Unusual case of retroperitoneal hematoma and duodenal ulcerative bleeding after nephrectomy: Case report.

RATIONALE: Retroperitoneal hematomas are relatively common in patients undergoing nephrectomy. Herein, we report an unusual case involving a giant retroperitoneal hematoma and subsequent duodenal ulcerative bleeding following a radical nephrectomy. PATIENT CONCERNS: A 77-year-old woman was admitted to our hospital for lower back pain, and she had severe right hydronephrosis and a urinary tract infection. DIAGNOSES: The patient was diagnosed and confirmed as high-grade urothelial carcinoma. INTERVENTIONS: After ineffective conservative treatments, a right radical nephrectomy and ureteral stump resection were performed. The patient received proton pump inhibitors to prevent stress ulcer formation and bleeding. On the first day post-surgery, she had normal gastrointestinal (GI) endoscopy findings. On the second day post-surgery, abdominal computed tomography revealed a retroperitoneal hematoma. Notably, 14 days post-surgery, massive GI bleeding occurred, and GI endoscopy identified an almost perforated ulcer in the bulbar and descending duodenum. OUTCOMES: The patient died on day 15 after surgery. LESSONS: Duodenal ulceration and bleeding might occur following a retroperitoneal hematoma in patients treated with nephrectomy. Timely intervention may prevent duodenal ulcers and complications, and thus could be a promising life-saving intercession.

Successful endoscopic combined with endovascular haemostasis of a ruptured pseudoaneurysm of the duodenal bulb: A case report.

Pseudoaneurysms are uncommon but their rupture and bleeding can lead to serious complications and be fatal. We present here a case of a man in his late 70s who was transferred to our hospital with persistent gastrointestinal bleeding. One month prior to his admission, he had undergone surgery for a fracture to his left knee. Endoscopic examination found pulsating blood vessels on a duodenal ulcer, which suddenly ruptured and caused significant bleeding. Immediate endoscopic haemostasis was administered and the bleeding decreased. Considering the high rate of rebleeding that may occur with a pseudoaneurysm, the patient underwent interventional radiology that culminated in a diagnosis of a pseudoaneurysm originating from gastroduodenal artery (GDA); successful embolization was achieved. Tests showed that the patient had Helicobacter pylori infection. We hypothesised that the H. pylori infection had led to the occurrence of the duodenal bulb ulcer, and the patient's left knee fracture and surgery a month previously had contributed to this predisposition for a pseudoaneurysm.

Concurrent laparoscopic highly selective vagotomy with closure of duodenal ulcer perforations show good clinical results as primary repair alone.

OBJECTIVE: To compare clinical and operative results between laparoscopic primary repair (LPR) alone and LPR with highly selective vagotomy (LPR-HSV) in patients with duodenal ulcer perforation. METHODS: Clinical data from patients who underwent either LPR or LPR-HSV by resecting both sides of the neurovascular bundle using an ultrasonic or bipolar electrosurgical device for duodenal ulcer perforations, between 2010 and 2020, were retrospectively collected. Between-group differences in continuous and categorical variables were statistically analysed. RESULTS: Data from 184 patients (mean age, 49.6 years), who underwent either LPR (n = 132) or LPR-HSV (n = 52) were included. The mean operation time was significantly longer in the LPR-HSV group (116.5 ± 39.8 min) than in the LPR group (91.2 ± 33.3 min). Hospital stay was significantly shorter in the LPR-HSV group (8.6 ± 2.6 days) versus the LPR group (11.3 ± 7.1 days). The mean postoperative day of starting soft fluid diet was also significantly shorter in the LPR-HSV group (4.5 ± 1.4 days) than in the LPR group (5.6 ± 4 days). No between-group difference in morbidity rate was observed. The learning curve of the HSV procedure showed a stable procedure time after 10 operations. CONCLUSIONS: LPR with HSV may be a safe and feasible procedure for selective cases who are at high risk for ulcer recurrence.

