The American Journal of Surgery (2009) 198, 319 323

Clinical Surgery-International

Controlled tube duodenostomy in the management of giant duodenal ulcer perforationa new technique for a surgically challenging condition
Pawanindra Lal, M.S., D.N.B., F.R.C.S. Ed., F.R.C.S. Glasg.*, Anubhav Vindal, M.S., D.N.B., M.R.C.S. Ed., N.S. Hadke, M.S.
Department of Surgery, Maulana Azad Medical College (University of Delhi), and Associated Lok Nayak Hospital, New Delhi, India KEYWORDS:
Duodenal ulcer perforation; Giant duodenal ulcer; Omental patch repair; Triple-tube-ostomy Abstract BACKGROUND: Giant duodenal ulcer (GDU) perforation remains an extremely uncommon but a rather challenging condition to manage wherein routine surgical procedures are fraught with an extremely high incidence of failure and mortality. It therefore follows that this condition must be identied and managed differently at laparotomy than are most duodenal perforations. We describe a method by which to deal with this condition using triple-tube-ostomy. METHODS: In a prospective setting, 20 patients underwent surgery using the technique described in the article. During the same period, 20 patients with GDU perforation, who were managed in the conventional manner, were evaluated. The outcomes of the 2 groups were compared. RESULTS: The success rate was 100% in the study group compared with 30% in the control patients. CONCLUSIONS: Based on the ease of the technique and the high success of the procedure in our experience in this select group, we recommend this procedure for the management of GDU perforation as a safe, reliable, and easy technique to learn. 2009 Elsevier Inc. All rights reserved.

Duodenal ulcer perforation is a common cause of peritonitis and remains a well-known surgical emergency requiring prompt surgical intervention. Most duodenal ulcer perforations are .5 to 1.0 cm in size, and, in emergency setting, the classic pedicled omental patch repair described by Cellan-Jones has remained the gold standard of treatment.1 However, larger-size perforations and delayed presentations are not uncommon in Indian surgical practice.

* Corresponding author. Tel.: 011-91-11-22541555; fax: 011-9111-23235574. E-mail address: profplal@gmail.com Manuscript received May 27, 2008; revised manuscript September 23, 2008

Duodenal ulcer perforation 2 cm have been dened as giant duodenal ulcer (GDU) perforation. Postsurgical leakage is a well-known complication after closure of GDU perforation using conventional techniques.2,3 This is accompanied by high mortality and morbidity rates.4 6 Although there have been some reports of GDU perforation in small series, there is no consensus yet on the appropriate type of surgical intervention for this rare and dangerous condition. We describe a method by which to accomplish GDU perforation repair that is a modication of controlled tube duodenosotomy, which has been described for duodenal trauma.7 This procedure has been used for primary surgical treatment of GDU perforation and the outcomes compared with patients undergoing standard surgical procedure for

0002-9610/$ - see front matter 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.09.028

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closure of GDU perforation during the study period in the same institution. The present series is one of the largest single-institution prospective studies reported in the literature regarding GDU perforation.

Methods
During a 10-year period, 40 patients with GDU perforation were included in this study. Of these, 20 patients were treated in the rst investigators surgical unit using the new technique (study group), whereas another 20 patients who were treated with conventional surgery in other surgical units with documented ndings of GDU perforation by the operating surgeon, were treated as controls. In all patients, bowel perforation was diagnosed using standard set of blood and radiologic investigations conrming evidence of pneumoperitoneum. All patients were adequately corrected for uid decit, electrolyte imbalance, and acidosis before undergoing laparotomy.

Details of controlled-tube duodenostomy

After thorough lavage of the entire peritoneal cavity, the rst step in laparotomy is Kocherisation of the duodenum to decrease any tension at the repair site. In the setting of chronic inammation, this step employs a careful approach, starting farther laterally than usual to avoid serosal injury to the wall of second and third parts of duodenum. After adequately mobilizing duodenum, the next step is to freshen the edges of the perforation. Usually the edges of the duodenal perforation are ragged, and excision of 2 to 3 mm of the margin would tend to increase the size of the perforation. Excision is best done with scissors, removing 2 to 3 mm from the entire ulcer margin and ensuring healthy bleeding from the edges. This is followed by primary repair of the duodenal perforation using 2 0 polyglactin (Vicryl; Ethicon, Somerville, NJ, USA) sutures. Thick bites are taken on each side of the perforation (full thickness; 1 cm from the edge on each side) in a single layer and in an interrupted fashion, keeping knots on the outside. The step of Kocherization would enable tension-free approximation of the ulcer edges in even the most inamed duodenum. The next step is identication of the jejunum 15 cm distal to the duodenojejunal exure and passage of a tube through an antimesenteric enterotomy (Malecots or Foley catheter; size 20F) in a retrograde fashion into the junction of the second and third parts of duodenum. Another Malecots catheter, size 16F, is passed through an enterotomy 5 cm distal to the rst one in an antegrade manner into the jejunum as a feeding jejunostomy. The investigators prefer Malecots red rubber catheter to Foleys and prefer to trim the owers of the catheter so that only 2 remain. A third tube is an optional-tube gastrostomy, the function of which can be well served by a 16F or 18F nasogastric tube (Fig. 1). However, the advantage of tube gastrostomy is the depen-

