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Surgery of the Duodenum
Surgery for peptic ulcer

The duodenum is the first part and "central processing unit" of the small bowel. It is the:

  • Beginning of small bowel motor activity (peristalsis)
  • Site of multiple hormones related to digestion
  • Entrance site for liver bile and pancreatic enzymes that aid digestion
  • Site of antibody production

It is easily approached for diagnostic testing but difficult to operate upon

Anatomy and Physiology

The duodenum connects the stomach to the jejunum, which is the second part of the small bowel (Figure 1)

  • It is 20 cm (8 inches) in length and divided into four parts
  • The duodenum is retroperitoneal (has peritoneum, the thin layer of tissue that lines the abdominal cavity) only on the anterior (front) side; fixed in location; wraps around the head, neck and body of the pancreas; and the superior mesenteric artery and vein (major blood vessels for the bowel) pass anterior to the 3rd portion
  • The ampulla of Vater (entrance site into duodenum of joined common bile duct and pancreatic duct) enters the medial (towards the midline) side of the 2nd portion of the duodenum
  • The accessory pancreatic duct enters slightly higher in the medial wall of the duodenum
  • The ligament of Treitz (a supporting band of peritoneum and muscle fibers) marks the point between the duodenum and jejunum The wall of the small bowel (Figure 2) is made up of four layers:
Figure 1 - Anatomy of the stomach, duodenum, pancreas and jejunum. See text. © C. McKee
  • The mucosa is the inner most layer and composed of small fingerlike projections (villi) covered with a single layer of cells (epithelium). Beneath the epithelium is a thin layer of connective tissue (lamina propria) and muscle (muscularis mucosa)
  • The submucosa is a thin strong layer containing connective tissue, vessels, nerves and lymphatics
  • The muscularis propria is composed of smooth muscle that has a thicker circular inner layer and thin outer layer that runs lengthwise
  • The serosa is the single cell thick outer layer similar to the peritoneum (visceral peritoneum)
Figure 2 - Microscopic appearance of the wall of the duodenum. © C. McKee

The duodenum produces many hormones that help regulate digestion. Liver bile and pancreatic secretions are added to the bowel through the ampulla of Vater. The actual passage and presence of food in the duodenum starts the flow of hormones, bile and pancreatic secretions. By the time food leaves the duodenum most of the ingredients necessary for digestion have been added. Little digestion and absorption (passage of nutrients from the bowel into the blood) take place in the duodenum.

Pathology

  • Ulcer (Figure 3). The first portion of the duodenum is the most common site of inflammation. Peptic ulceration erodes the mucosa and deeper bowel wall layers. For many years the cause has been attributed to hyperacidity (increased acid). More recently hyperacidity and a bacteria called Helicobacter pylori have been considered as the cause. The ulcer may be superficial with just mucosal ulceration or it may extend through all layers of the bowel wall with perforation (hole in the wall). The ulcers can cause obstruction, bleeding, and perforation or become intractable (persistent)
Figure 3 - Duodenal ulcer as seen through a gastroscope. Courtesy E. Fraiberg, MD
  • Crohn's disease is a chronic inflammatory disease that may involve any part of the intestinal tract from the mouth to the anus. It is described as a granulomatous (nodular inflammation) inflammatory process involving the terminal ileum most often. Deep ulcerations, thick scarring, fibrosis, and shortening of the bowel are present. The cause is uncertain and bacterial infection and autoimmune reactions are possible causes. Obstruction, bleeding, perforation, and intractability are complications of the disease
  • Diverticula (outpouchings) of the duodenum are common and infrequently cause symptoms. They most often occur on the pancreatic side of the duodenum and may be single or multiple. The diverticula may collect intestinal content and be subject to inflammation, obstruction, bleeding, and perforation
  • Benign and malignant tumors (Figure 4)
    1. Benign polyps may be adenomatous (arising from the epithelium) or hamartomatous (overgrowth of normal tissues). The polyps will be variable in size and symptoms. Symptoms will frequently cause obstruction or bleeding. Villous adenomas (broad based polyps) are more common in the duodenum, invariably large and malignant about half the time. Other benign tumors arise from the other tissues in the bowel wall such as fat, vessels, lymph vessels, nerve, and smooth muscle
    1. Adenocarcinoma (mucosal or epithelial cancers) is the most common malignancy of the small bowel. It is most common in the duodenum around the ampulla of Vater. The frequency of adenocarcinoma of the small bowel decreases as you go down the bowel. Malignancies of all the other tissues occur in the small bowel
Figure 4 - Mucinous duct ectasia of ampulla of Vater, a pre-cancerous tumor as seen through a gastroscope. Courtesy E. Fraiberg, MD
  • Ischemia (lack of blood supply) of the duodenum is rare whether due to atherosclerosis (hardening of artery with plaque build up) or embolic disease (passage of clot from one site to another). Ischemia may arise in prolonged low flow situations secondary to other reasons especially in critical care units

