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The problem of duodenal closure after gastrectomy for duodenal ulcer
The
Problem of Duodenal Closure after Castrectomy for Duodenal Ulcer
PHILIP COOPEK, M.D.,Providence,
From
the Surgical
Service of the Veterans
Hosvital. Providence. Rbode . of Surgery, Boston Universit> I
Island.
Rhode
Island,
AND DAVID V. PECOR.A, M.D.,Ray Brook,
Administration
The large ulcer involving the anterior wall of the first part of the duodenum presents a serious problem. The associated induration makes inversion of the duodenal wall ver! difficult. Closure may, however, frequently be accomplished if the duodenal stump is closed with interrupted Lembert or mattress sutures of siIk and these sutures are pIaced onIy partly through the thickness of the duodenal wall. The two;stage Finsterer type of resection has been employed when the uIcer was associated with considerable surrounding inflammatory reaction and induration. In recent years the use of a catheter in the duodenal stump has been employed as a temporary measure I,>WeIch” and Priestley and ButIer3 and has proved relatively satisfactory. The ulcer of the posterior wall of the first part of the duodenum frequently involves the duodenum to such an extent that after dissection an inadequate or unsatisfactory posterior duodena1 wall remains for the closure. It may be considerably edematous, indurated or estremeIy short. Again, the dissection breaking into the edge of the uIcer may show the absence of either a part of or the entire posterior duodenal wall to the edge of the ulcer and the surface of the pancreas. In a11 such situations, if the anterior duodenal wall is sufficiently pIiabIe, the closure can be accomplished in a simple manner without dissecting the duodenum from pancreatic tissue. This can be done with little fear of subsequent IocaI compIications. Nissen,’ has described a method of duodenal closure for this type of uIcer, utihzing both the proximal and dista1 edges of the ulcer by suturing the edges of the uIcer to the anterior wall of the duodenum in two layers with interrupted sutures. He employed a third layer of interrupted sutures through the capsule of the pancreas and the duodenum. With this method the anterior waI1 of the duodenum rested on the base of the ulcer. Some authors5--7 have
and the Devartment
School of Medicine,
New l.or/z
Boston,
Massucbusetts.
ARTIAL gastrectomy
is well established as a procedure for the treatment of peptic ulcer. However, there are differences in opinion as to the advantages of various points in technic, such as the placement of the jejunal loop anterior or posterior to the colon, and the comparative value of the Hofmeister or P6Iya types of anastomoses. The Billroth I procedure has been revived to some extent, but has limited value in the surgical treatment of the complicated duodenal ulcer. This presentation wilI be limited to the technical problems involved in the closure of the duodenal stump after partial gastrectomy for duodenal uIcer, with particular reference to a method of duodena1 closure developed by one of the authors (P. C.), and employed for the Iarge posterior wall ulcer of the first part of the duodenum. When the duodenal uIcer is limited in size and reIativeIy near the pyloric ring or in the second part of the duodenum, an adequate length of duodenum can be easily mobilized for the routine two- or three-layered closure. FrequentIy this is accompIished with an inner Connell suture of chromic catgut and an outer layer of interrupted Lembert or mattress sutures of No. oooo silk. A few additiona1 sutures of silk are used to approximate the soft tissues over the pancreas to the duodenum. The blood supply to the duodena1 stump must be adequateIy preserved, and the closure must be accompIished without undue tension. If the ulcer is near the common bile duct, and it appears that the dissection or the duodenal closure may compromise that structure, the insertion of a T-tube into the common bile duct, as recommended by Marshah,’ may be advisable.
P surgical
231
.-\wrican Journal
oJ Surgery,
Volume gr, February.
rodi
Cooper
and
Pecora
FIG. I. A, demonstration of the defect in the posterior duodena1 wall created by penetration of the dissection through the duodena1 waII at the proxima1 edge of the uker. B, transected duodenum and the absence of part of the posterior duodena1 waII to the edge of the uker shown. C, first Iayer of sutures. D, second Iayer of sutures. E, completed cIosure of duodenal stump.
