Exploring the neglected segment of the intestine: the duodenum and its pathologies

Intracorporeal linear‑stapled gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: Consideration of the intraoperative management of the duodenal wall between the transecting staple line and anastomotic staple line (Review)

The first part of the duodenum consists of the intraperitoneal segment, called the duodenal bulb, and the retroperitoneal segment. Regarding the blood supplying the duodenal bulb, which is the portion utilized in anastomosing the duodenum and remnant stomach following distal gastrectomy, the arterial pedicles branching off from the gastroduodenal artery are reported to reach the posterior wall first and then spread over the anterior wall, where they anastomose. When performing intracorporeal linear-stapled gastroduodenostomy following totally laparoscopic distal gastrectomy, the blood supply of the duodenal wall between the transecting staple line and anastomotic staple line needs to be considered because both transection of the duodenal bulb and the gastroduodenostomy are performed using an endoscopic linear stapler and the duodenal wall between the staple lines can be ischemic after the anastomosis. Since it needs to be decided intraoperatively whether this duodenal site is preserved or removed, the present review discusses the technical differences among several procedures for intracorporeal linear-stapled gastroduodenostomy, classifying them into two groups on the basis of the intraoperative management of this duodenal site. When this site is preserved, the blood supply of the duodenal wall needs to be retained with certainty. On the other hand, when this site is removed, the ischemic portion of the duodenal wall needs to be identified and removed. Furthermore, in both groups, an adequate anastomotic area needs to be secured. In conclusion, surgeons need to be familiar with the anatomical features of the duodenal bulb, including its blood perfusion and shape, when carrying out intracorporeal linear-stapled gastroduodenostomy.

Paroxysmal epigastric pain 30 years after abdominal trauma surgery-a case report

A 58-year-old male was admitted to the liver surgery ward of Peking Union Medical College Hospital as the result of recurrent cholangitis in the past six months. Preoperative abdominal CT and gastrointestinal radiography showed duodenal dilatation and reconstruction of gastrointestinal tract, which might be related to the laparotomy and hemostasis performed due to traffic accident 30 years ago. The operative method of that surgery might be the reason for the patient's choledocholithiasis and duodenal dilatation.

Superior mesenteric artery syndrome: Diagnosis and management

Superior mesenteric artery (SMA) syndrome (also known as Wilkie's syndrome, cast syndrome, or aorto-mesenteric compass syndrome) is an obstruction of the duodenum caused by extrinsic compression between the SMA and the aorta. The median age of patients is 23 years old (range 0-91 years old) and predominant in females over males with a ratio of 3:2. The symptoms are variable, consisting of postprandial abdominal pain, nausea and vomiting, early satiety, anorexia, and weight loss and can mimic anorexia nervosa or functional dyspepsia. Because recurrent vomiting leads to aspiration pneumonia or respiratory depression via metabolic alkalosis, early diagnosis is required. The useful diagnostic modalities are computed tomography as a standard tool and ultrasonography, which has advantages in safety and capability of real-time assessments of SMA mobility and duodenum passage. The initial treatment is usually conservative, including postural change, gastroduodenal decompression, and nutrient management (success rates: 70%-80%). If conservative therapy fails, surgical treatment (i.e., laparoscopic duodenojejunostomy) is recommended (success rates: 80%-100%).

Prenatal detection of gastrointestinal bubbles since early pregnancy: Clues to correct diagnosis

OBJECTIVE

To characterize gastrointestinal bubbles detected since early pregnancy and to describe corresponding diagnoses.

METHOD

A retrospective cohort review of all cases in which gastrointestinal bubbles were detected starting in early prenatal transvaginal scans at 14-17 weeks of gestation between the years 2007 and 2021. Sonographic features and data regarding associated anomalies, genetic abnormalities, and pregnancy outcome were evaluated.

RESULTS

Bubbles were detected in 23 of 27 073 early scans and a total of 31 394 scans. Diagnosis was available in 22 cases. Transient bubbles were detected in 10 cases and represented normal peristalsis. Fixed double bubble was detected in nine cases. Double-walled double bubbles represented duodenal duplications (three cases) and esophageal duplications (two cases). Simple cysts represented duodenal atresia (three cases) and a pancreatic cyst (one case). A triple bubble represented duodenal obstruction from Ladd bands in one case. Quadribubble was detected in two cases and represented jejunal atresia.

CONCLUSION

Prenatal detection of gastrointestinal bubbles can accurately diagnose physiological versus pathological upper gastrointestinal conditions. Transient bubbles are physiological. Fixed double bubbles might represent either duodenal atresia or esophageal/duodenal duplications when a double wall is demonstrated. Three or four bubbles might represent more distal intrinsic or extrinsic obstruction.

Surgical treatment of duodenal adenocarcinoma: ampullary vs. non-ampullary, short- and long-term outcomes

BACKGROUND

The aim of this study was to evaluate symptoms, diagnostic methods, short- and long-term outcomes of surgical treatment in patients with duodenal adenocarcinoma.

PATIENTS AND METHODS

A single center, retrospective, observational study of 52 consecutive patients with duodenal adenocarcinoma operated on with curative intent between 2006 - 2019. Duodenectomy as part of a hemipancreatoduodenectomy or total pancreatectomy procedure was performed for ADAC (ampullary duodenal/intestinal adenocarcinoma) or NADAC (non-ampullary duodenal adenocarcinoma).

RESULTS

Prevailing symptoms were obstructive jaundice in the ADAC group (P<0.0001) and bleeding in the NADAC group (P=0.005), with larger tumor size in patients with NADAC (P=0.001). Complication rate, morbidity and mortality were comparable. Primary total pancreatoduodenectomy predominated in the NADAC group, 16.6% vs. 2.9%, and salvage completion pancreatectomy in the ADAC group, 6% vs. 0%. Significant prognostic factors for OS were perineural invasion (P=0.006) and adjuvant chemotherapy (P=0.045) in the ADAC group, and for DFS the total number of resected lymph nodes (P=0.042) and lymph node ratio (P=0.031) in the NADAC group. Median OS is 21 months and 5-year survival 27.3% in the NADAC group and 41.5 months and 52% in the ADAC group.

CONCLUSION

Ampullary duodenal/intestinal adenocarcinomas are smaller than non-ampullary at diagnosis, with a higher rate of lymph node metastases, but with a better prognosis and long-term outcome in the presented cohort. Oral localisation of NADAC prevailed in the present cohort. Perineural invasion and postoperative oncological therapy are significant prognostic factors for OS in ADAC, but the total number of lymph nodes and lymph node ratio are significant prognostic factors for DFS in NADAC.