CURRENT REVIEWS IN GASTROINTESTINAL, MINIMALLY INVASIVE, &
ENDOCRINE SURGERY
Management of the Difficult Duodenum
Betty J. Tsuei, MD,* and Richard W. Schwartz, MD*†
*Department of Surgery, University of Kentucky College of Medicine, and †Veterans Administration Hospital,
Lexington, Kentucky
Since Bilroth described the technique of gastric resection with
gastrojejunal reconstruction in the 1800s, duodenal leak has
been a potentially devastating complication for the general sur-
geon. A variety of surgical techniques have been developed to
avoid duodenal stump blowout. In addition, the use of duode-
nostomy tubes for decompression has, alternatively, been es-
poused or decried in the surgical literature. The decline in du-
odenal ulcer disease, coupled with the widespread use of acid-
reducing medications in the last few decades, has made once
commonplace elective gastric resections relatively rare. More
recent developments in the management of the “difficult duo-
denum,” particularly the use of pyloric exclusion, have come
not from the general surgical literature, but from trauma sur-
geons treating blunt and penetrating duodenal injuries. The
aim of this paper is to provide a brief historical overview of the
management of the difficult duodenal closure after gastric re-
section and treatment of duodenal injuries, focusing on the use
of duodenostomy tubes and pyloric exclusion in these cases.
DISCUSSION
Disruption of a duodenal stump closure after surgery for ulcer
disease has long been considered a disastrous postoperative
complication. The classic clinical scenario of the patient with
complicated duodenal ulcer disease who does well after gastric
resection, only to develop overwhelming sepsis from stump
leakage, has prompted the term “duodenal stump blowout,”
illustrating the sudden onset and severity of this complication.
Although duodenal leak after gastric resection only occurs in
1% to 3% of patients, early reviews demonstrated that it was
associated with a 50% mortality.1,2 Although advances in sup-
portive care have reduced mortalities to approximately 12% in
the 30 years since those reports3,4 and to 0% in some recent
studies,4 duodenal stump leakage remains one of the most
feared complications of gastric resection.
The number of encounters with the “difficult duodenum”
has been decreasing for the general surgeon. It has been written
“that within the past decade, articles about duodenal blowout
have virtually disappeared from the literature”5; the year of that
Correspondence: Inquiries to Richard W. Schwartz, MD, Division of General Surgery,
University of Kentucky Medical Center, 800 Rose Street, Lexington, KY 40536; fax: (859)
323-6840; e-mail: rshw01@uky.edu
166 CURRENT SURGERY • © 2004 by the Association of Program Directors in Surgery
Published by Elsevier Inc.
publication was 1973. There appear to be several reasons for
this decline. Epidemiologic studies have indicated that duode-
nal ulcer disease was at its peak between 1940 and 1960 and
began to decline in incidence even before the use of histamine
antagonists.6-8 The introduction and widespread availability of
acid-reducing agents and the identification of the infectious
causes of peptic ulcer disease have made elective surgical inter-
vention a rarity. Today, most operations performed for ulcer
disease are emergent operations for complications such as hem-
orrhage, perforation, or obstruction.6,8,9 The surgical proce-
dures performed in these cases have also changed over time. The
nutritional consequences of duodenal bypass with Bilroth II
reconstruction resurrected the use of gastroduodenostomy for
reconstruction after gastric resection.5 In addition, the use of
vagotomy and drainage and the development of the highly se-
lective vagotomy have reduced the number of gastric resections
performed for ulcer disease and, hence, reduced the need to
contend with the difficult duodenal closure. Despite these de-
velopments, there will originate on occasion the need to address
the difficult duodenum.