History and Physical

  • Pain
    1. Visceral pain, pain within the thoracic or abdominal cavities, is poorly defined or localized. Small bowel pain will typically produce discomfort in a zone around the belly button. Duodenal pain (usually from ulcer) and pancreatic pain are primarily epigastric (mid upper abdomen). Sudden severe unrelenting epigastric pain may indicate duodenal perforation.
    2. Abdominal pain may be described as vague, diffuse, non localizing, heavy, burning, sharp, stabbing, crampy, intermittent, constant, localizing, and associated with sweating, nausea, and vomiting
    1. As inflammation progresses, the inflamed bowel begins to irritate the parietal peritoneum (lining the abdominal cavity) and gives rise to a localized pain over the irritated site
  • Irritation of the peritoneum gives rise to tenderness, guarding (resistance to the examiner's touch), rigidity, and absent bowel sounds
  • History of the pain regarding the onset, location, type of pain, progression of pain or changing pattern is extremely important. Chronic inflammation of the duodenum will be characterized by persistent epigastric discomfort frequently relieved by food or drink. Discomfort may awaken the individual at night
  • Nausea and vomiting is usually not present early. If inflammation progresses to partial or complete obstruction, anorexia (loss of appetite), nausea, and vomiting will occur with weight loss
  • If there is bleeding, black tarry like stools will be present and the patient may vomit blood (hematemesis). Chemical testing of stool for blood should be performed
  • Benign or malignant enlarging growths will not have any specific symptoms until they ulcerate, bleed or obstruct
  • Jaundice may occur if a growth presses on the ampulla region
  • Abdominal distention, masses, abdominal wall masses or defects and presence of intra abdominal fluid are noted
  • Rectal exams should be performed and pelvic examinations when indicated

Tests

  • Laboratory studies may include complete blood count, urinalysis, blood sugar, tests of pancreas function (amylase, lipase) and liver function (bilirubin, serum asparate aminotransferase, alkaline phosphatase), creatinine, electrolytes (salt in the blood) and pregnancy test
  • Radiological tests may include a chest x-ray with flat and upright films of the abdomen. The abdomen X-rays will provide information about the amount of gas in the bowel, where the gas is (very helpful regarding bowel obstruction or perforation), possible mass effect, abnormal calcifications (calcium deposits), presence of fluid, possibly organ enlargement and haziness of retroperitoneal structures
  • Gastroscopy, using a flexible lighted tube, may occasionally be necessary in evaluating upper abdominal pain or bleeding. The entire stomach and duodenum can be examined and biopsied if no obstructing process is present in the duodenum (Figures 3 and 4)
  • Upper GI (GastroIntestinal) Series ic carried out by the patient drinking a barium containing liquid that shows up on X-ray. The barium material outlines the abnormality such as a tumor or ulcer (Figure 5)
Figure 5 - Upper GI Series showing a tumor (lymphoma) of the duodenum that has an associated ulcer. J = jejunum. Courtesy S. Sadiq, MD
  • Ultrasound examination will provide information about the liver, gall bladder, common bile duct, pancreas, aorta, ovaries, tubes, uterus, abnormal fluid or abscess collections. Ultrasound provides limited information when there is excess gas in the bowel
  • Computerized axial tomography (CAT scan) will give information about solid organs, inflammatory processes, bowel wall thickening, mass effect, vascular structures, amount of fluid or gas in the intestinal tract or outside the intestinal tract, may identify point of obstruction and may show abdominal wall defects. The CAT scan is performed after the patient drinks material and is given a dye intravenously that shows up on X-ray