Gastric, Duodenal, and Small Bowel Emergencies.

Gastric and small bowel emergencies are often seen in the emergency department and require rapid assessment and intervention as patients can deteriorate quickly. Some of the more frequently seen gastric emergencies include gastric volvulus and peptic ulcer disease, which can present with ischemia, strangulation, perforation, or severe bleeding. Swift diagnosis is crucial to ensuring the proper management whether that is endoscopic or with surgical exploration. Perforated peptic ulcers that are not contained will require surgical intervention, whereas bleeding ulcers can often be controlled with endoscopic interventions.

[Laparoscopic treatment of perforated gastroduodenal ulcers]. / Laparoskopicheskaya tekhnologiya lecheniya probodnykh yazv zheludka i dvenadtsatiperstnoi kishki.

The review is devoted to laparoscopic technology in the treatment of perforated gastroduodenal ulcers. Searching for literature data was performed in the PubMed, Google, Springer Link online library, Cochrane Systematic Review databases. We analyzed reviews, prospective and retrospective studies devoted to various strategies in the treatment of perforated peptic ulcers. Demographic, clinical and epidemiological features of these patients, indications and contraindications for endoscopic suturing of perforations, features of laparoscopic procedures and causes of conversions to open surgery were studied. Finally, we compared the results of laparoscopic and open surgeries.

Duodenal ulcer perforation and its consequences.

Duodenal ulcer perforation, a frequent surgical emergency, needs simple closure with indirect Graham's Omentopexy which is effective with excellent results in majority of cases despite patients' late presentation. The objective of the study was to determine the frequency of postoperative complications of perforated duodenal ulcer, conducted in the Surgery Department, Jinnah Postgraduate Medical Centre, Karachi, from March 20, 2018 to September 20, 2018. The study was a descriptive case series of 108 patients of both genders with perforated duodenal ulcer > 1 week old with ASA score I & II. Patients with trauma and comorbidities were excluded. The patients underwent laparotomy and peritoneal toilet, and after noting the site of perforation indirect Graham's Omentopexy was performed. Complications like duodenal fistula, peritonitis, and paralytic ileus, and patient's death within 10 days of surgery were noted. Age ranged from 18 to 50 years with mean age of 35.027±5.13 years, mean weight 71.120±12.77 kg, mean height 1.541 ±0.09 metres, mean BMI 29.975±4.99 kg/m2, and the mean duration of complaint was 4.194±1.30 weeks. Male predominance in 75 (69.4%) patients. Duodenal fistula was seen in 10 (9.3%) patients, peritonitis 12 (11.1%), paralytic ileus 14 (13%) and mortality was in 11 (10.2%) patients.

Comparison of 'primary repair' and 'placing a drain without repair' methods in duodenum perforations.

BACKGROUND: Duodenal ulcer perforation is a serious condition. A number of methods have been defined and used in surgical treatment. In this study, it was aimed to compare the effectiveness of 'primary repair' and 'drain placement without repair' methods in duodenal perforations using an animal model. METHODS: Three equivalent groups of ten rats each were formed. Perforation was created in the duodenum in the first (primary repair/sutured group) and the second group (drain placement without repair/sutureless drainage group). In the first group, the per-foration was repaired with sutures. In the second group, only a drain was placed in the abdomen without sutures. In the third group (control group), only laparotomy was performed. Neutrophil count, sedimentation, serum C-reactive protein (CRP), serum total an-tioxidant capacity (TAC), serum total thiol, serum native thiol, and serum myeloperoxidase (MPO) analyses were performed on animal subjects in the pre-operative period and on the post-operative 1st and 7th days. Histological and immunohistochemical (transforming growth factor-beta 1 [TGF-ß1]) analyzes were performed. Blood analysis, histological, and immunohistochemical findings obtained from the groups were compared statistically. RESULTS: There was no significant difference between the first and second groups, except for the TAC on the post-operative 7th day and MPO values on the post-operative 1st day (P>0.05). Although tissue healing was more pronounced in the second group than in the first group, there was no significant difference between the groups (P>0.05). TGF-ß1 immunoreactivity observed in the second group was found to be significantly higher than in the first group (P<0.05). CONCLUSION: We think that the sutureless drainage method is as effective as the primary repair method in the treatment of duo-denal ulcer perforation and can be safely applied as an alternative to the primary repair method. However, further studies are needed to fully determine the efficacy of the sutureless drainage method.

