duodenal repair?

[nigthsurgeon]

Hi all,

I´ve  recently had 2 duodenal injury cases.
A adult with a crush injury that compromised 4th duodenal portion with a 
severe mesenteric vessels injury. What I did was: Repair mayor veins, resect 
crushed duodenum, stapled side to side anastomosis with remaining duodenum 
and jejunum, wich I moved from the original site transmesenterically to the 
rigth . Closed the pilorus with vicryl, placed a G tube, and performed a 
yeyunostomy for early feeding. (feb2, 2008) the patient did fine, hes back 
to work only with a little duodeno-gastric  bile reflux.
The other a 12 y/o kid fell from his bike hiting with the handle. from rural 
area came 5 days after the injury, with a bile peritonnitis, two, 2 cm 
injuries on the second portion of the duodenum., debrided the injuries and 
closed in 2 planes, chromic and silk, closed the pilorus, placed a G tube, a 
cholecistostomy tube, and a yeyunostomy tube for feeding. he is being feed 
by mouth now, and probably leaving the hospital this coming week end.
I think that defunctionalizing the injured duodenum is very important, tubes 
have always been fairly handy for this. If the remaining Intestine is 
healthy yeyunostomy feeding can be performed with comercial TEN , and 
followed with very fine blended food.


Porfirio Lango
General/Trauma Surgeon
Mazatlan Mexico

--------------------------------------------------
From: "Timothy Craig Hardcastle" <TimothyHar at ialch.co.za>
Sent: Tuesday, May 20, 2008 4:09 AM
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Subject: RE: duodenal repair?

> 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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