Duodenal Reconstruction Following Extended Right Colectomy: the Pedicled Ileal Flap Technique

Excerpt

An 87-year-old woman with no prior history was admitted for urinary sepsis, abdominal pain, and fever that had persisted for 3 days. Physical examination demonstrated abdominal tenderness with a mass that had developed at the right side of the abdomen. Laboratory tests showed moderate kidney failure with sepsis. Ultrasonography revealed dilation of the right pyelo-ureteral junction due to a mass compressing the ureter. Computed tomography (CT) confirmed the mass to be 20-cm in size, involving the right colon and fistulized in the retroperitoneum, the right ureter, and the genu inferius. The mesenteric vessels, inferior vena cava, and pancreatic head were free of tumor. A locally advanced right colonic carcinoma was suspected. After fluid resuscitation, broad-spectrum antibiotics, and preoperative nutritional support, the patient was taken to the operating room. En bloc mobilization of the right colon and kidney allowed us to pediculate the tumor on its duodenal adhesions. The antipancreatic border of the genu inferius was resected in free margins, leaving an 8 × 3 cm duodenal defect (Fig. 1). A 10-cm pedicled ileal flap was then taken and opened on its antimesenteric border in order to patch the duodenal defect. Appropriate patch size was determined by adjusting the antimesenteric resection to the duodenal diameter. Microvascularization at the patch extremities was enhanced by cutting the mesentery wider than the digestive patch, preserving the marginal vessels at the flap extremities. The ileal patch was then sewed to the duodenum using two continuous layers of absorbable monofilament (Fig. 2). The flap was retroperitonized, isoperistaltic ileotransversotomy was performed, and the mesenteric windows were closed. No signs of flap infarction, anastomotic leakage, or pouchitis were detected on postoperative CT. The patient was discharged 2 weeks later. The histological report confirmed a colonic adenocarcinoma that had extended to the duodenum, resected in free margins.

…