Pancreas-sparing partial duodenectomy as an alternative to emergency pancreaticoduodenectomy for a major duodenal perforation: a case report.

A 71-year-old woman underwent endoscopic submucosal dissection for early duodenal cancer at the second portion of the duodenum and developed acute peritonitis due to delayed duodenal perforation. Emergency laparotomy was performed. A huge perforation formed at the descending duodenum without ampulla involvement. Pancreas-sparing partial duodenectomy (PPD) with gastrojejunostomy was performed (250 min operative time) with 50 mL of intraoperative blood loss. She required intensive care for 3 days and was discharged on postoperative day 21 with no severe complications. Emergency treatment for a major duodenal injury or perforation remains challenging because of high morbidity and mortality. An appropriate treatment should be considered according to the nature of the defect. Although PPD is an acceptable procedure for patients with a duodenal neoplasm, its use in emergency surgery is rarely reported. PPD is more reliable than primary repair or anastomosis using a jejunal wall, and less invasive than pancreaticoduodenectomy, for emergency treatment. We performed PPD in this patient because the duodenal perforation was too large to reconstruct and did not involve the ampulla. PPD can be a safe and feasible alternative surgical procedure to pancreaticoduodenectomy for a major duodenal perforation, especially in patients with a duodenal perforation that does not involve the ampulla.

Perforated Stress Ulcer of the Duodenum: a Case of an Unexpected Diagnosis in a COVID-19 Patient Following Dilatation and Curettage Procedure.

Background: Stress ulcers in the upper gastrointestinal tract can arise from pathologies related to erosive or inflammatory insults in critically ill patients. The relationship between stressful bodily events and the ischemia and perforation of stress ulcers is poorly understood. Objective: We present a case of perforated stress ulcer following an abortion that was treated by dilatation and curettage (D&C) and complicated by a coronavirus disease 2019 (COVID-19) infection. Case presentation: A 40-year-old lady presented to the emergency room complaining of diffuse abdominal pain, she was recently diagnosed with an incomplete abortion and managed via a D&C procedure in an external hospital. A computed tomography (CT) scan was done at our center for the abdomen and pelvis, showing extensive pneumoperitoneum, which brought the radiologist's attention to suspect a small bowel perforation presumably accompanying a uterine perforation secondary to the D&C. There were no obvious signs of pelvic small bowel perforation in the initial CT images. The perforated duodenal stress ulcer was diagnosed the next day by a new CT scan following oral contrast ingestion and managed surgically by repair and omental patch, and no other bowel perforations were found upon surgical exploration. After the surgery, the patient was diagnosed with COVID-19, and her clinical status deteriorated gradually during the following week, and she passed away from a cardiac arrest. Conclusion: It is unclear whether septic abortion or COVID-19 has resulted in stress ulcer perforation in our patient. This case report highlights the importance of raising early suspicion in the diagnosis of stress ulcer perforation in critically ill patients to reduce the risk of morbidity and mortality.

Analysis of risk factors for duodenal leak after repair of a duodenal perforation.

