Duodenal Stump Leakage

Presented by Ri Supervisor: Dr 02/24/2003

Introduction

Duodenal stump: the portion of the duodenum not removed Leakage is the life threatening complication of Billroth II reconstruction Incidence: 1%~4% Mortality rate: < 5% currently

Billroth II Gastroenterostomy

Indications: acute perforation, massive hemorrhage Procedures:

Bilateral truncal vagotomy Hemigastrectomy Gastrojejunostomy

Figure of Billroth II

Causes of Duodenal Stump Leakage

Deep ulcer at posterior wall of duodenum Excessive use of suture Localized infection and sepsis Post-operative pancreatitis Obstruction of the afferent loop Parasites infection: very rare
Magyar Sebeszet, 53(1):25-6, 2000 Feb 5

Manifestations

Initial

Pain High fever and shock Mild pain, fever, leukocytosis Jaundice

Several days later

Diagnosis

Echo-guided aspiration CT-guided aspiration 99mTC-labeled HIDA scan

Medical Prevention

Sandostatin: long-acting analogue of

somatostatin Decrease the excretory function of liver, pancreas, and stomach Lowering of intracavitary pressure of duodenal stump Earlier closure of fistula
Klinicheskaia Khirurgiia, (9-10):78, 1997 8

Surgical Prevention-Nissens closure

The American Journal of Surgery, 162: 522-6, 1991

Surgical Prevention-Bancrofts closure

The American Journal of Surgery, 162:522-6, 1991

10

Surgical Prevention-Duodenostomy

11

Managements of Stump Leakage

Closing leaks primarily is uncommon Goals:

Create a controlled fistula to the skin Prevent stimulation of biliary and pancreatic secretions by food/chyme passing through the stomach

12

Methods of Management

Prompt and adequate closed-suction drainage of RUQ

Percutaneous radiologist-guided approach Operative drainage

NG tube decompression Feeding with jejunostomy Board-spectrum antibiotics

13

Thanks for Your Attendance!

Ref:
1. Maingots Abdominal Operations, 1997 2. Oxford Textbook of Surgery, 1994 3. Management of the Difficult Duodenal Stump, The American Journal of Surgery (162), P. 522~6 4. Postoperative insufficiency of duodenal stump sutures caused by Ascaris lumbricoides, Magyar Sebeszet. 53(1):25-6, 2000 Feb. 5. Use of sandostatin in the prevention of suture failure of the duodenal stump after resection of the stomach, linicheskaia Khirurgiia. (9-10):7-8, 1997.

14