Figure 1 Schematic line diagram showing placement of the various ostomies along with the steps of the procedure and the order in which they are performed. Step 1 Kocherization of the duodenum. Step 2 repair of the perforation after freshening its margins. Step 3 creation of a retrograde tube duodenostomy. Step 4 creation of a feeding jejunostomy. Step 5 creation of a tube gastrostomy (this can be replaced with a thick nasogastric tube).

dent and denite drainage of gastric contents and avoidance of the nasogastric tube, thereby decreasing respiratory complications. All of the tubes are xed using the Witzell technique. The portion of the jejunum bearing the retrograde duodenostomy and the 5-cm distal feeding jejunostomy is xed to the anterior abdominal wall at the sites where the ostomy tubes exit the wall using 2 0 silk sutures. All of the ostomy tubes exit from the left side of abdomen. Two large-bore drains (size 32F) are placed in the right subhepatic space and pelvis and taken out from the right side of abdomen. All tubes initially are kept unclamped to drain gastric, biliary, pancreatic, and enteral secretions. Daily total drain output is carefully measured, and uid and electrolyte replacement is performed as appropriate. Although the rectus sheath is closed with nonabsorbable no. 1 polypropylene suture, the skin of the abdominal wound is kept open electively to be closed in a delayed primary manner between the postsurgical days 4 and 9 depending on the status of the wound. Once bowel sounds return and the jejunostomy starts draining enteral uids (usually 48 to 72 hours), it is clamped for 24 hours, and the patient is monitored for adverse signs. If no abdominal distention occurs, jejunostomy feeds are started, initially with saline and then with a liquid diet, which is gradually built up to provide all calories enterally so that parenteral uids can be stopped. After 3 to 4 days after the start of jejunostomy feeding and provided the patient does not show any signs of intraabdominal leakage of intestinal contents and has moved his or her bowels, the nasogastric tube or gastrostomy (whichever of the 2 is used) is clamped and kept so for 2 days.

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Management of giant duodenal ulcer perforation

Table 1 Comparison of patient characteristics and outcomes in the two groups Parameter Age (y) 30 3050 50 Sex Male Female Size 23 cm 3 cm Surgery Preoperative tube drainage Tube duodenostomy Cellan Jones Graham Duration of peritonitis (h) 48 48 Preoperative morbidity Shock Septicemia Renal failure Respiratory infection Hospital stay (d) 15 15 to 20 21 to 25 26 to 30 30 30-day mortality Postoperative complications Intra-abdominal sepsis Wound infection Wound dehiscence Pneumonitis Recurrence of leakage Death Control group 3 14 3 15 5 15 5 5 20 18 2 5 15 14 15 3 8 0 0 0 2 5 13 12 16 15 12 14 13

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During this time, the duodenostomy tube remains unclamped and draining freely to keep the repair area decompressed. Large-volume drainage from the duodenostomy (ie, 1 to 3 L/day) is not unusual and should not cause alarm. If the output is less than this, tube blockage should be suspected and the tube ushed with saline. We suggest that a resident doctor ensure duodenostomy tube patency every 4 hours to 6 hours, the importance of which cannot be overemphasized. After the postsurgical day 7, the retrograde duodenostomy tube is clamped intermittently, and if a nasogastric tube has been used, it can now be removed. In contrast, if a tube gastrostomy has been fashioned, it remains clamped. The duodenostomy tube can be clamped after postsurgical day 9 or 10. The jejunostomy tube is also kept clamped except for feeding. If the patient has moved his or her bowels and does not vomit, oral liquids are started on postsurgical day 9 and are increased during the next 2 days. Thus, while the oral feeds are introduced, all 3 of the tubes (if a gastrostomy has been fashioned) remain in situ. If the patient tolerates oral liquids, the gastrostomy tube is the rst to be removed, and oral semisolid diet can be started. The retrograde duodenostomy tube is removed next after uneventful oral intake for 2 days. The feeding jejunostomy tube is removed last when it is certain that no nutritional supplementation will be required. The ostomy sites are managed by dry dressing in the usual manner. The removal of tubes may vary by 24 to 72 hours depending on the individual case. The patient can then be discharged between postsurgical days 12 and 16 days depending on his or her status.