Surgical closure of a duodenum inflamed or scarred from
chronic ulcer disease can be tenuous and, thus, predisposed to
leakage. In an attempt to reduce the potential for these compli-
cations, many surgical techniques have been developed to avoid
duodenal resection and closure. Those described by Ban-
croft4,11 and Nissen4,12 were developed early in the twentieth
century, and they have remained largely unchanged in the mod-
ern era. Nissen’s closure is particularly useful in those patients
who have a large deep, posterior duodenal ulcer with penetra-
tion through the posterior wall. In these cases, the ulcer bed
cannot be safely resected. Bancroft’s closure employs distal an-
tral submucosal dissection, and it is best suited for situations in
which inflammation and scarring prevent adequate dissection
around the pylorus. Two precautions must be taken with this
procedure. First, as the right gastric and gastroepiploic arteries
must be preserved, the decision to use the Bancroft closure must
be made before these vessels are ligated. Secondly, care must be
taken to remove all antral mucosa from the duodenal stump to
avoid marginal ulceration.
Although little contemporary data on closure techniques are
available, Burch et al4 reported a series of 200 patients under-
going gastric resection with Bilroth II reconstruction. Although
80% of these patients underwent standard duodenal closures,
0149-7944/04/$30.00
doi:10.1016/j.cursur.2003.06.002
FIGURE 1. Initial dissection required for Nissen’s closure. Reprinted with permission from Exerpta Medica, Inc. From Burch JM, Cox CL, Feliciano DV,
Richardson RJ, Martin RR. Management of the difficult duodenal stump. Am J Surg. 1991;162:523.
20% required alternative closure techniques. Nissen’s closure
was used in 25 (13%) patients, Bancroft’s closure was used in 6
(3%) patients, and tube duodenostomy used in the remaining 9
(4.5%) patients. The authors noted an overall 3.5% incidence
of duodenal leakage; no leaks occurred in the patients who
underwent Nissen or Bancroft closures. They suggest that these
closures, which are illustrated in detail in their publication, can
be successful in carefully selected patients when performed by
surgeons familiar with these techniques. Importantly, knowl-
edge of these techniques allows greater flexibility in decision
making at the time of operation.4
Tube duodenostomy has also been commonly employed for
the management of the difficult duodenum. Because high in-
traluminal duodenal pressures have been postulated as a cause
of stump leakage, tube decompression has been suggested as a
preventative measure. Although Langenbeck and Bilroth de-
scribed the indwelling duodenal catheter for feeding purposes
in the mid-nineteenth century, it was not until 1909 that Neu-
mann used this technique for duodenal decompression.13 This
technique, popularized in the 1950s, consists of placing a tube
either through the end or lateral wall of the duodenum.13-15
Conceptually, these two techniques differ. End duodenos-
tomy, which is placement of the tube through the suture line
closing the duodenum, is an effort to create a controlled duo-
CURRENT SURGERY • Volume 61/Number 2 • March/April 2004
denal fistula. This is employed when technical factors prevent
adequate surgical closure of the duodenal stump. However,
when large catheters are used for end duodenostomy, persistent
fistula drainage may result.13 Lateral duodenostomy, or place-
ment of the tube through the lateral wall of the second portion
of the duodenum, is primarily used for intraluminal decom-
pression. In these cases, the tube is used as a protective measure,
much as one would employ a proximal loop colostomy to pro-
tect a tenuous rectal anastomosis.
A study by Prigouris and Michas found that in 71 patients
with gastric resection and end duodenostomy tubes, there were
no complications or leakage, which led them to conclude that
end duodenostomy was a simple, effective, and safe measure for
the prevention of postgastrectomy duodenal stump leakage.16
In contrast, a later study by Burch et al found that of nine
patients with duodenostomy, eight of which were of the end
type, three patients (33%) developed leaks.4 The authors sug-
gested that this was an ineffective means of preventing duodenal
leak, although the number of patients undergoing duodenal
decompression was small. Other surgeons have suggested that
placing a duodenostomy tube through chronically scarred tissue
would certainly predispose it to leak and suggest that lateral
duodenostomy, where the tube is placed through healthy, non-
inflamed tissue, may be more effective.17 Other technical mod-
167
FIGURE 2. Technique of Nissen’s closure. Reprinted with permission from Exerpta Medica, Inc. From Burch JM, Cox CL, Feliciano DV, Richardson RJ,
Martin RR. Management of the difficult duodenal stump. Am J Surg. 1991;162:523.
ifications, such as retrograde duodenostomy, originated from
the study of duodenal injuries, as follows. With this procedure,
the tube enters the bowel near the ligament of Treitz and is
passed in a retrograde fashion to provide duodenal drainage.