reported various modifications of this type of closure. In those cases in which a pancreatic duct entered the base of the uIcer, Nissen recommended leaving the base of the uIcer uncovered by omitting the first row of sutures. The method to be described does not utilize the distaI edge, and usuaIIy omits the pIacing of sutures through the proximai edge of the uIcer. The technic is relatively simpIe and can be performed fairly rapidIy and safely, and with a minimum of dissection. In the surgica1 approach to the posterior waII duodena1 uIcer, the dissection of the duodenum is proceeded with in the usua1 manner. It is carried distaI to the gastroepiploic vesseIs and the right gastroepipIoic vesseIs are Iigated and cut. The right gastric vesseIs are aIso cIamped and cut. The position of the uIcer and the condition of the duodenum are carefuIIy evaIuated. If the position and size of the uIcer does not aIIow an ampIe and satisfactory posterior duodenal wall distal to it for the adequate standard open closure, the best method of duodenal closure is then determined. If the duodenal waII posteriorly is pIiabIe and in satisfactory condition to hold sutures of siIk, even though it is shortened, it may be utilized in the
cIosure which wiI1 be accompIished either with two Iayers of Lembert or mattress sutures of siIk. If the posterior wail is friabIe, edematous or excessiveIy thickened, the posterior dissection is carried down to the ulcer, and the posterior waII removed to the edge of the uIcer. (Figs. IA and B.) A satisfactory method is to continue bIuntIy freeing of the duodenum from the pancreas unti1 the uIcer is broken into intentionally. The posterior duodena1 waII bordering the uIcer edge IateraIIy is trimmed as indicated, and is preserved if it is in suitabIe condition for cIosure purposes. The anterior walI of the duodenum is trimmed adequateIy so that a redundant waI1 wiI1 not interfere with the subsequent cIosure. The foIIowing description refers to the duodenal cIosure totaIIy omitting a part of or the entire posterior waII in compIeting the cIosure. The first row of interrupted Lembert sutures of No. oooo siIk are placed as shown in Figure IC. There usualIy is no problem in placing these sutures near the edge of the uIcer, for as a ruIe there is some scarring in this area. The sutures shouId be pIaced superficiaIIy. The sutures on the duodenal side are pIaced through the seromuscuIar layers. After the first row of sutures 232
DuodenaI
CIosure after Gastrectomy
are tied, the second row is placed in a simiIar fashion. (Fig. ID.) At this time one may be beyond the indurated area in the pancreas and it may be advisabIe to place the sutures transversely, taking two or three bites of small amounts of tissue and then completing the suture on the duodenal side in the Lembert fashion. There need be no worry about the deep structures in the pancreas or the pancreatic tissue itseIf if these sutures are placed in the manner described. After the second layer of sutures are tied (Fig. II:), a third Iayer may be pIaced in a similar manner, or any neighboring fatty tissue used to cover the duodenal cIosure. Care must be taken to invert an adequate amount of duodena1 waI1 at the ends of the closure. Adequate bIood suppIy to the duodenal wail must be preserved, and the closure should be accomplished without undue tension. Some variations of this method wiII of necessity be employed, depending on the position and size of the ulcer, or i#nvoIvement of the upper or Iower border of the duodenum at the site of transection. The genera1 principles of the closure, however, remain unchanged. A specific factor which may interfere with the proper utilization of this method would be a thickened, scarred or edematous anterior \?;a11 which could not readily be inverted. In this situation, if an attempt has been made to cIose the duodenum and one is concerned, a smaI1 Foley catheter may be brought through the duodenal closure and the abdominal wall. The Foley bag is distended with 3 cc. of water, and the catheter can usually be removed safely in ten to twelve days. In 216 duodena1 cIosures folIowing gastrectomy for duodena1 ulcer performed at this hospital from July I, I 949 to March I, 1953, a two- or three-Iayer cIosure with interrupted silk sutures was employed in ninety-four patients. This method was used when the posterior duodenal wall was not considered adequate and safe for the application of a continuous catgut suture. In approximately forty of these patients the posterior wal1 was either penetrated intentionally at the edge of the uIcer and the waI1 above the ulcer excised, or the remaining posterior wall above the uIcer appeared so friabIe that it was considered advisabIe to excise it down to the Ieve of the pancreas to aIIow the closure to be accomplished without excessive tension. In this group the only compIication of 233
duodena1 stump closure was one subphrenic abscess which responded promptIy to drainage. By utiIizing the described method of duodenal closure, the posterior wal1 uIcer of the duodenum can be treated surgically in a safe and expeditious manner, and the number of gastroenterostomies, two-stage procedures and duodenal closures with catheter drainage, previousIy performed for this type of ulcer, can be considerably reduced. SUMMARY
The problem of closure of the duodenal stump after partia1 gastrectomy for duodenal uIcer has been discussed. Emphasis, however, has been placed on the surgical treatment of the posterior wall uIcer of the first part of the duodenum, and a simpIified approach to that problem presented. The method avoids unnecessary dissection which may traumatize the pancreas or common duct. The difficulties resuIting from dissection in this area have been discussed by MiIIbourn,x Warren9 and Dunphy.‘O Possible trauma to the pancreatic ducts or to the pancreatic bIood suppIy have been commented upon by these authors. The primary advantage of the described method is its simplicity and effectiveness. REFERENCES
I\~AKSHALL.,S. F. Surgical Practice of the Lahey Clinic. Philadelphia, 195 T. W. B. Saunders Co. 2. WELCH, C. E. Treatment of acute massive gastroduodenal hemorrhage. J. A. M. A., 141: I I IS1.
