Duodenojejunostomy, an Old Technique but Novel Solution for Giant Duodenal Perforations - A Report of Four Cases and Review of Literature

Background: Despite advances in the medical management of peptic ulcer disease, duodenal ulcer (DU) perforation remains a common surgical emergency. Most DU perforations are small and can be managed with omental patch repair. However, occasionally the surgeon may encounter a giant perforation not amenable to this. Giant DU perforations are defined as > 2cm. They are associated with high leak rates and mortality. Prognosis in elderly patients are particularly poor because of advanced age and comorbidities. Furthermore, there are no specific recommendations for their management despite a variety of repair techniques being described. Here, we aim to describe a novel technique used to treat such patients, especially those of advanced age, in our institution and to review the current literature. Case presentation: Four patients with giant DU perforation underwent emergency laparotomy and repair with our duodenojejunostomy technique at our hospital. Post-operatively, patients were monitored clinically and radiologically and discharged when well and tolerating diet. The mean age of the patients was 67 years with an equal gender distribution. The average Charlson Comorbidity Index (CCI) score was 3 (moderately severe). All presented with peritonitis and two had concomitant bleeding. There were two anterior and two posterior ulcers. One was a revision repair after a leak post laparoscopic omental patch repair for the initial perforation. In all cases, the duodenojejunostomy repair technique was used. Post-operative recovery was uneventful for all except one who developed pneumonia. In particular; there were no anastomotic leaks, intra-abdominal collections, gastric outlet obstructions or mortalities. Conclusion: Giant DU perforation remains a challenge to the general surgeon, particularly so in elderly patients with multiple comorbids. A review of the current literature suggests a myriad of surgical techniques but no perfect solution. Some suggested techniques include omental patch with pyloric exclusion, controlled tube duodenostomy, jejunal pedicled graft or serosal patch, gastric disconnection and partial gastrectomy. Here, we propose that isolated duodenojejunostomy can be a quick, safe and novel solution that ensures definitive repair of giant ulcer perforation in a single setting in the high-risk patient.