Because the proximal jejunum can be brought to the abdominal
wall, thus shortening the intraperitoneal portion of the fistula
tract, persistent drainage after tube removal may be minimized.
Another class of “difficult duodenum” that the general sur-
geon may encounter is caused by blunt and penetrating pancre-
aticoduodenal injuries. Although there is little chronic scarring
in these patients, the presence of significant tissue destruction or
devascularization can predispose these patients to duodenal
leak. Although the clinical presentation and diagnosis of duo-
denal injuries is beyond the scope of this paper, the techniques
used for management of significant injuries will be discussed.
The first successful surgical repair of duodenal rupture was in
1896 by Herczel.18 Early series reported, not surprisingly, high
mortalities, with isolated case reports of postoperative survivors.
Although nonoperative treatment of penetrating injuries pre-
vailed until the advent of World War I, military series through
the mid-twentieth century showed a decrease in mortality.18
Upon abdominal exploration for suspected duodenal injury,
a Kocher maneuver should be used to mobilize the duodenum
and to assess the extent of injury. The mechanism of injury, size
and site of injury, interval from injury to repair, and associated
injuries, particularly to the pancreas and biliary tree, are factors
168
affecting outcome and should be taken into consideration when
deciding upon the type of operation to perform.19
Approximately 80% of duodenal injuries can be adequately
treated using primary repair. Longitudinal duodenotomies can
be closed transversely if the length of the duodenotomy does
not exceed half of the circumference. If the duodenostomy is
longer than one-half of the circumference of the duodenum,
longitudinal closure is preferred. Transverse duodenostomy
with transverse closure results in significant narrowing and
should be avoided.20 As mobilization of the proximal duode-
num is limited by its anatomic relationship to the pancreas,
large duodenal defects may require techniques such as serosal or
mucosal patches, pedicle grafts, or Roux-en-Y duodenojejunos-
tomy.18,21 These techniques, however, can be time consuming
and thus are not applicable in the unstable trauma patient.
Adjuvant maneuvers to duodenal repair include tube duode-
nostomy, which has been described above. Retrograde duode-
nostomy was first described in the trauma literature in 1966,22
but as in the case of duodenal ulcer disease, the use of decom-
pressive duodenostomy has been controversial. Stone and Fa-
bian reported a high rate of duodenal complications and related
mortality without the use of decompression, a rate that de-
creased markedly after routine use of tube duodenostomy was
incorporated into their practice.22 Although these findings are
supported by other studies,23,24 several dispute the results.
Ivatury and colleagues found higher morbidity and mortality in
CURRENT SURGERY • Volume 61/Number 2 • March/April 2004
FIGURE 3. Bancroft’s closure. Reprinted with permission from Exerpta Medica, Inc. From Burch JM, Cox CL, Feliciano DV, Richardson RJ, Martin RR.
Management of the difficult duodenal stump. Am J Surg. 1991;162:524.
patients with injuries treated with duodenal repair and decom-
pression.25,26 Similarly, Cogbill and colleagues also stated there
was no role for tube duodenostomy.27 Still other authors find
neither benefit nor harm with decompression.19 Based on the
disparate results of these studies, perhaps the best recommen-
dation is the use of decompression in a selective fashion.
Two other surgical procedures may be used in patients with
severe duodenal injuries. Duodenal diverticulization, first de-
scribed at the turn of the twentieth century28,29 and later pop-
ularized by Berne, currently consists of primary duodenal repair
with external drainage, truncal vagotomy, antrectomy with gas-
trojejunostomy, and tube choledochostomy.30 This complex
procedure should be reserved for those patients with severe
duodenal and pancreatic injuries, and it may not be applicable
in the unstable patient.