1’15% ‘949.
3. PRIESTLEY, J. T. and BUTLER, D. B. Duodenostomy: a method of managing the duodenal stump in certain cases of partial gastrectomy. Proc. Staff Meet., Mayo Clin., 26: 65-69, rg5 I. 4. NISSEK, R. Duodenal and JejunaI Peptic UlcerTechnic of Resection. New York, 1945. Grune B Stratton, Inc. 5. \~.~NGENSTEEN, 0. R. The problem of surgicaI arrest of massive hemorrhage in duodenal uIcer: the t,echnique of closing the duodenum. .SurgertT, 8: 275-288, 1940. 6. ~~cNEAL~, K. W. Problems with duodenal stump in gastric resections. Surgery, 12: 207 -215. 1942. 7. GKHAII, R. R. TechnicaI surgical procedures for gastric and duodenal uIcer. Surg., Gynec. 6’ Ok., 66: 269-287, 1938. 8. LIILLBOURN, E. On acute pancreatic affections following gastric resection for uIcer or cancer and possibitities of avoiding them. Acta cbir. Scan&ma., 98: 1-22, 1949. 4. WARREN. K. W. Acute nancreatitis
and oancreatic injuries following subtota1 gastrectomy. Surgwy, 29: 643-657, rg5r. 10. DC.UPHY, J. E. et a1. Acute postoperative pancreatitis. Neul England J. Med., 248: 445-451, ‘953.
Problem of Duodenal Closure after Castrectomy for Duodenal Ulcer
PHILIP COOPEK, M.D.,Providence,
From
the Surgical
Service of the Veterans
Hosvital. Providence. Rbode . of Surgery, Boston Universit> I
Island.
Rhode
Island,
AND DAVID V. PECOR.A, M.D.,Ray Brook,
Administration
The large ulcer involving the anterior wall of the first part of the duodenum presents a serious problem. The associated induration makes inversion of the duodenal wall ver! difficult. Closure may, however, frequently be accomplished if the duodenal stump is closed with interrupted Lembert or mattress sutures of siIk and these sutures are pIaced onIy partly through the thickness of the duodenal wall. The two;stage Finsterer type of resection has been employed when the uIcer was associated with considerable surrounding inflammatory reaction and induration. In recent years the use of a catheter in the duodenal stump has been employed as a temporary measure I,>WeIch” and Priestley and ButIer3 and has proved relatively satisfactory. The ulcer of the posterior wall of the first part of the duodenum frequently involves the duodenum to such an extent that after dissection an inadequate or unsatisfactory posterior duodena1 wall remains for the closure. It may be considerably edematous, indurated or estremeIy short. Again, the dissection breaking into the edge of the uIcer may show the absence of either a part of or the entire posterior duodenal wall to the edge of the ulcer and the surface of the pancreas. In a11 such situations, if the anterior duodenal wall is sufficiently pIiabIe, the closure can be accomplished in a simple manner without dissecting the duodenum from pancreatic tissue. This can be done with little fear of subsequent IocaI compIications. Nissen,’ has described a method of duodenal closure for this type of uIcer, utihzing both the proximal and dista1 edges of the ulcer by suturing the edges of the uIcer to the anterior wall of the duodenum in two layers with interrupted sutures. He employed a third layer of interrupted sutures through the capsule of the pancreas and the duodenum. With this method the anterior waI1 of the duodenum rested on the base of the ulcer. Some authors5--7 have
and the Devartment
School of Medicine,
New l.or/z
Boston,
Massucbusetts.
