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Langenbeck's Archives of Surgery
Published in: Langenbeck's Archives of Surgery 8/2012

01-12-2012 | Original Article

Management of the difficult duodenal stump in penetrating duodenal ulcer disease: a comparative analysis of duodenojejunostomy with “classical” stump closure (Nissen–Bsteh)

Authors: Yogesh K. Vashist, Emre F. Yekebas, Florian Gebauer, Michael Tachezy, Kai Bachmann, Alexandra König, Asad Kutup, Jakob R. Izbicki

Published in: Langenbeck's Archives of Surgery | Issue 8/2012

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Abstract

Background

Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. “Classical” technique of closing a difficult duodenal stump (Nissen–Bsteh) has, up to now, not been compared with duodenojejunostomy (DJ) in larger patient sets. This also refers to the potential benefit of a gastric and biliary diversion under such conditions. The aim of the present study was to compare classical duodenal closure (CC) with DJ and to evaluate the impact of gastric and biliary diversion on postoperative outcome after surgery for penetrating, high-risk duodenal ulcer in a matched control study.

Methods

Out of 321 patients, treated for penetrating duodenal ulcer disease, the perioperative outcome of 62 DJ patients was compared with 62 patients undergoing CC matched for age, gender, biliary diversion, and the operating surgeon collective. A total of 70 patients, equally distributed between DJ and CC subsets, received temporary biliary diversion.

Results

Overall perioperative mortality was 10.5 %. However, DJ significantly reduced the mortality rate (4.8 %) associated with penetrating duodenal ulcer compared to CC (16.1 %, P < 0.04). The overall morbidity in DJ patients nearly equalled that in the CC group (P = 0.4). Differences in the prevalence of duodenal leakage rate between DJ (14.5 %) and CC (29 %) patients were of borderline significance (P = 0.05). Temporary biliary diversion was identified as a prognostic factor for closure consistency with lower duodenal leakage rates in both DJ (odds ratio 0.05, 95 % confidence interval 0.005–0.42) and CC patients (odds ratio 0.2, 95 % confidence interval 0.05–0.6). In contrast, gastric diversion performed in a subset of 35 DJ patients had no protective effect.

Conclusion

Duodenojejunostomy combined with temporary biliary diversion substantially improves perioperative outcome in management of penetrating duodenal ulcer.
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Metadata
Title
Management of the difficult duodenal stump in penetrating duodenal ulcer disease: a comparative analysis of duodenojejunostomy with “classical” stump closure (Nissen–Bsteh)
Authors
Yogesh K. Vashist
Emre F. Yekebas
Florian Gebauer
Michael Tachezy
Kai Bachmann
Alexandra König
Asad Kutup
Jakob R. Izbicki
Publication date
01-12-2012
Publisher
Springer-Verlag
Published in
Langenbeck's Archives of Surgery / Issue 8/2012
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI
https://doi.org/10.1007/s00423-012-0990-0

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