Management of the difficult duodenum

Systematic review of the significance of neutrophil to lymphocyte ratio in anastomotic leak after gastrointestinal surgeries

INTRODUCTION

The inflammatory response is thought to be a critical initiator of epigenetic alterations. The neutrophil to lymphocyte ratio (NLR), a biomarker of inflammation, is computed by dividing the number of neutrophils by the number of lymphocytes. The primary goal of this systematic review and meta-analysis was to evaluate the pre-operative NLR of gastrointestinal surgery patients who had an anastomotic leak (AL) in comparison to those who did not AL.

METHODS

We performed a comprehensive search for relevant papers published before May 4, 2022, using PubMed, Scopus, and Web of Science. Standardized mean difference (SMD) with a 95% confidence interval (CI) was pooled in meta-analysis to yield a summary estimate. We utilized the random-effects model to create pooled effects since we discovered a substantial heterogeneity level. For evaluating quality, the Newcastle-Ottawa scale (NOS) was implemented.

RESULTS

The research comprised 12 studies with a total of 2940 individuals who had GI operations, 353 of whom went on to develop AL. We discovered that patients who had GI surgeries and acquired AL had significantly higher NLR levels than those who did not (random-effects model: SMD = 0.75, 95% CI = 0.11-1.38, p = 0.02). Patients with AL showed significantly higher NLR levels than control group in retrospective studies (SMD = 0.93, 95% CI = 0.20-1.66, p=0.01) but not in prospective studies (SMD = - 0.11, 95% CI = - 0.65-0.43, p = 0.69), according to the subgroup analysis based on research design. Subgroup analysis based on ethnicity yielded that white patients with AL exhibited significantly higher NLR values than the control group (SMD = 1.35, 95% CI = 0.01-2.68, p = 0.04) but this result was not applied to East Asian patients (SMD = 0.14, 95% CI = -0.13-0.41, p = 0.29).

CONCLUSION

Our research suggests a potential association between preoperative NLR and postoperative AL. However, it is essential to acknowledge the variability in the findings, with significantly higher NLR levels observed in retrospective studies and among white patients, but not consistently replicated in prospective studies and among East Asian patients. Further investigations with larger and more diverse cohorts are warranted to validate these findings and explore potential factors contributing to the observed discrepancies.

Neutrophil/Lymphocyte Ratio as Predictor of Anastomotic Leak after Gastric Cancer Surgery

Introduction. Neutrophil/lymphocyte ratio (NLR) is known as a prognostic for the outcome of the patients with gastric cancer. As no definite risk marker for anastomotic leakage after gastric resection was identified, we investigated the possible role of NLR. Methods. Peripheral blood count for neutrophils and lymphocytes was done at the patient’s admission. We retrospectively evaluated 204 gastric cancer patients, who underwent gastric resection, comparing the values of NLR between the group of patients with anastomotic leakage and those without complications. Results. Using the ROC curve, we found the cutoff value of NLR, which permitted the comparison of the group with low NLR, presenting increased NLR. The cutoff value for NLR was 3.54. Between the two groups, we could observe statistically significant differences in developing fistula (p < 0.01) and complications leading to death (p < 0.025). The odds ratio for patients with NLR greater than 3.54 to develop anastomotic leak was 17.62, compared to those with lower NLR. Conclusion. Peripheral blood NLR proved to be a predictor for anastomotic leakage.

Distal Duodenogastrostomy or Proximal Jejunogastrostomy in the Management of Ultra-Short Bowel

Inflammatory bowel disease, vascular disease, volvulus, adhesions, or abdominal trauma may necessitate extensive small-bowel resection resulting in an ultra-short distal duodenal or jejunal stump. If this distal duodenal or short jejunal stump is too short for stoma creation and bowel continuity restoration is hazardous or not possible at all, a distal duodenogastrostomy or proximal jejunogastrostomy in combination with drainage of the stomach is an option to prevent stump leakage. Although successful, this distal duodenogastrostomy has been described only in very few patients and in older records. We reintroduced this technique and describe a recent series of patients that confirms its usefulness in certain conditions. The technique of the distal duodenogastrostomy or proximal jejunogastrostomy with gastric drainage was used for the management of the difficult distal duodenum stump in five critically ill patients undergoing extensive bowel resection. Four patients with small-bowel ischemia and one patient suffering from perforating Crohn's disease and small-bowel volvulus were treated  successfully. The gastrostomies were subsequently converted to a duodenotransversostomy (in two patients) or the patients underwent small-bowel transplantation (two patients). One patient still has a jejunogastrostomy just after the duodenal-jejunal transition. In all five patients, the distal duodenogastrostomy or proximal jejunogastrostomy in combination with gastric drainage functioned well up to restoration of bowel continuity. In one patient, distal duodenogastrostomy and transabdominal gastric drainage functioned well for 5 years. No anastomotic leakage occurred. This procedure provides a feasible solution for an ultra-short bowel at emergency laparotomy. It enhances the surgical armamentarium and provides treatment options for these patients that were perhaps previously deemed unsalvageable.

