Giant duodenal ulcers

How to manage difficult duodenal defects? Single center experience

Objectives

The aim of this study was to investigate the surgical treatment methods and outcomes of difficult duodenal defects due to perforation.

Material and Methods

Data of patients who had undergone surgery for difficult duodenal defect between January 2012 and November 2022 were collected. Duodenal defect size of 2 cm or more was defined as difficult duodenal defect. Characteristics of the patients, the etiology of perforation, American Society of Anesthesiology (ASA) scores, Mannheim peritonitis index (MPI), surgical treatment, need for re-operation, and morbidity and mortality were evaluated.

Results

Nineteen patients were detected. Etiology was peptic ulcer perforation in 12 (63.1%) patients, aortaduodenal fistula in 2 (10.5%), tumor implant in 2 (10.5%), cholecystoduodenal fistula in 1 (5.2%), endoscopic retrograde cholangio pancreatography (ERCP) in 1 (5.2%), and cholecystectomy related injury in 1 (5.2%) patient. The first surgical procedure was duodenoraphy + omentopexy in 8 (42.1%), Graham repair in 5 (26.3%), duodenal segment 3-4 resection and Roux-en-Y side to side duodenojejunostomy in 4 (21.0%), Roux-en-Y side to side duodenojejunostomy in 1 (0.5%), and 1 (0.5%) subtotal gastrectomy + duodenum 1st part resection + Roux-en-Y gastroenterostomy, cholecystectomy and external biliary drainage via cystic duct. Four patients who had previously undergone Graham repair (3) and duodenoraphy + omentopexy (1) required salvage surgery. As a salvage surgery; 1 end-to-side and 3 side-to-side Roux-en-Y duodenojejunostomies were performed. Overall, mortality occurred in 6 (31.6%) patients. High ASA score and MPI were considered as significant risk factors for mortality (p= 0.015, p= 0.002).

Conclusion

Primary repair techniques can be used in the surgical treatment of difficult duodenal defects when peritonitis is not severe and tensionfree repair is possible. Otherwise, duodenojejunostomy may be preferred as a fast, easy, and safe technique for both initial and salvage surgeries.

Peptic ulcer characteristics in oral opium and non-opium user patients with upper gastrointestinal bleeding

BACKGROUND/AIMS

Upper gastrointestinal bleeding (UGIB) is a frequent medical issue. The primary risk factors for bleeding peptic ulcers are Helicobacter pylori infection and non-steroidal anti-inflammatory drugs. The association between acute gastric/duodenal ulcer and opium use has been previously proposed; however, there is no available data on endoscopic findings of patients with acute UGIB who use opium.

MATERIALS AND METHODS

In the present descriptive cross-sectional study, endoscopic data of 50 consecutive patients with oral opium use and 50 consecutive patients without any opium use who were admitted for UGIB were recorded. The size (5-10 mm, 11-20 mm, or more than 20 mm), number (single, double, or multiple), and location of the ulcers (esophagus, gastric corpus including the fundus and body, antrum, angulus, or duodenum) were examined by endoscopy in both groups.

RESULTS

Three or more ulcers were observed in 46% and 16% of patients with oral opium use and without opium use, respectively (P-value = 0.001). The rate of giant ulcers (> 20 mm) was significantly higher in patients who used oral opium (40% vs. 12%; P-value = 0.007). Esophageal ulcers were also more common in oral opium users (30%) than non-users (8%) with UGIB (P-value = 0.01). Nevertheless, the location of the ulcers between the two groups generally was not statistically different.

CONCLUSIONS

This study has demonstrated that multiple, large peptic ulcers in GIB are potential complications of oral opium use. This could aid the needed modifications in the treatment protocol for these patients.

Liver Involvement by Perforated Peptic Ulcer: A Systematic Review

BACKGROUND AND OBJECTIVE

Liver penetration by a confined perforation of peptic ulcer is a rare but severe event. Its clinical and pathological features are unclear.

METHODS

In total, 41 qualified English publications were identified using the PubMed database and one in-house case.

