Routine versus selective upper gastrointestinal contrast series after omental patch repair for gastric or duodenal perforation.

BACKGROUND: There are no guidelines on the routine or selective use of contrast upper gastrointestinal series (UGI) after omental patch repair (OPR) of a gastric (GP) or duodenal perforation (DP). This study aims to elucidate whether the use of selective versus routine contrast study will lead to worse clinical outcomes. METHODS: A retrospective analysis of 115 (n = 115) patients with OPR of GP or DP was performed. Data were obtained from seven Florida Hospital campuses. Patients aged 18 and older from 2006 to 2016 were identified by ICD9 billing information. Patients were divided into two groups: UGI and no UGI. The UGI group was subdivided into selective versus routine. A selective UGI was defined as one or more of the following after post-operative day 3: WBC >12,000, peritonitis, fever >100.4 F, tachycardia >110 bpm on three or more assessments, and any UGI performed after POD 7. Perioperative symptoms, perforation location, size, abdominal contamination, laparoscopic or open, leak detection, length of stay, mortality, and reoperation within 2 weeks were also examined. RESULTS: No differences between the UGI group and non-UGI group relating to preoperative symptoms, leak detection, death, and reoperation rate were revealed. Differences in length of stay were found to be statistically significant with the UGI group and non-UGI at a median of 15.5 and 8 days, respectively. In the UGI subgroup, 20 of the 29 patients received selective studies. There were no statistical differences identified in leak detection, death, and reoperation. CONCLUSIONS: Rates of leak detection, reoperation, and death in patients with GP or DP repaired with omental patch utilizing an UGI study were not statistically significant. An increased length of stay was observed within the UGI group. There was no advantage demonstrated between a selective versus routine UGI; therefore, the use of selective UGI should be based upon clinical indications.

Perforated duodenal diverticulum case report.

INTRODUCTION: The duodenum is the second most common location of intestinal diverticula following the colon (Juler et al., 1969) [1]. Only 1-5% of patients with duodenal diverticula become symptomatic (Oukachbi, 2013) [2]. The least common but most serious complication of duodenal diverticula is perforation, which has a mortality rate of 20% (Oukachbi, 2013; Yin et al., 2001; Song, 2015; Schnueriger et al., 2008) [2-5]. PRESENTATION OF CASE: A 65year old female presented with sudden onset periumbilical and epigastric pain. Her abdomino-pelvic CT without contrast revealed a duodenal perforation of the anterior wall of the duodenum. After attempting a laparoscopic approach, the operation was converted to an open procedure to enhance visualization. A wide Cattell-Braasch maneuver was performed, mobilizing the duodenum, which revealed an inflamed diverticulum. Following a pyloric exclusion, a gastrojejunostomy and a Braun enteroenterostomy were completed in addition to a jejunostomy tube on the efferent limb. DISCUSSION: Clinical presentation of duodenal diverticula is vague and often varies. Although difficult to elucidate on imaging, the most sensitive exam to detect a duodenal diverticulum perforation is an abdominal CT scan, which can reveal thickened bowel wall, mesenteric fat stranding, and an extraluminal, retroperitoneal collection of air or fluid (Song, 2015) [4]. Due to the rareness of perforated duodenal diverticulum, surgical treatment guidelines are lacking. CONCLUSION: Ultimately, it is necessary to have a high index of suspicion to detect a duodenal diverticulum perforation. The perforation usually necessitates operative treatment that consists of a diverticulectomy and two-layer closer of the duodenum, Kocher maneuver, and drainage of the retroperitoneum.