Necrosis of the duodenum and a perforation towards the retroperitoneum - Forum

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bonjorno

Necrosis of the duodenum and a perforation towards the retroperitoneum - Ärzteforum

Post#1 »

Male,53 yo, operated one month before because of coronary cardiopathy, 3 bypasses, returns to Coronary Unit with acute massive upper digestive bleeding. Refers previous story of peptic ulcer disease, under Omeprazol, and massive ingestion of AINES because of cronic lumbago.

Requires 6 units of RC transfusion to keep his hemodinamic stable.

Panedoscopy : Antral erosive gastritis and active duodenal ulcer Forrest 2B.
Sclerotherapy is performed with adrenaline and monoethanolamine at usual doses.

As bleeding goes on,new sclerotherapy with same drugs is repeated.

Pt.refers upper abominal pain...Plain X ray plates show small quantity of air placed behind the duodenum.

CTscan informs duodenal perforation.

Operated through middle upper laparotomy, exploration reveals necrosis of the duodenum and a perforation towards the retroperitoneum.

A duodenopancreatectomy is performed with pancreatogastroanastomosis.

PO stormy, pancreatic fistulae, relaparotomized for cleansing ,is left widely open.

Ominous outcome, passed away 13 days after operation.

Would like to ask :

1.- Ever seen such a complication after sclerotherapy?

2.-Was the Whipple's operation a good choice considering the very poor condition of the pt.?

3.- What else could hae been done instead in order to save his life?


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Old surgeon

Re: Necrosis of the duodenum and a perforation towards the retroperitoneum - Ärzteforum

Post#2 »

The answer to the first 2 questions should be self-evident to all The simple answer to this 3rd question is to have managed it in the standard fashion widely established throughout the world--the massive bleeding was not going to stop, therefore surgery should have been done to stop the bleeding and take care of the ulcer diathesis in the simplest and fastest way possible, which is oversew of gastroduodenal artery thru a longitudinal duodeno- gastrotomy thru the pylorus, then a vagotomy and pyolroplasty. Your management was clearly non-standard--for some reason you seemed afraid to do the straightforward operation, thereby trading it for several units more bleeding and then an impossibly extensive operative procedure, thereby directly increasing this patient's chance of dying--in my view, directly contributing to this patient's death. What was the greater risk to the patient--an expeditious operation early on--at 4-6 units of blood--or 10-15 units of blood loss and a Whipple? Does this really need an answer? Sclerotherapy for active bleeding of a duodenal ulcer has very little if any role, and if used should only be a temporizing measure just to keep the patient alive long enough to get right to the OR--if this case does not prove the truth of that, nothing does.

Avicenna

Re: Necrosis of the duodenum and a perforation towards the retroperitoneum - Ärzteforum

Post#3 »

> 1.- Ever seen such a complication after sclerotherapy?
No I have not, though since it happens after variceal injection in the esophagus I suspect it can happen anywhere.

> 2.-Was the Whipple's operation a good choice considering the very poor condition of the pt.?
No a very aggressive operation in a situation like this.

> 3.- What else could hae been done instead in order to save his life?
Gastrojejunostomy and close what is lef of duodenum over a tube. I don't think anyting fancier is justified in this situation

canadian

Re: Necrosis of the duodenum and a perforation towards the retroperitoneum - Ärzteforum

Post#4 »

I posted a similar case about 1 month ago, with spontaneous retroperitoneal perforation (3/4 transection) of the duodenum due to non-steroidal anti-inflammatory drugs in a patient who was initially misdiagnosed and came in hypotensive. I did a vagotomy, pyloroplasty incorporating the 3/4 perforation. He had spontaneously mobilized the right colon up off the duodenum and pancreas from the inflammatory retroperitoneal process. He died after developing pancreatic fistula, respiratory failure, etc., etc., profound malnutrition (albumin about 1.2, profound hypomagnesemia, profound hypophosphatemia, etc.).

Answers I got re what to do if I ever see something like this again were to place tubes in stomach and duodenum, and essentially exclude the duodenum plus drain the retroperitoneal process (especially the pancreas). I suspect my poor patient would have died anyway, but will remember this simpler approach if I ever encounter another case like this.

bonjorno

Re: Necrosis of the duodenum and a perforation towards the retroperitoneum - Ärzteforum

Post#5 »

I think I have not been as clear as I expected to be or you are not in a mood of understanding the real problem.

Let's see :

1.- The general condition of the patient was so poor that we even did not think of performing any kind of surgery at the beginning.

2.- That's why sclerotherapy was performed...We knew that the pt would not tolerate major agressive attitudes, not even exploration and suture of the bleeding ulcer plus vagotomy and drainage at that moment.

3.- But the complication of sclerotherapy was established and we had to operate this very severely ill patient in order to try to save his life.

4.- And what did we found?...A necrotic duodenum with a perforation due to the repeated sclerotherapy...The chances were from one part to resect the duodenum and disconnect the area through a gastrostomy, a proximal yeyunostomy and try to divert the pancreatic secretions outside the abdo cannulating the Wirsung duct...Sounds queer,doesn't it?...From the other, the chance was to performed the Whipple's operation, what we did, with the disasterous result already mentioned.

5.- No way thinking in opening that necrotic, greenish, aperistaltic duodenum to perform any type of local hemosthasis...Had to be resected.

6.- Finally, facing same problem in another kind of patient, we might have act as you proposed, "in the standard fashion widely established throughout the world" but it happened to be, and that's what I wanted to point out and the reason for my question that this case was not a standard one.

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