Indications and Contraindications for Surgery

The majority of indications for duodenal surgery will be for:

  • Bleeding
  • Perforation
  • Obstruction
  • Inflammation
  • Neoplasia (tumors)

Contra indications to duodenal surgery would be determined by the patients overall health and other existing problems. Often, it is necessary to accept an increased risk because non-surgical options will not resolve the situation

Surgical Procedures

  • Patients requiring surgery need special attention to fluid and electrolyte balance. Get the patient's condition back to near normal lessens the risk of surgery
  • Duodenal surgery is performed under general anesthesia with the patient supine (on the back)
  • A nasogastric tube is inserted through the nose into the stomach for drainage
  • A catheter is placed in the urinary bladder to monitor urinary output
  • Central venous catheters and/or an arterial catheter may be placed
  • Midline (up and down) or transverse (from side to side) incisions may be used
  • Different types of drains may be left in the abdominal cavity and brought out through the abdominal wall. The amount of drainage determines removal
  • Temporary feeding tubes may be placed in the stomach or small bowel
  • Peptic ulceration of the duodenum used to be a frequent reason for surgery of the upper small bowel. Today, perforation, bleeding and obstruction of the duodenum are less frequent because of improved medical therapy. Persistent duodenal ulceration can be treated with several operations:
    1. Highly selective parietal cell vagotomy (division of the fibers of the vagus nerve that go to the body of the stomach. This interrupts acid secretion of the stomach. (Figures 6 A, B)
    2. Vagotomy and Antrectomy. This surgery divides both vagal nerves (truncal vagotomy) and removes the antrum (lowest part) of the stomach and first portion of duodenum. (Figures 7 A, B)
    3. Vagotomy and Pyloroplasty. Both vagal nerves are divided and the pylorus (muscle at the end of the stomach) is cut to improve drainage of food from the stomach. (Figures 8 A, B)
Figure 6A - Selective Vagotomy. The anterior and posterior vagus nerves are seen lying on the stomach. © C. McKee Figure 6B - The branches of the vagus nerves going to the stomach are cut to give the selective vagotomy. © C. McKee
Figure 7A - Vagotomy and Antrectomy. The lines of incision to remove the lower portion of the stomach (antrum), pylorus, and a small amount of duodenum. The vagus nerves are also cut (truncal vagotomy). © C. McKee Figure 7B - The bowel is reconstructed by closing the end of the duodenum and bringing up a loop of jejunum to anastomose to the stomach. This is called a Billroth II reconstruction. © C. McKee
Figure 8A - Vagotomy and pyloroplasty. Along with a truncal vagotomy the pylorus is incised in the direction of the bowel. © C. McKeeFigure 8B - The incision in the pylorus is closed perpendicular to the line of incision thus widening the pylorus. © C. McKee
  • Cancer of the duodenum
    1. Adenocarcinoma of the first and second portions of the duodenum requires extensive resection (removal). This includes cancer of the ampulla of Vater, head of pancreas and lower common bile duct. This operation is called the Whipple procedure (Figures 9A, B)
    • The Whipple procedure requires resection of the entire duodenum, head of pancreas, lower common bile duct, cholecystectomy and previously the lower stomach. A pylorus sparing procedure has been done more recently allowing preservation of the entire stomach and pylorus in cancer of the head of the pancreas (the part of the pancreas next to the duodenum)
    • Several anastomoses (joining together) are required, pancreas to small bowel, common bile duct to small bowel, stomach or preserved pylorus to small bowel (Figure 9B)
    1. Malignancies of the third and fourth portions of the duodenum require aggressive local resections of the bowel with the distal pancreas sometimes included · Duodenal diverticula are not uncommon and rarely require resection · Benign polyps of the duodenum can frequently be removed with the gastroscope
  • Large adenomas may require resection of the third or fourth portion of the duodenum. A Whipple procedure may be necessary if in the first or second portion
Figure 9A - The Whipple procedure for removal of a tumor or the duodenum. The antrum of the stomach, duodenum and adjoining pancreas are cut along the lines noted. © C. McKeeFigure 9B - The bowel is reconstructed. The pancreas is joined to the cut end of the small bowel. The common bile duct is reattached to the small bowel and a Billroth II reconstruction joins the stomach and jejunum. © C. McKee