Study group 1 16 3 16 4 12 8 6 20 0 0 4 16 15 15 2 9 12 6 1 0 0 1 4 8 2 8 0 1

Results
Forty consecutive patients with GDU perforation presenting in an emergency setting were included in this study during a period of 10 years. Twenty patients in the study group were treated using the technique described previously. The remaining 20 patients, who were treated using conventional surgery for GDU perforation repair, served as controls. Both of the groups were matched with respect to the patient demography and other features. The majority of the patients (75%) ranged in age from 30 to 50 years, whereas only 4 and 6 patients were 30 years and 50 years, respectively. Thirty-one patients (77.5%) presented after 48 hours of the onset of peritonitis. All the patients had 1 comorbid condition in the form of shock, septicemia, acute renal failure and/or respiratory infection at the time of presentation. All patients had perforations 2 cm, and 32.5% had perforations 3 cm (Table 1). Of the 20 patients in the control group, 18 underwent simple closure with pedicled omental patch (Cellan-Jones), and 2 underwent an omental patch repair (Graham). Of these, 6 patients underwent initial tube drainage of the peritoneal cavity under local anesthesia because of poor

general condition precluding a more denitive procedure. In the study group, 6 patients underwent initial tube drainage of peritoneal cavity before denitive surgery because of their poor general condition at the time of presentation. The remaining patients underwent surgery directly after resuscitation (Table 1). All patients had major or minor postsurgical complications ranging from wound infection to intra-abdominal sepsis, but the incidence of severe complications was greater in the control group. Fourteen patients in the control group had a failure of repair in the form of leakage, but none of the patients in the study group had leakage of perforation repair after the index procedure. Of the 14 patients in the control group with postsurgical leakage of perforation repair, 6 were managed conservatively with parenteral nutritional support and laparostomy wound dressings. Eight underwent re-exploration, including such procedures as duodenal exclusion,2 partial gastrectomy,1 gastric disconnection2 and classical triple-tube-ostomy,3 which were all performed by

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The American Journal of Surgery, Vol 198, No 3, September 2009 giant ulcer perforations or repair after releakage, the failure rates reported in literature are high.2,3,9,11 Therefore, various techniquessuch as partial gastrectomy,12 jejunal serosal patch,2,13 jejunal pedicle graft,14 free omental plug11 and gastric disconnection15 have been advocated for repair of perforation in such cases. Leakage after duodenal ulcer repair is not uncommon (2% to 10%) and is associated with high mortality (10% to 35%), which increases with delay in re-exploration.5,6,16 Various procedures have been advocated keeping in mind the friability of tissues during re-exploration. Cranford et al advocated gastric disconnection with truncal vagotomy, antrectomy, and triple-tube-ostomy and managed 4 patients successfully using these techniques.15 Recently, a novel technique using pedicled rectus abdominis muscle ap was described for repair of postsurgical leakage after duodenal ulcer perforation repair.17 However, as is clear, each of these procedures not only prolongs the surgical time but also requires a high degree of surgical expertise, which may not be available in the emergency setting. Moreover, some patients are already in a morbid condition after leakage. In addition, each of these procedures carries a degree of morbidity. None of these procedures is immune to the risk of postsurgical leakage, which has been the main concern against using omental patch for the repair of GDU perforation.2,3 Management protocols for GDU perforation have been discussed either as small series or as case reports with high morbidity and/or mortality.2,3,9 11,14,15 The present series of 40 cases of this rare entity stands out as one of the largest reported single-institution series for GDU perforation. Controlled-tube duodenostomy as a surgical procedure has been described classically for duodenal trauma and is specially designed for large tears in duodenum.7 The simplicity of the triple-ostomy (retrograde duodenostomy, feeding jejunostomy, and gastrostomy) as an emergency procedure cannot be overemphasized. The same principle has been used in our study as a primary modality of treatment of GDU perforation. This procedure, in addition to being easy to perform, involves key steps and procedures with which the general surgeon is well versed. It conforms to the basic surgical principle of doing the minimum harm to a sick patient in an emergency setting that will save the life. Also, with the availability of better antiulcer drugs, all patients might not require denitive ulcer surgery in the long run.18 We believe that the success of this procedure depends on several key steps in the technique, such as proper Kocherization of duodenum, which ensures tension-free repair, good vascularity of the duodenal ulcer site after adequate freshening of its edges, and a good size retrograde duodenostomy to be placed at the junction of second and third parts of duodenum, which should drain freely. Thus, the procedure relies mainly on keeping the duodenum empty and tension free by decompressing all of the uids that either enter or are secreted in the region. It is therefore of

