Blunt abdominal trauma with duodenal dissection: A case report

We describe a new case of duodenal wound with complete transection in a 22-year-old patient following a motorcycle accident. He presented to the emergency room of the rural Regional Hospital of Edéa in Cameroon with a clinical picture of acute abdomen and post-trauma hemodynamic instability. A peritoneal puncture brought back an incoagulable blood. An exploratory laparotomy revealed a large hemoperitoneum mixed with food debris. A tear of the omentum and transverse mesocolon and a complete section of the third duodenum at the beginning of its free portion were observed. The surgeon performed emergency closure of both duodenal stumps and performed an isoperistaltic lateral gastrojejunal bypass. A transfer to a specialized center for a more anatomical continuity was considered, but the imminence of a humanitarian mission in the hospital prompted the surgeon to seize the opportunity of this mission for the reoperation. This surgical revision was performed on the fifth postoperative day. A resection of the distal duodenal stump and the adjacent jejunal segment including the anastomosis was performed. Continuity was restored by a mechanical duodenal-jejunal anastomosis. The patient was discharged on the 18th postoperative day. This type of lesion is difficult to manage in an emergency situation in a structure with limited technical resources. Unfortunately, surgeons treating polytraumatized civilians are encountering an increasing number of blunt duodenal wounds requiring laborious management.

A case report of percutaneous direct injection of N-butyl-2-cyanoacrylate (NBCA) to treat a pancreatic duodenal stump leak after a simultaneous pancreas and kidney transplantation

Background Simultaneous pancreas and kidney transplantation (SPK) is a treatment option for patients with end-stage renal disease due to type 1 diabetes mellitus. We report a patient with a refractory fistula due to leakage from the duodenal stump of the pancreas graft after an SPK with bladder drainage who was successfully treated with a percutaneous direct injection of N-butyl-2-cyanoacrylate (NBCA). Case presentation A 60-year-old female with a 33-year history of type 1 diabetes mellitus and a 10-year history of renal replacement therapy underwent an SPK in 2015. At the time of transplantation, an abdominal aortic aneurysm with a high risk of rupture was treated by a Y-graft replacement prior to the SPK. Bladder drainage of the pancreas graft was chosen to avoid a vessel graft infection. The patient’s postoperative course was uneventful. The patient was discharged on postoperative day 93 with good-functioning pancreas and kidney grafts. One and a half years after the operation, the patient was found to have acute graft pancreatitis and a leak from the duodenal stump of the pancreas graft due to a paralytic neurogenic bladder. The insertion of an indwelling catheter into the bladder and the endoscopic-guided insertion of a catheter into the graft pancreatic duct through the duodenum/bladder anastomosis did not result in the closure of the fistula. Therefore, NBCA was injected at the site of the leak point using CT-guided technique. The fistula was completely closed immediately after the injection, with no recurrences of leaks. Conclusions A percutaneous direct injection of NBCA is one of the treatment options to treat intractable fistulas.

Iatrogenic injury of duodenum: malady of a therapeutic misadventure

Endoscopic procedures are the front-runner of the management of bleeding duodenal ulcer. Rarely, surgical intervention is sought for acute bleeding, not amenable to endoscopic procedures. Oversewing of the gastroduodenal artery at ulcer crater by transduodenal approach is the most acceptable and recommended method of treatment. We describe a case of an intraoperative duodenal injury that occurred during an attempt to oversew the gastroduodenal artery after a duodenotomy, leading to an unsatisfactory and meagre duodenal stump. This case will highlight the intraoperative turmoil, postoperative complications and management of a series of anticipated but unfortunate events that have rendered us wiser in terms of surgical management of a bleeding duodenal ulcer.

Management of gastrojejunostomy leakage after emergency gastrectomy

Ulcer perforation remains a life-threatening disease, which can be treated in several surgical approaches, however in some cases an emergency gastrectomy is the only option. Emergency gastrectomy has been associated to high morbidity and local mortality rates, namely systemic complications, such as, duodenal stump leak, gastrojejunostomy leakage and intra-abdominal collections. The treatment of gastrojejunostomy leakage, is still generating controversy, despite nowadays, the conservative approach is preferred. We present a clinical case of a 62-years-old male patient, in which a gastrojejunal leakage occurred, after emergency gastrectomy due to an ulcer perforation. Computed tomography of the abdomen did reveal peritoneal liquid near duodenal stump and gastrojejunostomy with no oral extravasation. At 24th post-operatory day, the patient deteriorated and we decided to perform a laparotomy exploration. Identified and treated, 2 small leakages (6 mm each), on the anterior face of the gastrojejunal anastomosis, using directed fistulization with Pezzer catheters. The patient was kept under total parenteral nutrition followed by enteral feeding and anti-microbial therapeutic. At the consultation, Radiography with oral contrast and Computed Tomography Scan with intravenous and oral contrast showed no evidence of anastomotic leak or abscesses, showing the success of this therapeutic approach.

Duodenal Stump Reinforcement with Purse-string Suture in Distal Gastrectomy under Laparoscope Combined with Uncut Roux-en-Y Reconstruction in Patients with Gastric Cancer

Background: This study aimed to compare patient outcomes after laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction for gastric cancer between a group who underwent a duodenal stump reinforcement procedure and those who did not.Methods: Data from 233 patients with gastric cancer (GC) undergoing distal gastrectomy under laparoscope combined with uncut Roux-en-Y reconstruction were retrospectively investigated. Patients were divided into two groups. The non-reinforcement group (NR) underwent surgery from June 2014 to March 2015 with no reinforcement of the duodenal stump (n=54) and the reinforcement group (R) underwent surgery from April 2015 to June 2018 with reinforcement of the duodenal stump (n=179). In group R, the duodenum was divided using an endoscope-assisted linear stapler, which was reinforced by a purse-string suture along the duodenal staple line. Results: Duodenal stump leakage was observed in 2 patients from group NR (3.7%), while no duodenal stump leakage or fistula was detected in group R. In addition, no significant difference was observed in the patient characteristics between group NR and R.Conclusions: The incidence of duodenal stump leakage can be reduced by reinforcement with a purse-string suture.