Gastroduodenal and pancreatic surgeries: indications, surgical techniques, and imaging features

This review article focuses on gastroduodenal and pancreatic surgeries with the goal of identifying radiologic findings that translate to important surgical considerations. The topics covered include partial gastrectomy with reconstruction techniques, total gastrectomy, pancreaticoduodenectomy, and pancreaticojejunostomy. Indications, contraindications, surgical techniques, and postoperative imaging are described within each of these topics. Knowledge of these surgical techniques is extremely helpful for the interpreting radiologists to identify expected postoperative anatomy and related complications that would remain clinically relevant to our surgical colleagues and direct timely patient management.

Novel jejunoduodenostomy technique for prevention of duodenal stump blowout following gastrectomy

INTRODUCTION

Many patients undergo gastrectomy every year with a risk of duodenal stump blowout. We compared the conventional surgical techniques with a new and simple method of reconstruction to prevent this complication.

METHODS

We reviewed the medical records of all the patients who underwent gastrectomy from 2002 to 2013 (total or partial distal gastrectomies with Billroth II, Roux-en-Y, and our new technique of reconstruction) in Shohada Tajrish University hospital, Tehran, Iran.

RESULTS

A total of 179 patients were eligible for the study: 101 had undergone the new technique (study group) and 78 had undergone the conventional methods (control group). There were three cases of duodenal stump blowout, all in the control group (4 %, P<0.05). One was fatal (1 %). The post-operative hospital stay was significantly shorter in the study group (8.93 vs. 11.51 days, P<0.05).

DISCUSSION

Our results show that this new technique can effectively prevent duodenal stump blowout. Other advantages of this technique include the maintenance of physiological passage of food and a safe route for future diagnostic and therapeutic endoscopic interventions.

CONCLUSIONS

We present a simple technique that eliminates the risk of duodenal stump blowout. Randomized controlled trials are necessary to confirm our findings.

Delayed duodenal stump blow-out following total gastrectomy for cancer: Heightened awareness for the continued presence of the surgical past in the present is the key to a successful duodenal stump disruption management. A case report

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Duodenal stump disruption is not a surgical anachronism, because it still remains one of the most dreadful postgastrectomy complications.

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Postgastrectomy duodenal stump disruption poses an overwhelming therapeutic challenge.

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Historical surgical sense and familiarity with the various well established methods for the treatment of duodenal stump disruption can provide to the surgical team the ability to successfully manage this devastating complication.

INTRODUCTION

Duodenal stump disruption remains one of the most dreadful postgastrectomy complications, posing an overwhelming therapeutic challenge.

PRESENTATION OF CASE

The present report describes the extremely rare occurrence of a delayed duodenal stump disruption following total gastrectomy with Roux-en-Y esophagojejunostomy for cancer, because of mechanical obstruction of the distal jejunum resulting in increased backpressure on afferent limp and duodenal stump. Surgical management included repair of distal jejunum obstruction, mobilization and re-stapling of the duodenum at the level of its intact second part and retrograde decompressing tube duodenostomy through the proximal jejunum.

DISCUSSION

Several strategies have been proposed for the successful management post-gastrectomy duodenal stump disruption however; its treatment planning is absolutely determined by the presence or not of generalized peritonitis and hemodynamic instability with hostile abdomen. In such scenario, urgent reoperation is mandatory and the damage control principle should govern the operative treatment.

CONCLUSION

Considering that scientific data about duodenal stump disruption have virtually disappeared from the current medical literature, this report by contradicting the anachronism of this complication aims to serve as a useful reminder for gastrointestinal surgeons to be familiar with the surgical techniques that provide the ability to properly manage this dreadful postoperative complication.

Repair of gastric defects with an equine pericardial patch

PURPOSES

The objective of this study was to test the efficacy of an equine pericardial patch for repairing full-thickness defects of the stomach wall.