As an alternative, Vaughn and colleagues described a simpler
and less time-consuming procedure.31 A gastrotomy is made
along the greater curvature, through which the pylorus is closed
with a running absorbable suture. The gastrotomy is then used
for gastrojejunostomy reconstruction. In using this technique,
care must be taken not to exclude any antral tissue, which can
CURRENT SURGERY • Volume 61/Number 2 • March/April 2004
cause ulceration. As the initial description of pyloric exclusion,
several modifications, including the use of different suture ma-
terials, stapling devices, and operative techniques, have been
described.32,33 Regardless of the method used, most authors
agree that spontaneous opening of the pylorus usually occurs
within several weeks.
The need for concomitant vagotomy to avoid marginal ul-
ceration remains an issue of debate. Although the initial de-
scription of pyloric exclusion did not include vagotomy, Buck
and colleagues found a 33% incidence of marginal ulceration in
17 patients and suggested that vagotomy should be added to the
initial operation.34 In contrast, several larger studies have re-
ported low rates of ulceration. Martin et al found only 4 of 128
patients treated with pyloric exclusion developed marginal ul-
ceration35; similar low rates of ulceration were reported by Fe-
liciano et al.36
The techniques used in pyloric exclusion continue to evolve.
In a recent paper by Ginzburg, the need for concomitant gas-
trojejunostomy was questioned. In their review of 12 patients
with complex penetrating duodenal injuries, 8 were treated
with pyloric exclusion and gastrojejunostomy, whereas 4 were
169
treated with exclusion alone. All patients demonstrated sponta-
neous opening of the pylorus, and only one patient developed
marginal ulceration. Based on these findings and the need to
focus on other associated injuries at the time of operation, they
suggested that gastrojejunostomy should not be routinely used
in patients undergoing exclusion.37 Along these lines, it is no-
table that in the large series of patients examined by Martin, no
complications were directly attributable to the pyloric exclu-
sion, but four were associated with the gastrojejunostomy.35
Additional future studies may alter the standard approach to
pyloric exclusion.
SUMMARY
Disruption of a duodenal stump closure after surgery for ulcer
disease has long been considered a disastrous postoperative
complication, with significant morbidity from fistulas or intra-
abdominal sepsis and high mortality. Although technological
advances have improved overall outcomes from this complica-
tion, the mainstay of the surgical armamentarium used to com-
bat the “difficult duodenum” has largely remained unchanged
during the past century. In addition, the widespread use of
acid-reducing medications has resulted in a decline in elective
gastric resections, with most ulcer operations today being per-
formed under emergent circumstances. Antrectomy, once the
mainstay of surgical treatment for ulcer disease, may not be an
option in the unstable patient, and it is often replaced with
vagotomy and drainage or highly selective procedures. None-
theless, the general surgeon of today will still encounter the
tenuous duodenal stump. Familiarity with proven surgical tech-
niques, such as the Nissan and Bancroft closures, may give
further options in closing the difficult duodenum. Decompres-
sive duodenostomy, either by placing the tube through the end
of the duodenum to create a controlled fistula or in a lateral or
retrograde position to act as protective measure, may be useful
in selected cases. The use of duodenostomy tubes in the treat-
ment of duodenal injuries is controversial, with as many authors
advocating routine use as those decrying them altogether. In the
light of conflicting studies, most authors agree that selective use
of decompressive duodenostomy is probably the most prudent
course. Pyloric exclusion with gastrojejunostomy has also been
advocated as protecting the tenuous duodenal repair after blunt
or penetrating injury. Absorbable and nonabsorbable sutures as
well as stapling devices have been employed, with spontaneous
reopening of the pylorus occurring within several weeks, re-
gardless of the method used. In performing pyloric exclusion,
care must be taken not to exclude any antral tissue, which can
cause ulceration. Although marginal ulceration can be a com-
plication of gastrojejunostomy, literature on the need for con-
comitant vagotomy remains divided at this time. Most larger
series, however, report low incidences of ulceration and do not
advocate vagotomy. More recent studies have questioned even
the need for concomitant gastrojejunostomy, and further inves
tigation may alter the standard approach to the techniques of
pyloric exclusion (Figs. 1-3).
170
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