We report the first case of rupture at the Duodeno-jejunal Junc- tion.Only one case of perforation at the DJ has been reported which was a spontaneous perforation in an 8 month old infant reported by L limi et al.1
Duodenal, especially Duodeno- jejunal Junction (DJ) perforation in is rare. Commonly, gastrointestinal perforation is seen as a result of trauma (blunt or penetrating), in- fection, volvulus, adhesions, intus -susception or strangulated hernia. The most common site of gastrointestinal perforation is the ileum followed by colon, stomach and oesophagus. Diagnosis of duodenal perforation poses a challenge, as its presentation is subtle, especially in those without trauma. Our patient was a victim of bullet injury, clinically he had abdominal pain and tendernees on palpation, associated CT findings of free air and free fluid in the abdomen [fig 1]. He was timely operated and we discovered his injuries intraoperatively. We confirm that double layer repair at the DJ with effective closure can ensure adequate management option for injuries to the DJ.
A young 38 years old male came to the emergency of our hospital with history of gun shot injury with an entry wound of about 1 cm over his left side of the chest just 1.5 cm below and lateral to the xiphoid process. There was no exit wound. The patient was not very ill looking but was in a lot of pain mainly over his abdomen & lower back. His initial BP was around 110/70 and Pulse was about 98 bpm with a good oxygen saturation. His chest examination revealed a normal air entry on both sides, abdominal examination revealed mild tenderness all over the abdomen with severe pain in the lower back. We report this case as the first case of Duodeno-jejunal Junction rupture after bullet injury as in literature only one case has been reported of spontaneous DJ perforation in an 8 month old infant .
We did Chest and abdomen CT scan, which revealed normal chest scan , but free air and free fluid in the abdomen, and the bullet at the level of L2, vertebra with commu- nited fracture of the said vertebrae [Fig 2,3].
The patient was taken to the Operating theatre where he under- went Laparotomy, which revealed large amount of recently eaten food material, on further inspecting we found a perforation in the anterior wall of stomach around 2 cm x 1.5 cm which was repaired in two layers after freshening the edges, we mobilized the greater omentum and opened the lesser sac to look for any other injury and we found posterior gastric perforation around 3 cm x 4 cm which was repaired in a similar manner. There was no pancreatic injury noticed. There was a rent in the mesentry and after following the same we found a near complete transaction at the DJ involving the around 70- 75 % of the circumference as seen in Figure (4 & 5). There was a non expanding retroperitoneal hematoma but all the other viscera was normal. The DJ was repaired primarily in two layers, and after that a leak test was done with methylene blue to confirm the integrity of repair which showed a minor leak at the corner, so 2 -3 sutures were reinforced and again a leak test did not reveal any leak, a nasogastric tube was inserted as low as the D2 and the abdomen was closed over two drains one at the site of DJ re- pair and other in the pelvis. On day 3 we removed the lesser sac drain. Patient remained in the ICU he was nil by mouth for 4 days we delayed orals until we assured that there are no signs of leak. On 5th day we did CT abdomen with oral contrast did not reveal any leak with distal run off of the contrast to the small bowel and no collection noticed as in. So he was started on oral fuid then progressively increased to soft diet, on 6th day the drains were removed subsequently. Later on the 10th day he was operated by neurosurgery, the patient was discharged, he has come for follow up once and is doing fine [fig 6].
The incidence of duodenal injuries varies from 3% to 5% of all trauma laparotomies. Most (80%) of these injuries are caused by penetrating trauma, with gunshot, stab, and shotgun injuries responsible for 75%, 20%, and 5%, respectively. Duodenal injuries cause morbidity in up to 65%, and an overall mortality rate was between 5.3% and 30%, but injuries to the duodenum itself are responsible for a mortality rate of approximately 10% [.3-5]. Throughout the years, surgeons have developed several innovative and temporizing procedures to both repair the wounded duodenum and prevent fistulization from repair breakdown. The first method of suture line protection was the ‘‘triple tube ostomy’’ described by Stone and Fabian. Despite its technical simplicity and encouraging initial results, reports from others have failed to show improved outcomes with this technique. Ivatury et al. Found an increased incidence of duodenal fistula and complications when duodenal decompression was used (Stone and Fabian’s ‘‘triple ostomy’’), and their current preference was to avoid them.