METHODS

Circular defects, 1.5 cm in diameter, were created on the anterior wall of the stomach of 12 female New Zealand rabbits. The defects were repaired by an equine pericardial patch. After euthanasia at different time intervals (3 days to 8 weeks) a macroscopic evaluation of the abdominal cavity (including adhesion scoring), mechanical testing and a histological examination of the stomach were performed.

RESULTS

The animals survived the surgical procedure and underwent an uneventful recovery until euthanasia. None of the patches failed. Adhesions were observed in all animals and were significant in 3/12 animals. Bursting pressure testing indicated that the repair was durable and that adequate strength to prevent patch failure was achieved by the second week. A histological examination showed gradual narrowing of the perforation site by mucosal and limited muscular regeneration.

CONCLUSIONS

The equine pericardial patch was successfully used to repair a gastric defect in our experimental model, and it seems that it could have potential as a material suitable for further research concerning the repair of upper gastrointestinal defects.

Numerical and experimental analysis of factors leading to suture dehiscence after Billroth II gastric resection

The main goal of this study was to numerically quantify risk of duodenal stump blowout after Billroth II (BII) gastric resection. Our hypothesis was that the geometry of the reconstructed tract after BII resection is one of the key factors that can lead to duodenal dehiscence. We used computational fluid dynamics (CFD) with finite element (FE) simulations of various models of BII reconstructed gastrointestinal (GI) tract, as well as non-perfused, ex vivo, porcine experimental models. As main geometrical parameters for FE postoperative models we have used duodenal stump length and inclination between gastric remnant and duodenal stump. Virtual gastric resection was performed on each of 3D FE models based on multislice Computer Tomography (CT) DICOM. According to our computer simulation the difference between maximal duodenal stump pressures for models with most and least preferable geometry of reconstructed GI tract is about 30%. We compared the resulting postoperative duodenal pressure from computer simulations with duodenal stump dehiscence pressure from the experiment. Pressure at duodenal stump after BII resection obtained by computer simulation is 4-5 times lower than the dehiscence pressure according to our experiment on isolated bowel segment. Our conclusion is that if the surgery is performed technically correct, geometry variations of the reconstructed GI tract by themselves are not sufficient to cause duodenal stump blowout. Pressure that develops in the duodenal stump after BII resection using omega loop, only in the conjunction with other risk factors can cause duodenal dehiscence. Increased duodenal pressure after BII resection is risk factor. Hence we recommend the routine use of Roux en Y anastomosis as a safer solution in terms of resulting intraluminal pressure. However, if the surgeon decides to perform BII reconstruction, results obtained with this methodology can be valuable.

Early rupture of an ultralow duodenal stump after extended surgery for gastric cancer with duodenal invasion managed by tube duodenostomy and cholangiostomy

When dealing with gastric cancer with duodenal invasion, gastrectomy with distal resection of the duodenum is necessary to achieve negative distal margin. However, rupture of an ultralow duodenal stump necessitates advanced surgical skills and close postoperative observation. The present study reports a case of an early duodenal stump rupture after subtotal gastrectomy with resection of the whole first part of the duodenum, complete omentectomy, bursectomy, and D2+ lymphadenectomy performed for a pT3pN2pM1 (+ number 13 lymph nodes) adenocarcinoma of the antrum. Duodenal stump rupture was managed successfully by end tube duodenostomy, without omental patching, and tube cholangiostomy. Close assessment of clinical, physical, and radiological signs, output volume, and enzyme concentration of the tube duodenostomy, T-tube, and closed suction drain, which was placed near the tube duodenostomy site to drain the leak around the catheter, dictated postoperative management of the external duodenal fistula.

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

BACKGROUND

Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. "Classical" technique of closing a difficult duodenal stump (Nissen-Bsteh) has, up to now, not been compared with duodenojejunostomy (DJ) in larger patient sets. This also refers to the potential benefit of a gastric and biliary diversion under such conditions. The aim of the present study was to compare classical duodenal closure (CC) with DJ and to evaluate the impact of gastric and biliary diversion on postoperative outcome after surgery for penetrating, high-risk duodenal ulcer in a matched control study.

METHODS

Out of 321 patients, treated for penetrating duodenal ulcer disease, the perioperative outcome of 62 DJ patients was compared with 62 patients undergoing CC matched for age, gender, biliary diversion, and the operating surgeon collective. A total of 70 patients, equally distributed between DJ and CC subsets, received temporary biliary diversion.