BACKGROUND: Repairing of a duodenal perforation is a well accepted procedure, but clinically, approximately 4% of patients develop duodenal leaks after perforation repair, increasing the risk of death. We retrospectively analyzed clinical data from 168 patients at our hospital to explore risk factors for duodenal leak after perforation repair and developed a nomogram for predicting postoperative duodenal leak. METHODS: This retrospective case-control study totalled 168 patients undergoing repair of a duodenal perforation with omentopexy at the General Surgery Department, Dongnan Hospital of Xiamen University, from January 2012 to January 2022. The patients were divided into the non-leak group and the leak group. Risk factors were evaluated by analyzing the patient's sex, shock, diameter and anatomic position of the ulcer, use of NSAIDS and Glucocorticoid, history of drinking, diabetes, chronic diseases, age, time of onset of symptoms and lab tests. RESULT: One hundred fifty-six patients (92.9%) who did not develop leaks after repair of a duodenal perforation were included in the non-leak group, and 12 (7.1%) developed leaks were included in the leak group. In univariate analysis, there were significant differences between the two groups referring to age, shock, NSAIDs, albumin, and perforation size (P < 0.05). The area under the ROC curve for perforation diameter was 0.737, the p-value was 0.006, the optimal cutoff point was 11.5, sensitivity was 58.3%, and specificity was 93.6%, the positive predictive value is 41.1%, and the negative predictive value is 98.0%. In the internal validation of the performance of the nomogram, the C-index and AUC of the model were 0.896(95%CI 0.81-0.98), demonstrating that the nomogram model was well calibrated. CONCLUSION: The study discussed the risk factors for postoperative duodenal leak in patients undergoing repair of a duodenal perforation, and a nomogram was constructed to predict the leak. Future prospective studies with large sample sizes and multiple centres are needed to further elucidate the risk of duodenal leak after repair of a duodenal perforation.

Gastroduodenal Perforation in Cancer Patients: Association with Chemotherapy and Prognosis.

BACKGROUND: Gastroduodenal perforation stands out as one of the complications in cancer patients. Despite its high mortality, its characteristics are still poorly described. This study aimed to evaluate the characteristics and outcomes of cancer patients who had gastroduodenal perforation, and the influence of chemotherapy (CMT) in these cases. METHOD: A retrospective analysis of patients who underwent emergency surgery with an intraoperative finding of gastroduodenal perforation. Patients who performed CMT within 60 days before perforation were considered as the CMT group. RESULTS: Among 45 patients included, 16 (35.5%) were classified as the CMT group and the remaining 29 (64.5%) patients as the non-CMT group. There was no difference between the groups regarding sex, age, BMI, comorbidity, and laboratory exams. ECOG 2-3 was significantly more frequent in the CMT group (68.8% vs. 34.5% p = 0.027). Major postoperative complications were similar between both groups (75% vs. 58.6%, p = 0.272). The sepsis of abdominal focus was the main postoperative complication. The 30-day mortality was 55.6%, with no difference between non-CMT and CMT groups (62.5% vs. 51.7%, respectively; p = 0.486). A multivariate analysis of risk factors showed that only an age of ≥65 years was related to 30-day mortality. CONCLUSIONS: Patients with gastroduodenal perforation and oncologic treatment present high mortality, regardless of receiving recent CMT.

Experience in diagnosis and treatment of duodenal ulcer perforation in children.

