problem in closing the duodenum by other methods appeared to create an unsafe situation or when a catheter duodenostomy was the alternate choice. A review of our cases showed that it was used for this purpose on ten occasions. There was no mortality or morbidity pertaining to this techLCER

BASE

FIG. 5. Suggestedanchor stitch for a routine gastroduodenostomy. Vol. 11.5.March1968

nit. Its modification is being used for all gastroduodenostomies. SUMMARY A technic is described for the treatment of the “difficult” duodenal stump. It uses the stomach remnant with its rather healthy tissue to “close” the duodenal stump, no matter how short its cti and to what degree the tissue texture had been changed by the underlying disease process. This technic eliminates an unsafe closure of the duodenum and a catheter duosenostomy with their associated mortality and morbidity. Its application in ten typical cases resulted in postoperative courses free of mortality and morbidity related to the gastroduodenostomy. REFERENCES 1. NISSEN,R. Local causes of mortality and early morbidityin gastroduodenalresectionsfor peptic ulcer. J. Internat.Co.%Surgeons,13: 549, 1950. 2. SXINUG,G. E. and CAVANNAGH, C. R. Analysisof morbidityand mortalityfollowinggastricsurgery for ulcer..Am./. &rg.,~lO4:224, 1962. - 3. HARVEY. H. D. ComDlicationsin hosDi& following pa& gastrectom;for pepticulcer: 1936to 1959. Sztrg.Gynec.b Obst.,117: 211, 1963. 4. RIJDKO, M. and PRICE,W. E. Duodenalstumpperforation. J. Oklahoma M. A., 58: 337, 1965. 5. ROSENBURG, S. A. and BUCHMAN, J. J. Duodenal closurein complicatedulcerwith penetrationand pancreaticulceration.Am. Surgeon, 32: 383,1966. 6. WELCH,C. E. Secondary operations upon the stomach after gastric resection for duodenal ulcer. VirginiaM. Montk., 94: 3, 1967. 7. PEARSON, S. C., MACKENZIE, R. J., and Ross, T. Use of catheter duodenostomyin gastric resec-

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tion for duodenal ulcer. Am. J. Surg., 106: 194, 1963. JORDAN, G. L., JR. Gastroenteric cutaneous fistula: tract occlusion for treatment. Arch. Surg., 88: 540, 1964. DE BAKEY, M. E. Yearbook of General Surgery 1964-65, p. 548. Chicago, 1965. Yearbook Medical Publishers, Inc. EDWARDS, L. W., EDWARDS, W. H., SAWYERS, J. L., GOBBEL, W. G., JR., HERRINGTON,J. L., JR., and SCOTT,H. W., JR. Surgical treatment of duodenal ulcer by vagotomy and antral resection. Am. J. Surg., 105: 352, 1963. HARKINS, H. N. Stomach and duodenum. In: Surgery, Principles and Practices, 2nd ed., p. 697. By Allen, J. G., Harkins, H. N., Moyer, C. A.,

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and Rhoads, J. E. Philadelphia, 1961. J. B. Lippincott Co. WARREN, K. W. and BRAASCH, J. B. Surgical treatment of duodenal ulcer. In: Surgical Practice of the Lahey Clinic. Edited by Caffell, R. B. Philadelphia and London,1962. W. B. Saunders Co. COPELLO, A. J. Practical closure of the duodenal stump. Surgery, 54: 713, 1963. NISSEN, R. Die Resektion des tiefsitzenden Duodenalgeschwueres. Zentralbl. Chir., 60: 483, 1933. WILMER, H. A. The blood supply of the first part of the duodenum. Surgery, 9: 679, 1941. NOER, R. J., DERR, J, W., and JOHNSTON, C. G. The circulation of the small intestine: an evaluation of its revascularization potential. Ann. Surg., 130: 608, 1949.

American Journal of Surgery