 

Complications are described by organs:

  • Duodenum - bleeding, leak at any suture line (fistula), infection, abscess, ischemia of bowel (inadequate blood supply), bowel obstruction, development of blood clots in abdomen, evisceration (wound breakdown with intestine extruding through the wound) and hernias developing at incision site
  • Stomach - stress induced bleeding, collections of excessive blood or intestinal contents in the stomach
  • Pulmonary (lung) - aspiration of bowel content into lungs, atelectasis (failure to expand peripheral portions of lungs), pneumonia
  • Urinary - infections and bleeding because of catheters
  • Extremities- insidious development of blood clots in veins · Nasopharynx - sinus infections, ulceration of nasopharynx or bleeding because of the nasogastric tube
  • Diabetes mellitus -difficult to control blood sugar because of stress and pancreatic resection
  • Late complications of duodenal surgery:
    1. Dumping - occurs after meals (due to rapid emptying of stomach contents into small bowel, especially carbohydrates) and may include rapid heart rate, sweating, low blood pressure, and abdominal pain. This usually improves with time
    2. Diarrhea - occurs early and usually improves with time
    3. Dumping and diarrhea have similar post operative incidences of complications: highly selective parietal cell vagotomy 0-5% incidence; truncal vagotomy and pyloroplasty 1-15%; truncal vagotomy and antrectomy 1-20%
    4. Bile reflux gastritis - due to bile stasis in stomach or reflux of bile into the stomach
    5. Recurrent ulceration:
    • Vagotomy and antrectomy or vagotomy and pyloroplasty is preferable in the face of duodenal bleeding, perforation, obstruction, failed previous ulcer surgery or heavy smoker
    • Highly selective vagotomy has a higher ulcer recurrence rate (10-20%) but fewer complications and risk
    • Truncal vagotomy with pyloroplasty has a 10% recurrence rate with less complications and risk
    • Vagotomy and antrectomy has the lowest recurrence rate (2%) but the highest risk

Postoperative Care

The following description is of an uncomplicated postoperative course following an uncomplicated antrectomy and vagotomy

  • Vital signs (blood pressure, temperature, heart rate, and respiratory rate) are performed every 1-4 hours for the first 24 hours and tapered gradually
  • Urinary output is checked every 2-4 hours the first day, less frequently the second day and bladder catheter is usually removed by 3rd or 4th day
  • Nasogastric tube is irrigated every 4-6 hours, usually removed by the 3rd or 4th day
  • Intravenous (IV) fluids are usually necessary for 3-4 days or until the patient is drinking adequately
  • Pain control medications are given intravenously for 2-3 days and intramuscular (in the muscle) or oral pain medication later
  • Antibiotics are given for 24 hours IV if the bowel resection is clean and longer if contaminated
  • Anticoagulants (blood thinners) are usually given subcutaneously (under the skin) every 8-12 hours until the patient is actively walking
  • Lozenges may be given to help with nasogastric tube discomfort
  • Pulmonary, abdominal, nervous system and extremity examination every eight hours
  • Deep breathing is encouraged frequently and emphasized
  • Ambulation is started the first day and as frequent as possible
  • The nasogastric tube is usually removed by day 3 or 4. Patients are started on clear liquids the first day after tube removal, soft diet on the second day and regular diet on the third day
  • A few laboratory studies, such as a complete blood count, urinalysis, electrolytes, calcium and blood sugar may be done
  • A chest X-ray may be necessary if lung complications are suspected
  • In severely depleted patients, nutrition may be given IV
  • Tube feedings to enhance nutrition may be necessary in certain situations
  • The patient usually goes home on day 6-7

After Discharge

  • The patient usually sees the surgeon in the office 5 -10 days after discharge
  • No heavy lifting or straining for 6-8 weeks
  • No driving for 7-10 days
  • Return to work 4-8 weeks after surgery
  • Malignant conditions may require assessment for radiation or chemotherapy
  • Crohn's disease patients should be followed indefinitely
  • Continue with recommended medications
  • See the surgeon before returning to work and follow ups as recommended