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Two Centimeter D1–2 Anterior Perforation Presenting 24 Hours Later
Published in Savio George Barreto, Shailesh V. Shrikhande, Dilemmas in Abdominal Surgery, 2020
The patient was found to have 1.5 L of bilio-purulent fluid in the peritoneal cavity and the bowel was covered with fibrin exudates. There was a 2 cm perforation on the anterior wall of the junction of the first and second part of the duodenum. The margins of the perforation were unhealthy but the surrounding tissues were supple with minimal scarring. The margins were freshened and the perforation was repaired with an omental patch (Graham patch repair). Interrupted 3-0 atraumatic silk sutures were used for the repair (alternatively, Polydioxanone can also be used). The first suture was placed at the proximal margin of the ulcer with each bite around 5 mm from the ulcer edge. Both ends of the suture were held separately using artery clips which allowed the placement of subsequent sutures under direct vision, thereby avoiding the risk of incorporation of the posterior wall of the mucosa in the sutures. Subsequent sutures were placed 5 mm apart. A vascularized omental pedicle was placed over the defect in the duodenal wall and the sutures were gently tied over the omental pedicle. The sutures were neither too tight nor too loose.
Developments in the Diagnosis and Management of Cholecystoenteric Fistula
Published in Journal of Investigative Surgery, 2022
Ying-Yu Liu, Shi-Yuan Bi, Quan-Run He, Ying Fan, Shuo-Dong Wu
At present, the surgical treatment of CEF should be case-specific. We conducted 11 literature reviews on surgical treatment of CEF in the last five years, excluding patients diagnosed with gallstone ileus. A total of 58 cases of CEF (37 cases of CDF, 13 cases of CCF, 7 cases of CGF, and 1 case of CDF with CCF) were reported [31–41]. Patients underwent surgery laparoscopically in 53 cases, although 16 (30.1%) of those were converted to open surgery. Most cases underwent cholecystectomy with gastrointestinal tract repair, with or without T tube drainage. Duodenal repair mostly utilized a Graham patch. In patients with serious inflammation and adhesion of the gallbladder, subtotal cholecystectomy can be implemented. Fistulas that have been diagnosed preoperatively can be sutured using an endoscopic stapling device. Routine pathological examination or intraoperative frozen pathological examination should be carried out to detect premalignant or malignant lesions.
Perforation of the excluded segment without pneumoperitoneum following Roux-en-Y gastric bypass surgery: case report and literature review
Published in Acta Chirurgica Belgica, 2021
Maxime Peetermans, Jana Vellemans, Guido Jutten, Pieter D’hooge, Peter Delvaux, Frederik Huysentruyt, Anneleen Van Hootegem, Jos Callens, Olivier Peetermans
Due to the refractory pain, clinical and laboratory deterioration, and increased amount of free abdominal fluid, eventually a laparoscopic exploration was executed. A large amount of biliary ascites was encountered and removed by suction. Inspection of the duodenum revealed a perforation just distal to the pylorus. This perforation was closed using absorbable sutures and buttressed with omentum (Graham patch repair). A thorough abdominal lavage was done and a drain was left behind in the Morrison’s pouch. Postoperatively, amoxicillin clavulanic acid and a proton pump inhibitor, both given intravenously, were administered for five days. By the fourth postoperative day, the drain was removed and the day after the patient was fully recovered and was discharged with orally administered proton pump inhibitors. At 6 weeks’ follow-up, no complications or complaints were recorded.
Diagnosis and management of duodenal perforations: a narrative review
Published in Scandinavian Journal of Gastroenterology, 2019
Daniel Ansari, William Torén, Sarah Lindberg, Helmi-Sisko Pyrhönen, Roland Andersson
The main surgical treatment is simple repair of the perforation site. This can be performed as a primary closure with or without the addition of an omental patch. Alternatively, a pedicled omental flap (Cellan–Jones repair) [6] or free omental plug (Graham patch) [7] can be sutured into the perforation. Sutureless techniques have also been developed using a gelatin sponge and fibrin glue to seal off the perforation [55]. There seem to be no significant differences in terms of postoperative morbidity and mortality rates when comparing primary closure, omentopexy or tegmentation (without closure) [55–57]. Surgical repair can be performed either with conventional open surgery or with laparoscopy. The results of a recent meta-analysis including seven randomized controlled trials showed a significant benefit for the laparoscopic approach for the treatment of perforated peptic ulcer disease with a significant reduction in postoperative complications and hospital stay [58].