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Duodenal Stump Leakage

Presented by Ri 蔡川忠Supervisor: Dr 柯文哲

02/24/2003

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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

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Billroth II Gastroenterostomy

Indications: acute perforation, massive hemorrhage

Procedures: Bilateral truncal vagotomy Hemigastrectomy Gastrojejunostomy

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Figure of Billroth II

Magyar Sebeszet, 53(1):25-6, 2000 Feb 5

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

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Manifestations

Initial Pain High fever and shock

Several days later Mild pain, fever, leukocytosis Jaundice

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Diagnosis

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

Klinicheskaia Khirurgiia, (9-10):7-8, 1997 8

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

The American Journal of Surgery, 162: 522-6, 1991 9

Surgical Prevention-Nissen’s closure

The American Journal of Surgery, 162:522-6, 1991 10

Surgical Prevention-Bancroft’s closure

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Surgical Prevention-Duodenostomy

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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

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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

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Thanks for Your Attendance!

Ref:1. Maingot’s Abdominal Operations, 19972. Oxford Textbook of Surgery, 19943. Management of the Difficult Duodenal Stump, The

American Journal of Surgery (162), P. 522~64. 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.