ARTIAL gastrectomy
is well established as a procedure for the treatment of peptic ulcer. However, there are differences in opinion as to the advantages of various points in technic, such as the placement of the jejunal loop anterior or posterior to the colon, and the comparative value of the Hofmeister or P6Iya types of anastomoses. The Billroth I procedure has been revived to some extent, but has limited value in the surgical treatment of the complicated duodenal ulcer. This presentation wilI be limited to the technical problems involved in the closure of the duodenal stump after partial gastrectomy for duodenal uIcer, with particular reference to a method of duodena1 closure developed by one of the authors (P. C.), and employed for the Iarge posterior wall ulcer of the first part of the duodenum. When the duodenal uIcer is limited in size and reIativeIy near the pyloric ring or in the second part of the duodenum, an adequate length of duodenum can be easily mobilized for the routine two- or three-layered closure. FrequentIy this is accompIished with an inner Connell suture of chromic catgut and an outer layer of interrupted Lembert or mattress sutures of No. oooo silk. A few additiona1 sutures of silk are used to approximate the soft tissues over the pancreas to the duodenum. The blood supply to the duodena1 stump must be adequateIy preserved, and the closure must be accompIished without undue tension. If the ulcer is near the common bile duct, and it appears that the dissection or the duodenal closure may compromise that structure, the insertion of a T-tube into the common bile duct, as recommended by Marshah,’ may be advisable.
P surgical
231
.-\wrican Journal
oJ Surgery,
Volume gr, February.
rodi
Cooper
and
Pecora
FIG. I. A, demonstration of the defect in the posterior duodena1 wall created by penetration of the dissection through the duodena1 waII at the proxima1 edge of the uker. B, transected duodenum and the absence of part of the posterior duodena1 waII to the edge of the uker shown. C, first Iayer of sutures. D, second Iayer of sutures. E, completed cIosure of duodenal stump.
reported various modifications of this type of closure. In those cases in which a pancreatic duct entered the base of the uIcer, Nissen recommended leaving the base of the uIcer uncovered by omitting the first row of sutures. The method to be described does not utilize the distaI edge, and usuaIIy omits the pIacing of sutures through the proximai edge of the uIcer. The technic is relatively simpIe and can be performed fairly rapidIy and safely, and with a minimum of dissection. In the surgica1 approach to the posterior waII duodena1 uIcer, the dissection of the duodenum is proceeded with in the usua1 manner. It is carried distaI to the gastroepiploic vesseIs and the right gastroepipIoic vesseIs are Iigated and cut. The right gastric vesseIs are aIso cIamped and cut. The position of the uIcer and the condition of the duodenum are carefuIIy evaIuated. If the position and size of the uIcer does not aIIow an ampIe and satisfactory posterior duodenal wall distal to it for the adequate standard open closure, the best method of duodenal closure is then determined. If the duodenal waII posteriorly is pIiabIe and in satisfactory condition to hold sutures of siIk, even though it is shortened, it may be utilized in the
cIosure which wiI1 be accompIished either with two Iayers of Lembert or mattress sutures of siIk. If the posterior wail is friabIe, edematous or excessiveIy thickened, the posterior dissection is carried down to the ulcer, and the posterior waII removed to the edge of the uIcer. (Figs. IA and B.) A satisfactory method is to continue bIuntIy freeing of the duodenum from the pancreas unti1 the uIcer is broken into intentionally. The posterior duodena1 waII bordering the uIcer edge IateraIIy is trimmed as indicated, and is preserved if it is in suitabIe condition for cIosure purposes. The anterior walI of the duodenum is trimmed adequateIy so that a redundant waI1 wiI1 not interfere with the subsequent cIosure. The foIIowing description refers to the duodenal cIosure totaIIy omitting a part of or the entire posterior waII in compIeting the cIosure. The first row of interrupted Lembert sutures of No. oooo siIk are placed as shown in Figure IC. There usualIy is no problem in placing these sutures near the edge of the uIcer, for as a ruIe there is some scarring in this area. The sutures shouId be pIaced superficiaIIy. The sutures on the duodenal side are pIaced through the seromuscuIar layers. After the first row of sutures 232
DuodenaI
CIosure after Gastrectomy