RESULTS

Among the 42 patients, 20 patients had liver involvement by a perforated duodenal ulcer and 22 by a gastric ulcer. Among the 23 cases of known ulcer histology, 2 ulcers were malignant and were adenocarcinomas in the gastric remnant and the remaining 21 ulcers were confirmed as histologically benign (for frequency of malignancy in duodenal versus gastric ulcers, p = 0.48). The presence of hepatocytes was the clue of diagnosis for 19 cases. The median ages of the patients were 64.5 years (95% Confidence Intervals [CI] 53.40-71.90) for duodenal ulcer and 65.5 years (95% CI: 59.23-70.95) for gastric ulcer, respectively. The male to female ratio was 1.5:1 for duodenal ulcers and 2:1 for gastric ulcers. Patients with liver involvement of a perforated gastric ulcer were more likely to have a larger ulcer (median largest dimension, 4.75 cm versus 2.5 cm, p = 0.014). Female patients with liver involvement of a gastric ulcer were older than male patients (median age 72 versus 60 years, p = 0.045). There were no differences in gender, region (Asia, Europe, America versus others), use of non-steroidal anti-inflammatory drugs (n = 15), H. Pylori positivity (n = 10), possible history of peptic ulcer disease (n = 19) or mortality (n = 32) between duodenal and gastric ulcers.

CONCLUSIONS

Careful histologic examination, clinicopathological correlation, and immunohistochemistry are critical to establish the diagnosis and avoid misdiagnosing liver involvement as malignancy.

Emergent Repair of a Perforated Giant Duodenal Ulcer in a Patient With an Unmanaged Ulcer History

Giant duodenal ulcers (GDUs) are full-thickness disruptions of the gastrointestinal epithelium greater than 3cm in diameter. The significant size and disease chronicity lead to deleterious outcomes and high mortality risk if ulcer progression is not halted. While still prevalent in developing countries, GDUs are increasingly rare in industrialized nations. Here, we present the case of an 82-year-old woman with perforated GDU requiring emergent surgical intervention complicated by prior duodenal surgery requiring a previously unreported triple-layered omental patch. Discussion of this technique and novel approaches to GDU repair ensue.

The characteristics of 83 giant peptic ulcers in Chinese children: Evaluation and follow-up

BACKGROUND/AIMS

Giant peptic ulcers (GPUs) are detrimental for all patients, especially for children. However, few reports have described GPUs in children. This study aims to evaluate the characteristics of GPUs in Chinese children and to identify risk factors.

PATIENTS AND METHODS

We retrospectively analyzed patients at the Children's Hospital of Fudan University from April 2014 to August 2017. Patients with GPUs (>2.0 cm) were included in the study, and the clinical data, pathological characteristics and presence of Helicobacter pylori (H. pylori) infection were analyzed to evaluate the outcomes.

RESULTS

A total of 19208 children underwent gastroscopic examinations, and 83 patients with GPUs were enrolled. The mean age of onset for GPU patients was 9.7 ± 3.2 years(range, 1-15). The main complaints were abdominal pain (92.7%), anemia (53%), retching (45.8%), hematochezia (21.7%) and hematemesis (16.9%). With respect to the types of GPU, 68 patients (81.9%) had duodenal ulcers, and 15 patients (18.1%) had gastric ulcers. Compared to the group <6 years of age, the group ≥6 years was more susceptible to GPU (P < 0.05). Among GPU patients, 71.1% of cases were H. pylori (*) (59/83), and 16.9% (14/83) of patients were H. pylori (-). Compared to the H. pylori (-) group, the H. pylori (*) group showed inflammatory activity, atrophy and lymphoid follicular formation in the gastric mucosa (P < 0.05).

CONCLUSIONS

This study suggests that GPUs are strongly associated with H. pylori infection in Chinese children. Duodenal ulcers are the main type of GPU in patients older than 6 years. Appropriate diagnosis, treatment and follow-up are necessary for children with GPUs.

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.