Management of Difficult Duodenal Stump: VGH-Kaohsiung Experience

十二指腸潰瘍術後高難度殘端之處理：高雄榮總的經驗

張博閔(Po-Min Chang) ； 劉絮穎(Shiuh-Inn Liu) ； 莫景棠(King-Tong Mok) ； 周楠華(Nan-Hua Chou) ； 蔡正中(Cheng-Chung Tsai) ； 王炳惠(Being-Whey Wang) ； 葉名焮(Ming-Hsin Yeh) ； 陳玉佳(Yu-Chia Chen) ； 陳以書(I-Shu Chen)

《Formosan Journal of Surgery》 38卷5期 (2005/10) Pp. 230-237

https://doi.org/10.29833/FJS.200510.0003

摘要

近二十年來，隨著消化性潰瘍的內科治療的長足進步，消化性潰瘍接受選擇性手術治療的病人數目有了明顯的減少。然而因為消化性潰瘍引起之併發症，例如潰瘍穿孔、出血及胃出口阻塞，必須接受緊急手術治療之病患並沒有因此減少，反而有增加的趨勢。這些病患通常是慢性十二指腸潰瘍的患者，在接受緊急手術時，部分胃切除手術常是不可避免的選擇，然而這些十二指腸潰瘍往往因為較大的潰瘍及嚴重的瘢痕組織，增加術後十二指腸殘端縫合之困難程度及術後殘端滲漏的機會，而引起術後嚴重的併發症及死亡率。
本文回顧了高雄榮總十二年來因為十二指腸潰瘍接受部分胃切除手術之結果，從1990年11月到2002年七月，總共242位患者因為十二指腸引起之併發症接受了部分胃切除手術及Billroth-Ⅱ之重建手術，其中總共有33位發生了十二指腸殘端滲漏的併發症，比例為13.6%，242位患者中有85位被認為有困難處理的十二指腸殘端，這些病患有比較高的術後併發症及死亡率。我們把Nissen's手術方法作了一些調整，使用單層可吸收縫線由近而遠整層的縫合方式，有9位困難處理之十二指腸殘端患者接受了此一縫合方式，沒有發生術後殘端滲漏的併發症。
我們認為對於困難處理之十二指腸殘端患者，這是一種簡便而安全的縫合方式，期能藉由本院之成果提供大家另一種縫合十二指腸殘端的方法，以避免在術後因為殘端滲漏而引起嚴重的併發症及死亡率。

並列摘要

Purpose: Although most peptic ulcers are currently treated successfully with medical treatment, some still need surgical intervention because of the complications caused by peptic ulcer disease, such as bleeding, perforation and obstruction. Partial gastrectomy with Billroth Ⅱ reconstruction is one of the commonly performed procedures. However, in those patients with a difficult duodenal stump, which is usually caused by chronic ulcer in the posterior wall of the duodenal bulb, the duodenal stump leakage rate is high if it is closed by a traditional method. Hence, alternative methods to the conventional duodenal closure have been reported for the management of the so-called ”difficult duodenal stump”, including Nissen's closure, Bancroft's closure and tube duodenostomy, etc. We report our experience in the management of the difficult duodenal stump and present our modified method of Nissen's closure.
Methods: A retrospective study was performed in reviewing patients with duodenal ulcers who underwent partial gastrectomy with Billroth Ⅱ reconstruction. Patient profile, incidence of difficult stumps, method for duodenal stump closure, post-operative morbidity and mortality were collected and analyzed. We modified Nissen's closure with an interrupted far-near whole layer suture for duodenal stump closure as an easier method.
Results: From November 1990 to July 2002, 242 patients underwent partial gastrectomy with Billroth Ⅱ reconstruction due to complications of duodenal ulcer. The overall duodenal stump leakage rate was 13.6% (n=33). Eighty-five patients were considered to have a difficult duodenal stump and had significantly higher leakage, complication and mortality rates. No stump leakage was noted in either Nissen's or our modified Nissen's closure.
Conclusions: Gastric resection is usually unavoidable at the management of complications of duodenal ulcer. Facing the difficult duodenal stump after gastric resection, especially in chronic and large-sized duodenal ulcers at the posterior wall of the duodenal bulb, our modified Nissen's closure is a good and safe alternative method for easy duodenal stump closure.

並列關鍵字

difficult duodenal stump ； duodenal ulcer ； partial gastrectomy ； Nissen's closure