Recent Trends In Management Of Patients with duodenal Perforation
Mohamed Ahmed Lotfy Elmaghraby;
Abstract
Duodenal perforation is a very serious complication that carries a high mortality rate especially when diagnosed late, but it is also infrequently injured due to its deep and relatively protected anatomical site by many nearby organs. Thus,duodenal perforation is rarely an isolated injury.
The time of diagnosis and the site of the injury are the most important prognostic factors. Primary repair of the must be reserved for injuries detected intra operatively or on the first postoperative day. Afterwards, direct suture could result in the failure of the procedure and more complex surgical management would be needed.
Duodenum may perforate due to traumatic or non traumatic causes. Traumatic perforation may be due to blunt injury: civil violence, road traffic or motor car accidents, seat belt injury, or penetrating injury: gunshot ,knife, within few hours.
Iatrogenic injury e.g. during ERCP,nephrostomy,open or laparoscopic operation. Non traumatic perforationmay be due to perforated peptic ulcer, perforated diverticulum.
Due to the retroperitoneal site of duodenum, the clinical diagnosis is difficult unless a high index of suspicion is maintained initial physical examination is usually generally negative and diagnostic delay is common. Mild pain is the most common symtom followed by signs of chemical peritonitis within few hours.
CT scan with both oral and intravenous contrast medium is of paramount importance and the development of multi detector row has improved the ability to examine and detect duodenal injuries.
With modern improvements in resuscitative care and acid suppressive therapy with PPI’s, a less aggressive operative approach has been shown to be effective in the management of gastroduodenal perforation.
Patients with low grade duodenal injuries, simple reair is adequate, patients with severe duodenal injuries may require more sophisticated repair if suture wound dehiscence is expected.
There are new protocols for management of duodenal perforation post duodenal ulcer and ERCP, also laparoscopic repair of duodenal is a trend that can be done concerning many cases of duodenal perforation under certain conditions.
Surgery may be performed either using open or laparoscopic techniques with equivalent outcomes. In a small subset of patients who present with minimal symptoms, contained perforations, and without systemic derangements, nonoperative management is an option, but requires close observation and a low threshold for surgical intervention if clinical deterioration occurs.
The time of diagnosis and the site of the injury are the most important prognostic factors. Primary repair of the must be reserved for injuries detected intra operatively or on the first postoperative day. Afterwards, direct suture could result in the failure of the procedure and more complex surgical management would be needed.
Duodenum may perforate due to traumatic or non traumatic causes. Traumatic perforation may be due to blunt injury: civil violence, road traffic or motor car accidents, seat belt injury, or penetrating injury: gunshot ,knife, within few hours.
Iatrogenic injury e.g. during ERCP,nephrostomy,open or laparoscopic operation. Non traumatic perforationmay be due to perforated peptic ulcer, perforated diverticulum.
Due to the retroperitoneal site of duodenum, the clinical diagnosis is difficult unless a high index of suspicion is maintained initial physical examination is usually generally negative and diagnostic delay is common. Mild pain is the most common symtom followed by signs of chemical peritonitis within few hours.
CT scan with both oral and intravenous contrast medium is of paramount importance and the development of multi detector row has improved the ability to examine and detect duodenal injuries.
With modern improvements in resuscitative care and acid suppressive therapy with PPI’s, a less aggressive operative approach has been shown to be effective in the management of gastroduodenal perforation.
Patients with low grade duodenal injuries, simple reair is adequate, patients with severe duodenal injuries may require more sophisticated repair if suture wound dehiscence is expected.
There are new protocols for management of duodenal perforation post duodenal ulcer and ERCP, also laparoscopic repair of duodenal is a trend that can be done concerning many cases of duodenal perforation under certain conditions.
Surgery may be performed either using open or laparoscopic techniques with equivalent outcomes. In a small subset of patients who present with minimal symptoms, contained perforations, and without systemic derangements, nonoperative management is an option, but requires close observation and a low threshold for surgical intervention if clinical deterioration occurs.
Other data
| Title | Recent Trends In Management Of Patients with duodenal Perforation | Other Titles | الطرق الجراحية الحديثة في معالجة مرضى ثقب الإثنى عشر | Authors | Mohamed Ahmed Lotfy Elmaghraby | Issue Date | 2015 |
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