are tied, the second row is placed in a simiIar fashion. (Fig. ID.) At this time one may be beyond the indurated area in the pancreas and it may be advisabIe to place the sutures transversely, taking two or three bites of small amounts of tissue and then completing the suture on the duodenal side in the Lembert fashion. There need be no worry about the deep structures in the pancreas or the pancreatic tissue itseIf if these sutures are placed in the manner described. After the second layer of sutures are tied (Fig. II:), a third Iayer may be pIaced in a similar manner, or any neighboring fatty tissue used to cover the duodenal cIosure. Care must be taken to invert an adequate amount of duodena1 waI1 at the ends of the closure. Adequate bIood suppIy to the duodenal wail must be preserved, and the closure should be accomplished without undue tension. Some variations of this method wiII of necessity be employed, depending on the position and size of the ulcer, or i#nvoIvement of the upper or Iower border of the duodenum at the site of transection. The genera1 principles of the closure, however, remain unchanged. A specific factor which may interfere with the proper utilization of this method would be a thickened, scarred or edematous anterior \?;a11 which could not readily be inverted. In this situation, if an attempt has been made to cIose the duodenum and one is concerned, a smaI1 Foley catheter may be brought through the duodenal closure and the abdominal wall. The Foley bag is distended with 3 cc. of water, and the catheter can usually be removed safely in ten to twelve days. In 216 duodena1 cIosures folIowing gastrectomy for duodena1 ulcer performed at this hospital from July I, I 949 to March I, 1953, a two- or three-Iayer cIosure with interrupted silk sutures was employed in ninety-four patients. This method was used when the posterior duodenal wall was not considered adequate and safe for the application of a continuous catgut suture. In approximately forty of these patients the posterior wal1 was either penetrated intentionally at the edge of the uIcer and the waI1 above the ulcer excised, or the remaining posterior wall above the uIcer appeared so friabIe that it was considered advisabIe to excise it down to the Ieve of the pancreas to aIIow the closure to be accomplished without excessive tension. In this group the only compIication of 233
duodena1 stump closure was one subphrenic abscess which responded promptIy to drainage. By utiIizing the described method of duodenal closure, the posterior wal1 uIcer of the duodenum can be treated surgically in a safe and expeditious manner, and the number of gastroenterostomies, two-stage procedures and duodenal closures with catheter drainage, previousIy performed for this type of ulcer, can be considerably reduced. SUMMARY
The problem of closure of the duodenal stump after partia1 gastrectomy for duodenal uIcer has been discussed. Emphasis, however, has been placed on the surgical treatment of the posterior wall uIcer of the first part of the duodenum, and a simpIified approach to that problem presented. The method avoids unnecessary dissection which may traumatize the pancreas or common duct. The difficulties resuIting from dissection in this area have been discussed by MiIIbourn,x Warren9 and Dunphy.‘O Possible trauma to the pancreatic ducts or to the pancreatic bIood suppIy have been commented upon by these authors. The primary advantage of the described method is its simplicity and effectiveness. REFERENCES
I\~AKSHALL.,S. F. Surgical Practice of the Lahey Clinic. Philadelphia, 195 T. W. B. Saunders Co. 2. WELCH, C. E. Treatment of acute massive gastroduodenal hemorrhage. J. A. M. A., 141: I I IS1.
1’15% ‘949.
3. PRIESTLEY, J. T. and BUTLER, D. B. Duodenostomy: a method of managing the duodenal stump in certain cases of partial gastrectomy. Proc. Staff Meet., Mayo Clin., 26: 65-69, rg5 I. 4. NISSEK, R. Duodenal and JejunaI Peptic UlcerTechnic of Resection. New York, 1945. Grune B Stratton, Inc. 5. \~.~NGENSTEEN, 0. R. The problem of surgicaI arrest of massive hemorrhage in duodenal uIcer: the t,echnique of closing the duodenum. .SurgertT, 8: 275-288, 1940. 6. ~~cNEAL~, K. W. Problems with duodenal stump in gastric resections. Surgery, 12: 207 -215. 1942. 7. GKHAII, R. R. TechnicaI surgical procedures for gastric and duodenal uIcer. Surg., Gynec. 6’ Ok., 66: 269-287, 1938. 8. LIILLBOURN, E. On acute pancreatic affections following gastric resection for uIcer or cancer and possibitities of avoiding them. Acta cbir. Scan&ma., 98: 1-22, 1949. 4. WARREN. K. W. Acute nancreatitis
and oancreatic injuries following subtota1 gastrectomy. Surgwy, 29: 643-657, rg5r. 10. DC.UPHY, J. E. et a1. Acute postoperative pancreatitis. Neul England J. Med., 248: 445-451, ‘953.