an experienced surgeon of the rank of registrar or consultant. Ninety-ve percent of the patients in the study group stayed in the hospital for 12 to 20 days after surgery, and only 1 patient stayed 20 days. In contrast, all of the patients in the control group had a hospital stay 25 days, with 60% having a stay 30 days. In all, there were 13 deaths (65%) within 30 days of the rst surgery in the control group. In contrast, the only death in the study group occurred because of associated fulminant pulmonary tuberculosis leading to respiratory failure that was unresponsive to mechanical ventilation (Table 1).

Comments
Duodenal ulcer perforation remains a common surgical emergency in developing and developed nations of the world alike despite a decrease in elective surgery for duodenal ulcer disease. Factors such as old age, comorbid conditions, shock at presentation, large size of perforation, and delay in presentation and treatment have been identied as adverse factors in the management of this condition.4,8 Although the rst 24 hours after the onset of symptoms are usually considered as the ideal time when a radical denitive procedure may be considered in patients with hemodynamic stability and minimal contamination, none of our patients met this criteria. GDU perforation remains a distinct surgical entity with high rates of leakage and mortality. Unfortunately, this condition has remained underreported and, therefore, denite protocols for its management have not been formulated. Moreover, there is no consensus in published literature on the denition of what constitutes GDU perforation. Principally, any duodenal ulcer perforation that cannot be managed by the conventional methods of repair because of the size of the perforation and the extent of native tissue loss is to be considered as a special entity and should be managed in a different manner. Two related but different terms used in literature must not be used interchangeably: giant duodenal ulcer and giant duodenal ulcer perforation. Here we talk about the latter, for which various investigators have used different criteria, some dening GDU perforation as 1 cm2, some 2 cm9,10 and others 2.5 cm in size.11 However, a 2 cm is the criterion used by most of the investigators describing the entity of GDU perforation and also used by us in the present series. A size criterion of 2 cm also ensures that smaller perforations are not unnecessarily overtreated while at the same time ensuring that the larger atypical ones at risk of failure using the conventional techniques are not undertreated. GDU perforation is considered hazardous because of extensive duodenal tissue loss and surrounding inammation and edema, precluding simple closure using an omental patch.2,3 Although an omental patch remains an effective treatment for repair of small perforations, when used for

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323 We believe that the success of this procedure lies in the sound surgical basis on which the procedure is based. The procedure is safe, reliable, and easy to learn and perform for the average surgical trainee and trained surgeon alike.

paramount importance that all of the drains, especially the duodenostomy tube in the duodenum, drain copiously and freely. We recommend not accepting a dry drainage tube under any circumstance because this tube is in the region of the ampulla, which is a high output area. Blockage of a previously draining tube can be caused by a clot of thick gastric contents obstructing the eye of the tube, and this will require mechanical cleansing with forceful ushing. A decrease in quantity of the aspirate from this tube, which in our experience remains the life line for the patient, should never be attributed to uid decit because this is never the case. The success of the present surgery in managing this difcult condition is brought out in the present series where concomitantly performed conventional surgeries in a matched subset of patients were fraught with a high incidence of postsurgical leakage of repair and mortality. The fact that none of the patients in the study group had a failure of repair stands out in stark contrast to the published data in the world literature. Although postsurgical complications, ranging from mild wound infection to intra-abdominal sepsis and pneumonitis, were seen in the study group, the only death occurred because of pulmonary tuberculosis, which complicated pneumonitis and lead to respiratory failure. The low mortality rate in the present series (5%) is significantly less than that reported for this condition in the world literature. We believe that patients with GDU perforation are candidates for this procedure during the initial surgery itself. Late presentation, well-established peritonitis, and presence of a large duodenal ulcer perforation ( 2 cm) should alert the operating surgeon to the presence of GDU perforation. The suggested method of managing GDU perforation might appear to be a proscribed one. In patients with GDU perforation, an average hospital stay of 3 weeks to 4 weeks is acceptable considering the dismal results and complications associated with either the traditional repairs or alternative approaches15,17 described in the literature, both of which increase the hospital stay much beyond 3 to 4 weeks and at the same time also increase patient morbidity and mortality exponentially. Based on our experience in successfully managing this extremely challenging condition in the present series of 40 patients, we recommend controlled-tube duodenostomy for the primary and denitive management of GDU perforation.

References
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