RESULTS

Overall perioperative mortality was 10.5%. However, DJ significantly reduced the mortality rate (4.8%) associated with penetrating duodenal ulcer compared to CC (16.1%, P < 0.04). The overall morbidity in DJ patients nearly equalled that in the CC group (P = 0.4). Differences in the prevalence of duodenal leakage rate between DJ (14.5%) and CC (29%) patients were of borderline significance (P = 0.05). Temporary biliary diversion was identified as a prognostic factor for closure consistency with lower duodenal leakage rates in both DJ (odds ratio 0.05, 95% confidence interval 0.005-0.42) and CC patients (odds ratio 0.2, 95% confidence interval 0.05-0.6). In contrast, gastric diversion performed in a subset of 35 DJ patients had no protective effect.

CONCLUSION

Duodenojejunostomy combined with temporary biliary diversion substantially improves perioperative outcome in management of penetrating duodenal ulcer.

Pancreas sparing duodenectomy as an emergency procedure

Background

The operative techniques to close extensive wounds to the duodenum are well described. However, postoperative morbidity is common and includes suture line leak and the formation of fistulae. The aim of this case series is to present pancreas sparing duodenectomy as a safe and viable alternative procedure in the emergency milieu.

Methods

Five patients underwent emergency pancreas sparing duodenal excisions. Re-implantation of the papilla of Vater or the papilla with a surrounding mucosal patch was performed in two patients. In one, the procedure was further supplemented with a duodenocholangiostomy, stapled pyloric exclusion and enterogastrostomy to defunction the pylorus. In another three patients, distal duodenal excisions were done.

Results

In four patients, an uneventful recovery was made. One patient died following a myocardial infarction. The surgery lasted meanly 160 minutes with average blood loss of approximately 500 milliliters. The mean hospital stay was 12 days. Enteral nutrition was introduced within the 20 hours after the surgery. Long term follow-up of all surviving patients confirmed a good outcome and normal nutritional status.

Conclusion

Based on the presented series of patients, we suggest that pancreas-sparing duodenectomy can be considered in selected patients with laceration of the duodenum deemed unsuitable for surgical reconstruction.

Computer simulation of flow and mixing at the duodenal stump after gastric resection

AIM: To investigate the flow and mixing at the duodenal stump after gastric resection, a computer simulation was implemented.

METHODS: Using the finite element method, two different Billroth II procedure cases (A and B) were modeled. Case A was defined with a shorter and almost straight duodenal section, while case B has a much longer and curved duodenal section. Velocity, pressure and food concentration distribution were determined and the numerical results were compared with experimental observations.

RESULTS: The pressure distribution obtained by numerical simulation was in the range of the recorded experimental results. Case A had a more favorable pressure distribution in comparison with case B. However, case B had better performance in terms of food transport because of more continual food distribution, as well as better emptying of the duodenal section.

CONCLUSION: This study offers insight into the transport process within the duodenal stump section after surgical intervention, which can be useful for future patient-specific predictions of a surgical outcome.

A life-saving but inadequately discussed procedure: tube duodenostomy. Known and unknown aspects

OBJECTIVE

The most successful method of managing the difficult duodenum, including the stump leakage, has been the tube duodenostomy technique, but it has not gained wide acceptance and is rarely used. The purpose of this study is to describe the details of the procedure for indication, technical approach, and postoperative care.

METHODS

During the period from 1998 to 2006, a tube duodenostomy was performed in 31 patients for possible insecure duodenal stump closure during gastric resection, postoperative duodenal stump leakage, duodenal leak after primary closure of duodenum for perforation or injury, or anostomotic leak after choledochoduodenostomy. All of the tube duodenostomies were performed through the open end of the duodenum. We also inserted a T-tube into the common bile duct in 19 of 31 patients (61.2 %) with tube duodenostomy.

RESULTS

A tube duodenostomy was performed in the primary operation in 15 of 31 patients. None of those 15 patients required a second operation, and there were no leaks and no deaths. Among the larger group (31 patients), there was one (3.2 %) duodenal stump leak after tube duodenostomy, and it ceased spontaneously; one patient had a subhepatic collection after removal of the duodenostomy tube, and three patients had associated incisional infections. Two patients died; one after a myocardial infarction and the other from irreversible sepsis. The mean length of hospital stay was 26.9 days.

CONCLUSIONS

We conclude that tube duodenostomy is a simple, effective, and safe method to prevent rupture of an insecure duodenal stump or to treat the leakage from the duodenal stump or primary repair on the duodenum.