A NEW SURGICAL TECHNIQUE FOR PREVENTION OF LEAKAGE AFTER DUODENAL REPAIRS

Abstract

Background: Duodenal injuries, due to their retroperitoneal location, are a diagnostic challenge to the surgeon; for this reason, they are identified in a late stage, and thus associated with increased morbidity and mortality. The diagnosis of duodenal injury requires a high level of suspicion. Delayed diagnosis and management of these injuries results in increased morbidity and mortality rates. It must be remembered that the retroperitoneal location of the duodenum usually precludes early detection of injury by physical examination, which is characterised by minimal findings. Signs of defence, abdominal rigidity and absence of bowel sounds indicate intra-abdominal injury and lead to a surgical procedure. There are many different surgical procedures based on injury complexity, one of which is the tube duodenostomy technique. Despite the advances in surgical technique, duodenal lesions are still associated with high morbidity and mortality rates. Purpose: The purpose of this presentation is to describe a new surgical technique in the management of duodenal injuries. Surgical Technique: The technique was performed on a patient, presented with Crohn’s disease together with intestinal tuberculosis, in the management of duodenal injury secondary to duodenocolic fistula and abscess during the postoperative follow-up. The patient was operated on due to invagination, intra-abdominal abscess and general condition deterioration. The second operation was performed because of contrast extravasation from the duodenum. Especially the third part of the technique, application of negative pressure through a tube enterostomy in order to prevent the accumulation of secretions and pressure increase in the duodenum, minimized the intra-duodenal pressure and decreased the risk of anastomotic dehiscence and fistula formation (Figure 1). For this purpose, continuous negative aspiration was performed with an aspiration cannula extended through the enterostomy tube during the first 14 days. The patient was recovered without any complications. Conclusion: The authors concluded that this new technique of “pyloric exclusion, the repair of the mucosal layer of the primary wound in the duodenum with a stapler and of serosa with vicryl, minimizing intra-duodenal pressure by applying negative pressure with the enterostomy tube” can be considered to be an alternative solution for duodenal injuries.