BACKGROUND: This study aims to summarize our experience in diagnosis and treatment of pediatric duodenal ulcer perforation in a National Center for Children's Health. METHODS: Fifty-two children with duodenal perforation hospitalized in Beijing Children's Hospital Affiliated to Capital Medical University from January 2007 to December 2021 were retrospectively collected. According to the inclusion and exclusion criteria, patients with duodenal ulcer perforation were included in the group. They were divided into the surgery group and the conservative group according to whether they received surgery. RESULTS: A total of 45 cases (35 males and 10 females) were included, with a median age of 13.0 (0.3-15.4) years. Forty cases (40/45, 88.9%) were over 6 years old, and 31 (31/45, 68.9%) were over 12 years old. Among the 45 cases, 32 cases (32/45, 71.1%) were examined for Helicobacter pylori (HP), and 25 (25/32, 78.1%) were positive. There were 13 cases in the surgery group and 32 cases in the conservative group, without a significant difference in age between the two groups (P = 0.625). All cases in the surgery group and the conservative group started with abdominal pain. The proportion of history time within 24 h in the two groups was 6/13 and 12/32 (P = 0.739), and the proportion of fever was 11/13 and 21/32 (P = 0.362). The proportion of pneumoperitoneum in the surgery group was higher than that in the conservative group (12/13 vs. 15/32, P = 0.013). The fasting days in the surgery group were shorter than those in the conservative group (7.7 ± 2.92 vs. 10.3 ± 2.78 days, P = 0.014). There was no significant difference in the total hospital stay (13.6 ± 5.60 vs14.8 ± 4.60 days, P = 0.531). The operation methods used in the surgery group were all simple sutures through laparotomy (9 cases) or laparoscopy (4 cases). All patients recovered smoothly after surgery. CONCLUSION: Duodenal ulcer perforation in children is more common in adolescents, and HP infection is the main cause. Conservative treatment is safe and feasible, but the fasting time is longer than the surgery group. A simple suture is the main management for the surgery group.

Laparoscopic Graham Patch for Anterior Duodenal Perforation in a 6-Year-Old.

Peptic ulcer disease causing perforation is extremely rare in children and primarily affects teenagers. We present a case of a perforated peptic ulcer in a 6-year-old with abdominal pain and emesis with CT findings of moderate pneumoperitoneum and pelvic free fluid without a distinct cause. He was emergently transferred, found to be peritonitic, and taken to the operating room for diagnostic laparoscopy revealing an anterior duodenal ulcer, and underwent laparoscopic Graham patch repair. Postoperatively, the child had positive fecal antigen for H. pylori. He was treated with triple therapy and underwent subsequent testing to confirm eradication. Perforated peptic ulcer is an uncommon pediatric surgical problem, and imaging may not be diagnostic as in the case presented here. Thus, clinicians need to maintain a high index of suspicion when evaluating children with free air and a surgical abdomen in the setting of long-standing abdominal pain.

Comparison between traumatic and atraumatic over-the-scope clips in patients with duodenal ulcer bleeding: a retrospective analysis with propensity score-based matching.

BACKGROUND AND AIMS: Over-the-scope clips (OTSCs) substantially improved the endoscopic armamentarium for the treatment of severe GI bleeding and can potentially overcome limitations of standard clips. Data indicate a superiority of OTSCs in hemostasis as first- and second-line therapy. However, the impact of the OTSC designs, in particular the traumatic (-t) or atraumatic (-a) type, in duodenal ulcer bleeding has not been analyzed so far. METHODS: This was a retrospective analysis of a prospective collected database from 2009 to 2020 of 6 German endoscopic centers. All patients who underwent emergency endoscopy and were treated using an OTSC for duodenal ulcer bleeding were included. OTSC-t and OTSC-a patients were compared by the Fisher exact test, χ2 test, or Mann-Whitney U test as appropriate. A propensity score-based 1:1 matching was performed to obtain equal distribution of baseline characteristics in both groups. RESULTS: The entire cohort comprised 173 patients (93 OTSC-a, 80 OTSC-t). Age, gender, anticoagulant therapy, Rockall score, and treatment regimen had similar distributions in the 2 groups. However, the OTSC-t group showed significantly more active bleeding ulcers (Forrest Ia/b). Matching identified 132 patients (66 in both groups) with comparable baseline characteristics. Initial bleeding hemostasis (OTSC-a, 90.9%; OTSC-t, 87.9%; P = .82) and 72-hour mortality (OTSC-a, 4.5%; OTSC-t, 6.0%; P > .99) were not significantly different, but the OTSC-t group revealed a clearly higher rate of recurrent bleeding (34.9% vs 7.6%, P < .001) and necessity of red blood cell transfusions (5.1 ± 3.4 vs 2.5 ± 2.4 concentrates, P < .001). CONCLUSIONS: For OTSC use, the OTSC-a should be the preferred option for duodenal ulcer bleeding.