duodenal repair?

Tue May 20 11:09:35 BST 2008

Karim

My understanding of the exclusion is for a simpler reasoning: Divert the stomach content (and food - I've fed them by mouth, done about 10 or so) into the small bowel DISTAL to the duodenum that prevents the stimulation of the excessive secretion of bile and pancreatic juice and this is SUPPOSED to them decrease the leak incidence, as there is less activated pancreatic juice.

My 2c

Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
Deputy director: Trauma Unit and Trauma ICU
Inkosi Albert Luthuli Central Hospital / UKZN
800 Bellair Road
Mayville, Durban

Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal

timothyhar at ialch.co.za 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Karim Brohi
Sent: 20 May 2008 11:04
To: Trauma &amp, Critical Care mailing list
Subject: Re: duodenal repair?

I've not been totally convinced by the pyloric exclusion.  It does presume
that all 'badness' comes from the stomach and that bile on the inside and
anything else sloshing around will not cause the same problem.  In my
(fairly limited) experience, duodenal leaks seem to be related more to the
presence of associated pancreatic (and possibly stomach) injury than what's
going on inside the duodenum.

If there is enough duodenal injury that after debridement it can't be
primarily repaired simply without tension/narrowing etc, I like a
end-to-side jejuinal Roux-en-Y up to the duodenal injury.  This allows you
not to 'skimp' on the debridement to achieve closure and ensures a good
blood supply.  Whether you should do this *and* a pyloric exclusion I have
no idea. (Of course this is during reconstruction, not damage control)

Karim

On Mon, May 19, 2008 at 7:39 PM, Ronald Simon <Traumamd at nyc.rr.com> wrote:

> The pyloric closure is temporary. Continuity will be restored in 2-3 weeks
> when the vicryl melts.
> Ron simon
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:
> trauma-list-bounces at trauma.org]
> On Behalf Of josemaya01
> Sent: Monday, May 19, 2008 12:53 PM
> To: trauma-list
> Subject: Ref:duodenal repair?
>
> I´m a little confused about this, you close the pylorus, but you don´t do a
> gastrojejunostomy, you place a G tube so the patient won´t have to bear
> with
> a NG tube, my question is how do you establish GI continuity, the pylorus
> is
> closed and nothing is supposed to travel through the duodenum, the G tube
> is
> in the stomach but does not reach to the jejunum, unless it is only for
> decompression.
> José Mayagoitia
>
>
> De : traumamd at nyc.rr.com
> Para : "Trauma &amp, Critical Care mailing list" trauma-list at trauma.org
> Copia : "Sise, Mike MD" Sise.Mike at scrippshealth.org
> Fecha : Sun, 18 May 2008 20:55:52 -0400
> Asunto : duodenal repair?
>
>
> > If i am nervous, i close the pylorus by opening the stomach, grabbing the
> pylorus with alice clamps and suture it closed with 2-0 vicryl. I like
> vicryl cause it goes away in 2-3 weeks and if the patient is better faster
> i
> get GI to go in and cut the sutures. I do NOT do a gastrojej but i place a
> G-tube so the patient doesnt have to sit with an NG tube. I beleive a
> gastrojej is just too invasive. Works fine for me for the 5 or so times i
> have done it.
> > ron simon
> > bellevue hospital center
> >
> > ---- "Sise wrote:
> > > Duodenal injuries - when to interrupt the pylorus and how to do it.
> > >
> > > Difficult duodenal repair for injury to the 4th portion not involving
> the pancreas and remote to the ampulla. Through and through 45 caliber
> gunshot wound suture closure but concern for the repair. Vena cava also
> repaired. 12 units of pRBCs, 12 of FFP and, a 12 pack of platelets.
> Planning
> a temporary abdominal wall closure. Do you interrupt the pylorus and, if
> so,
> how do you do it.
> > >
> > > Mike Sise
> > > San Diego
> > >
> > > "Scripps Information Security"
> > >
>
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