OBJECTIVETo summarize the experience with duodenal perforations to determine a systematic management approach.

METHODSA total of 11 250 patients who received endoscopic retrograde cholangiopancreatography(ERCP) in The First People's Hospital of Hangzhou from January 2005 to December 2011 and 15(0.13%) patients developed duodenal perforation. The clinical data of these 15 cases were analyzed.

RESULTSThere were 6 males and 9 females. The age ranged from 45 to 87 years. Seven patients developed perforation after sphincterotomy of the duodenal papilla. Five patients perforated due to the endoscope, and 3 due to guide wire and net basket. All the patients presented varying degree of abdominal pain and distention. CT scan of the upper abdomen showed peripancreatic and retroperitoneal air or fluid. Diagnosis was confirmed in 7 patients using abdominal X-ray. Eight patients developed postoperative abdominal pain and distention, subcutaneous emphysema, and fever 3 hours to 5 days after surgery, and diagnosis was confirmed using plain abdominal X-ray or upper abdominal CT scan. Nine patients were managed conservatively, 4 of whom were diagnosed within 3 hours after perforation and were managed by endoscopic metal clip and nasobiliary drainage and no abdominal abscesses developed. The length of hospital stay ranged from 10 to 15 days. Five patients were diagnosed 10 hour to 5 days after perforation, of whom 2 had intestinal fistula, 4 had abscess, and one died, the length of hospital stay ranged from 15 to 105 days. Six patients were managed surgically, 4 received surgery within 4 to 8 hours after perforation and no abscess developed, and the length of hospital stay ranged from 18 to 21 days. The other 2 patients were operated at 24 hours and 30 hours after perforation respectively, one of whom had recurrent intra-abdominal bleeding after surgery and one died from intra-abdominal abscess and multiple organ failure.

CONCLUSIONSFor duodenal perforations related to ERCP, early diagnosis can be made by prompt intraoperative identification and postoperative CT scan. Endoscopic metal clip and nasobiliary drainage should be considered aside from surgical intervention.

Aged ; Aged, 80 and over ; Cholangiopancreatography, Endoscopic Retrograde ; adverse effects ; Duodenal Diseases ; diagnosis ; etiology ; therapy ; Female ; Humans ; Intestinal Perforation ; diagnosis ; etiology ; therapy ; Male ; Middle Aged ; Retrospective Studies

A 71-year-old male patient was readmitted to our hospital 1 month after discharge because of relapse of abdominal pain. He had been diagnosed with hepatocellular carcinoma (HCC) 1 year prior and had undergone repeated transcatheter arterial chemoembolization and radiotherapy. During the last hospitalization, he was diagnosed with a liver abscess complicated by previous treatments for HCC and was treated with intravenous antibiotics and abscess aspiration. Follow-up abdominal computed tomography revealed a liver abscess with a duodenal fistula, which was successfully treated with endoscopic Histoacryl injection into the fistula. Liver abscesses with duodenal fistulas rarely occur, but they are intractable and possibly fatal in patients with HCC. In the literature, they have frequently been managed only with abscess treatment without fistula management. We herein report the first case of a patient with a liver abscess complicated by a fistula between the duodenum and the abscess, which was treated with endoscopic Histoacryl injection.
Abscess/*complications ; Aged ; Carcinoma, Hepatocellular/radiotherapy ; Chemoembolization, Therapeutic/*adverse effects ; Cholangiopancreatography, Endoscopic Retrograde ; Duodenal Diseases/*etiology/therapy ; Enbucrilate/*administration & dosage ; Humans ; Intestinal Fistula/*etiology/therapy ; Liver Diseases/*etiology/therapy ; Male ; Radiotherapy/adverse effects

OBJECTIVETo summarize the nutritional supporting experiences in duodenal stump leakage after gastrectomy for gastric carcinoma and to increase the therapeutic level of duodenal stump leakage.

METHODSData of 18 cases of duodenal stump leakage after gastrectomy for gastric carcinoma in our hospital from January 1997 to December 2006 were analyzed retrospectively.

RESULTSAll the cases were treated with abdominal cavity drainage, continuous gastrointestinal decompression and parenteral nutrition combined with enteral nutrition. Sixteen cases received glutamine enrichment, 12 cases somatostatin infusion, 8 cases recombinant human growth hormone. Five patients healed within 21-30 d, 12 patients within 30-72 d. One case died of abdominal cavity hemorrhage and upper gastrointestinal hemorrhage 62 days postoperatively.

CONCLUSIONAbdominal cavity drainage, continuous gastrointestinal decompression, parenteral nutrition combined with enteral nutrition, intensive support with glutamine, somatostatin and recombinant human growth hormone are the important factors for the healing of duodenal stump leakage.