Procedures for complete diversion of the gastrointestinal stream were soon developed. Berne et al. excluded repairs by ‘‘diverticulizing’’ the duodenum. Although effective in diverting enzymatic secretions, the procedure is complex, is time consuming, and resects normal tissue in young, often healthy patients. Today, diverticulization is seldom performed. Vaughan et al.10 in 1977 described the first pyloric exclusion, but despite its technical simplicity and swiftness, the procedure entails a permanent alteration of the gastrointestinal tract with the construction of the gastrojejunostomy. Pyloric exclusion offers minimal advantage over adequate nasogastric drainage when primary duodenal repair is performed and is associated with increased operative time, an extra intestinal anastomosis, and gastric suture line ulcers.11-13 Postpyloric exclusion marginal ulceration occurred in approximately 10% of patients who underwent postoperative surveillance endoscopy.
Significant controversy exists regarding the best surgical treatment for complex penetrating duodenal injuries. Debridement and primary repair or resection and anastomosis are suitable for the majority of duodenal injuries, especially for penetrating injuries. The physiologic presentation of the patient is the most important factor in predicting mortality in patients with traumatic duodenal injuries.15,16 Ivatury et al. classified treatment according to the hemodynamic status of the patients and pointed out that in the hemodynamically unstable patient, a damage-control approach consisting of hemorrhage control, rapid sealing or resection of gastrointestinal perforations without establishing continuity, temporary abdominal closure, and ICU resuscitation should initially be performed and gastrointestinal tract integrity restoration should be accomplished in a second operation. In hemodynamically stable patients, lower-grade lesions of the duodenum, low-velocity penetrating wounds with no delay in diagnosis and treatment, simple primary repair is an adequate treatment for the majority of duodenal injuries.3,7,8 As seen in our patient optimal management was primary repair and was associated with shorter operative time and with simple and fast damage-control surgery and good postoperative recovery. The surgeon should be aware that treatment with a minimalistic approach, with only primary repair, may be ideal.4
Duodenal injuries are often associated with multiple major intra-abdominal vascular and solid organ injurie. These associated injuries compromise the patient’s hemodynamic status and quickly descends them into the triad of acidosis, hypothermia, and coagulopathy. Lengthy, complex procedures in these cases inevitably lead to poor outcomes. For these reasons, the principles of damagecontrol surgery come into play to manage organ-specific injuries. The management philosophy is the avoidance of complex reconstructive procedures but at the same time advocating necessary debridement and adequate drainage.17
The traditional treatment of a postoperative duodenal fistula is adequate drainage and control via an anterior laparotomy with or without drain placement and with or without an open abdomen/ temporary abdominal closure system. The retroperitoneal approach that has been previously described by Van Vyve et al.18 coined retroperitoneal laparostomy has also been used as an alternative drainage method for the management of postoperative blunt duodenal trauma complications, This approach allows a total exploration anddrainage of the duodenum and permits reexploration and removal of necrotic retroperitoneal secretions without the risk of intra-peritoneal cross-contamination.
Application of basic damage-control techniques for Penetrating Duodenal Trauma leads to improve survival and an acceptable incidence, primary repair of the perforation at the DJ is adequate enough surgical management in a fresh case of trauma.
Furthermore, the management of possible subsequent complications of initial damage-control management can be managed with the same philosophy of simplicity with acceptable outcomes. Retroperitoneal laparostomy is an effective means for treating a duodenal leak and associated extensive retroperitoneal abscess and should be performed sooner than later. On the basis of our findings, we believe that the general rule that ‘‘less is better’’ should be adopted for the management of all penetrating duodenal injuries.
Perforation of Duodeno-jejunal Junction in an 8-month-old Infant: A Management Challenge to a General Surgeon Med J Malaysia Vol 66 No 2 June 2011
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