Management of the difficult duodenal stump in penetrating duodenal ulcer disease: a comparative analysis of duodenojejunostomy with "classical" stump closure (Nissen-Bsteh)

[Potential risk to patient safety by discontinuation of production of classical T-drains? : Nationwide survey in Germany and statement of the surgical working group for liver, gall bladder and pancreatic diseases (CALGP) of the German Society for General and Visceral Surgery (DGAV)]

The revision of the medical device regulation (MDR) legislation by the European Union and supplementations by the member states has been implemented for good reasons but causes dramatic side effects. It is no longer allowed to produce some rarely used medical devices by various manufacturers that have been successfully used for decades. Before production, a new application to the MDR would be necessary, which is not a realistic business case for companies producing rarely used devices. This problem currently relates to the Kehr T‑drain made from soft rubber or latex that has been in use since the late nineteenth century. A surgically placed T‑drain, although rarely necessary nowadays, is still in use worldwide for special indications in an attempt to avoid severe complications. These special indications include complex hepato-pancreato-biliary (HPB) procedures and perforations of the upper gastrointestinal (GI) tract where T‑drains may be used to secure the hepatojejunostomy or to create a stable fistula. The HPB working group (CALGP) of the German Society of General and Visceral Surgery (DGAV) provides a statement from a surgical perspective on this matter after a survey of all its members. Politics should be very careful not to generalize when implementing useful new regulations at a European and national level. Established and comprehensible treatment concepts should not be restricted and exemption permits should be quickly granted in these cases because the discontinuation of these niche products may lead to potential patient safety issues and even fatalities.

Duodenal stump leakage. Lessons to learn from a large-scale 15-year cohort study

BACKGROUND

Duodenal stump leakage is a challenging condition causing significant morbidity and mortality. The aim of this study is to identify the risk factors associated with duodenal leak and advocate modification to prevent the incident.

METHODS

A retrospective cohort study was performed to include patients who had gastrectomy with excluded duodenum in a single surgical centre in the period of Jan 2003-March 2017. Analysis of associated factors was performed. Patients with duodenal leak were further analyzed and the treatment strategy was reviewed.

RESULTS

During the study period, 678 patients had gastrectomy with excluded duodenum. 502 patients had elective gastrectomy and 176 patients had emergency gastrectomy. 52 patients had subsequent duodenal stump leakage (7.7%). The existence of duodenal ulcer, intra-operative contamination, lower pre-operative haemoglobin and duodenostomy were the independent associated factors for duodenal leak.

CONCLUSION

This is the largest cohort in studying associated factors regarding duodenal leak in both emergency and elective gastrectomy. The independent associated factors were identified. We advocate a conservative approach for duodenal leak with adequate drainage, nutrition and antibiotics.

The selective use of laparoscopic repair is safe in high-risk patients suffering from perforated peptic ulcer

BACKGROUND

The use of laparoscopic repair for perforated peptic ulcer (PPU) was shown to be safe and recommended in low-risk patients. However, whether the approach is safe to apply to high-risk patients is uncertain.

STUDY DESIGN

This was a retrospective study of all patients with PPU admitted between January 2002 and December 2012. The laparoscopy-first approach (LFA) was adopted as a routine for all patients. The outcomes of LFA for PPU were reviewed and assessed to determine if the approach was safe in high-risk patients.

RESULTS

Three hundred and seventy three patients that suffered from PPU were included into the study and 50.9% received laparoscopic repair. There was a significant increase in the number of operations performed yearly by the LFA (P < 0.001). 25.2% of the patients had a Boey score of ≥2. High-risk patients that received LFA suffered from larger ulcers (P < 0.001) with more severe contamination (P = 0.006) that required conversion (P = 0.002) when compared to the low-risk patients. When compared to open surgery, more high-risk patients in the open group had ASA grade ≥3 (P = 0.007) and suffered from mortality (P = 0.001). The only significant predictor to mortality in high-risk patients was ASA grade ≥3 (P = 0.014).

CONCLUSIONS

The adoption of LFA in patients suffering from PPU was associated with acceptable rates of mortality and morbidity. The approach could also be selectively adopted in patients with Boey score ≥2 provided their ASA grading is low and hemodynamically stable.