Adult ; Aged ; Duodenal Diseases ; etiology ; therapy ; Female ; Gastrectomy ; adverse effects ; Humans ; Intestinal Fistula ; etiology ; therapy ; Male ; Middle Aged ; Nutritional Support ; Postoperative Complications ; therapy ; Retrospective Studies ; Stomach Neoplasms ; surgery ; therapy

Endoscopic retrograde biliary drainage (ERBD) is useful for the palliative decompression of biliary obstruction. However, the complications of ERBD include cholangitis, hemorrhage, acute pancreatitis, obstruction of the stent, and duodenal perforation. Pressure necrosis on the duodenal mucosa by the stent may contribute to perforation. Although duodenal perforation following ERBD is very rare compared to other complications, it can result in a fatal outcome. Recent reports describe nonsurgical treatment for small gastrointestinal perforation with localized peritonitis and suggest that endoclipping may be appropriate in the management of a well selected group of patients with iatrogenic perforation. We describe a case of duodenal perforation secondary to ERBD that was successfully treated with approximating using endoclip and detachable snare.
Bile Ducts, Extrahepatic ; Biliary Tract Diseases/complications/surgery ; Cholangiopancreatography, Endoscopic Retrograde ; Drainage ; Duodenal Diseases/*diagnosis/etiology/therapy ; Female ; Gallbladder Neoplasms/diagnosis ; Humans ; Intestinal Perforation/*diagnosis/etiology/therapy ; Middle Aged ; Plastics ; Stents/*adverse effects ; Tomography, X-Ray Computed

Duodenal varices result from retroperitoneal portosystemic shunts that usually come from the pancreaticoduodenal vein and drain into the inferior vena cava. Because they are a rare but fatal cause of gastrointestinal bleeding, a prompt hemostatic intervention is mandatory. A 62-year-old man who had a history of excessive alcohol consumption presented with massive hematemesis and melena. Emergent endoscopy revealed ruptured varices with an adhering whitish fibrin clot on the postbulbar portion of the duodenum. Abdominal computed tomography demonstrated a cirrhotic liver with venous collaterals around the duodenum and extravasated contrast in the second and third portions. The collaterals originated from the main portal vein and drained via the right renal vein into the inferior vena cava. Endoscopic injection sclerotherapy with cyanoacrylate was successful in achieving hemostasis, and resulted in the near eradication of duodenal varices at a 6-month follow-up.
Cyanoacrylates/therapeutic use ; Duodenal Diseases/diagnosis/etiology/*therapy ; Duodenum/*blood supply ; Endoscopy, Gastrointestinal ; Gastrointestinal Hemorrhage/etiology/*therapy ; Humans ; Male ; Middle Aged ; Portal Vein ; Rupture ; Sclerosing Solutions/therapeutic use ; *Sclerotherapy ; Tomography, X-Ray Computed ; Varicose Veins/complications/*therapy

Complications associated with an intramural hematoma of the bowel, is a relatively unusual condition. Most intramural hematomas resolve spontaneously with conservative treatment and the patient prognosis is good. However, if the symptoms are not resolved or the condition persists, surgical intervention may be necessary. Here we describe internal incision and drainage by endoscopy for the treatment of an intramural hematoma of the duodenum. A 63-yr-old woman was admitted to the hospital with hematemesis. The esophagogastroduodenoscopy (EGD) showed active ulcer bleeding at the distal portion of duodenal bulb. A total of 10 mL of 0.2% epinephrine and 2 mL of fibrin glue were injected locally. The patient developed diffuse abdominal pain and projectile vomiting three days after the endoscopic treatment. An abdominal computed tomography revealed a very large hematoma at the lateral duodenal wall, approximately 10X5 cm in diameter. Follow-up EGD was performed showing complete luminal obstruction at the second portion of the duodenum caused by an intramural hematoma. The patient's condition was not improved with conservative treatment. Therefore, 21 days after admission, endoscopic treatment of the hematoma was attempted. Puncture and incision were performed with an electrical needle knife. Two days after the procedure, the patient was tolerating a soft diet without complaints of abdominal pain or vomiting. The hematoma resolved completely on the follow-up studies.
Drainage ; Duodenal Diseases/*diagnosis/pathology/surgery ; Endoscopy, Digestive System ; Female ; Gastrointestinal Hemorrhage/*etiology/therapy ; Hematoma/*diagnosis/pathology/surgery ; Humans ; Intestinal Obstruction/*etiology/therapy ; Middle Aged ; Tomography, X-Ray Computed

Acute esophageal necrosis (AEN) is a very rare disorder typically presenting as a diffuse black esophageal mucosa on upper endoscopy. For this reason, AEN is often considered to be synonymous with 'black esophagus'. The pathogenesis of entity is still unknown. We report a case of AEN with duodenal ulcer causing partial gastric outlet obstruction. A 53-year-old man presented with hematemesis after repeated vomiting. The upper gastrointestinal endoscopy revealed circumferential black coloration on middle 315 to lower esophageal mucosa that stopped abruptly at the gastroesophageal junction. Pyloric ring deformity and active duodenal ulceration with extensive edema was observed. After conservative management with NPO and intravenous proton pump inhibitor, he showed clinical and endoscopic improvement. He resumed an oral diet on day 7 and was discharged. In our case the main pathogenesis of disease could be accounted for massive esophageal reflux due to transient gastric outlet obstruction by duodenal ulcer and following local ischemic injury.
Acute Disease ; Duodenal Ulcer/drug therapy/etiology ; Endoscopy, Gastrointestinal ; Esophageal Diseases/complications/*diagnosis/drug therapy ; Esophagus/*pathology ; Gastric Outlet Obstruction/*complications/pathology ; Humans ; Ischemia/pathology ; Male ; Middle Aged ; Necrosis ; Proton Pump Inhibitors/therapeutic use ; Tomography, X-Ray Computed

