How to manage difficult duodenal defects? Single center experience.

Objectives: The aim of this study was to investigate the surgical treatment methods and outcomes of difficult duodenal defects due to perforation.

Material and methods: Data of patients who had undergone surgery for difficult duodenal defect between January 2012 and November 2022 were collected. Duodenal defect size of 2 cm or more was defined as difficult duodenal defect. Characteristics of the patients, the etiology of perforation, American Society of Anesthesiology (ASA) scores, Mannheim peritonitis index (MPI), surgical treatment, need for re-operation, and morbidity and mortality were evaluated.

Results: Nineteen patients were detected. Etiology was peptic ulcer perforation in 12 (63.1%) patients, aortaduodenal fistula in 2 (10.5%), tumor implant in 2 (10.5%), cholecystoduodenal fistula in 1 (5.2%), endoscopic retrograde cholangio pancreatography (ERCP) in 1 (5.2%), and cholecystectomy related injury in 1 (5.2%) patient. The first surgical procedure was duodenoraphy + omentopexy in 8 (42.1%), Graham repair in 5 (26.3%), duodenal segment 3-4 resection and Roux-en-Y side to side duodenojejunostomy in 4 (21.0%), Roux-en-Y side to side duodenojejunostomy in 1 (0.5%), and 1 (0.5%) subtotal gastrectomy + duodenum 1^st part resection + Roux-en-Y gastroenterostomy, cholecystectomy and external biliary drainage via cystic duct. Four patients who had previously undergone Graham repair (3) and duodenoraphy + omentopexy (1) required salvage surgery. As a salvage surgery; 1 end-to-side and 3 side-to-side Roux-en-Y duodenojejunostomies were performed. Overall, mortality occurred in 6 (31.6%) patients. High ASA score and MPI were considered as significant risk factors for mortality (p= 0.015, p= 0.002).

Conclusion: Primary repair techniques can be used in the surgical treatment of difficult duodenal defects when peritonitis is not severe and tensionfree repair is possible. Otherwise, duodenojejunostomy may be preferred as a fast, easy, and safe technique for both initial and salvage surgeries.