With the rapid advancement of minimally invasive new technology, laparoscopic surgery and robotic surgery are now regarded as the main direction in surgical treatment for stomach cancers. Recent evidence has confirmed the safety and feasibility of laparoscopic surgery for early gastric cancer and advanced gastric cancer. However, gastrointestinal surgeons should pay more attention to complications after laparoscopic gastrectomy because of rich blood supply, complex tissue layers and lymph node metastasis. Common complications related to laparoscopic surgery are associated with laparoscopic instruments and operating, intra-abdominal bleeding, anastomotic leakage, anastomotic bleeding, pancreatic leakage, duodenal stump leakage, lymphatic leakage and so on. This article mainly focuses on the causes, prevention and treatment of the complications after laparoscopic gastrectomy.
Anastomotic Leak ; Duodenal Diseases ; Female ; Gastrectomy ; adverse effects ; instrumentation ; methods ; Humans ; Laparoscopy ; adverse effects ; instrumentation ; methods ; Lymphatic Metastasis ; Male ; Postoperative Complications ; etiology ; prevention & control ; therapy ; Robotic Surgical Procedures ; adverse effects ; instrumentation ; methods ; Stomach Neoplasms ; complications ; surgery

Duodenal injury is a serious abdominal organ injury. Duodenal fistula is one of the most serious complications in gastrointestinal surgery, which is concerned for its critical status, difficulty in treatment and high mortality. Thoracic and abdominal compound closed injury and a small part of open injury are common causes of duodenal injury. Iatrogenic or traumatic injury, malnutrition, cancer, tuberculosis, Crohn's disease etc. are common causes of duodenal fistula, however, there has been still lacking of ideal diagnosis and treatment by now. The primary treatment strategy of duodenal fistula is to determine the cause of disease and its key point is prevention, including perioperative parenteral and enteral nutrition support, improvement of hypoproteinemia actively, avoidance of stump ischemia by excessive separate duodenum intraoperatively, performance of appropriate duodenum stump suture to ensure the stump blood supply, and avoidance of postoperative input loop obstruction, postoperative stump bleeding or hematoma etc. Once duodenal fistula occurs, a simple and reasonable operation can be selected and performed after fluid prohibition, parenteral and enteral nutrition, acid suppression, enzyme inhibition, anti-infective treatment and maintaining water salt electrolyte and acid-base balance. Double tube method, duodenal decompression and peritoneal drainage can reduce duodenal fistula-related complications, and then reduce the mortality, which can save the lives of patients.
Abdominal Injuries ; complications ; Anti-Infective Agents ; therapeutic use ; Decompression, Surgical ; Digestive System Surgical Procedures ; adverse effects ; methods ; Drainage ; Duodenal Diseases ; diagnosis ; etiology ; prevention & control ; therapy ; Duodenum ; blood supply ; injuries ; surgery ; Enteral Nutrition ; Humans ; Hypoproteinemia ; therapy ; Intestinal Fistula ; diagnosis ; etiology ; prevention & control ; therapy ; Ischemia ; prevention & control ; Nutritional Support ; Parenteral Nutrition ; Postoperative Complications ; prevention & control ; therapy ; Suture Techniques ; Thoracic Injuries ; complications

Duodenal varix is a rare cause of hemorrhage in patients with portal hypertension, however their rupture is serious and often life threatening. Treatments for duodenal variceal bleeding include endoscopic procedures, surgery, or interventional radiologic procedures. We report a case of duodenal varices rupture in a 45-year-old man with alcoholic liver cirrhosis who presented with melena and dizziness. Emergent upper endoscopy revealed large nodular varices with a ruptured erosion on the top in the distal second portion of duodenum. Two consecutive injections with 1.0 mL of n-butyl-2-cyanoacrylate (Histoacryl; Braun-Melsungen, Germany) mixed with 1.0 mL of lipiodol (Laboratoire-Guerbet, France) were performed intravariceally and achieved successful hemostasis. This suggests that endoscopic injection sclerotherapy with histoacryl may be an effective therapeutic option for the control of ruptured duodenal variceal bleeding.
Duodenal Diseases/etiology/*therapy ; Duodenoscopy ; Duodenum/*blood supply ; Enbucrilate/*analogs & derivatives/chemistry/therapeutic use ; Gastrointestinal Hemorrhage/etiology/*therapy ; Humans ; Liver Cirrhosis, Alcoholic/complications ; Male ; Middle Aged ; Rupture ; Sclerosing Solutions/*therapeutic use ; *Sclerotherapy ; Tissue Adhesives/therapeutic use ; Tomography, X-Ray Computed ; Varicose Veins/complications/*therapy