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      Gastroduodeno-plasty performed by distal gastric transection.- A new technique for large duodenal defect closure

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          Abstract

          Introduction

          Duodenal ulcer lesions can represent a surgical challenge, especially if the duodenal wall is chronically inflamed, the defect exceeds a diameter of 3 cm and the ulceration is located in the second part of the duodenum.

          Patient and method

          We present the case of a 70-year-old male, who suffered from a 3 x 4 cm duodenal defect caused by duodenal pressure necrosis due to a 12.5 x 5.5 x 5 cm gallstone. Additionally, this stone caused intestinal obstruction (Bouveret’s syndrome) and bleeding with signs of shock. Besides the gallstone extraction, the common bile duct was drained by a T-tube and the duodenal defect closure was performed by a gastroduodeno-plasty and Bilroth II gastroenterostomy. The postoperative phase was uneventful. The reconstructed duodenum was endoscopically accessible and showed no pathological findings on follow-up.

          Conclusion

          The reconstruction of a large defect (> 3 cm) of the second part of the duodenum is safely feasible by a gastroduodeno-plasty. The critical gastroduodenal anastomosis can be protected by duodenal decompression, achieved by placing a T-tube in the common bile duct.

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          Most cited references17

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          Gallstone Ileus–Clinical and therapeutic aspects

          Gallstone ileus represents a rare (0.3–0.5%)[15], but serious complication of a common illness–the gallbladder lithiasis and the incidence of this fascinating disease has remained the same over the years. The main actual characteristics of this pathology are the age over 65, the female gender (men/women ratio 1/5:1:10–due to the high rate of vesicular lithiasis) and the under 50% diagnostic established preoperatively. The frequency of gallstone ileus recurrence is of 4,7–5%. In this article, we discuss the pathogenesis of this illness presenting all the mechanisms described in the medical literature. The Rigler triad found at the abdominal CT–scan generally established the diagnosis. Still, in 25% of the cases we have a misdiagnosis because of the underestimation of the size of the gallstone. Finally, the treatment of gallstone ileus has had major changes from the past. We described the endoscopic and laparoscopic approach, which represents the modern treatment of this disease. Despite these diagnostic and therapeutic possibilities, the mortality remains high and the common causes are associated comorbidities and late presentation to the physician.
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            The management of large perforations of duodenal ulcers

            Background Duodenal ulcer perforations are a common surgical emergency, but literature is silent on the exact definition, incidence, management and complications of large perforations of duodenal ulcers. Methods The case files of 162 patients who underwent emergency laparotomy for duodenal ulcer perforations over a period of three years (2001 – 2003) were retrospectively reviewed and sorted into groups based on the size of the perforations – one group was defined as 'small 'perforations (less than 1 cm in diameter), another 'large' (when the perforation was more than 1 cm but less than 3 cms), and the third, 'giant'(when the perforation exceeded 3 cm). These groups of patients were then compared with each other in regard to the patient particulars, duration of symptoms, surgery performed and the outcome. Results A total of 40 patients were identified to have duodenal ulcer perforations more than 1 cm in size, thus accounting for nearly 25 % of all duodenal ulcer perforations operated during this period. These patients had a significantly higher incidence of leak, morbidity and mortality when compared to those with smaller perforations. Conclusion There are three distinct types of perforations of duodenal ulcers that are encountered in clinical practice. The first, are the 'small' perforations that are easy to manage and have low morbidity and mortality. The second are the 'large' perforations, that are also not uncommon, and omental patch closure gives the best results even in this subset of patients. The word 'giant' should be reserved for perforations that exceed 3 cms in diameter, and these are extremely uncommon.
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              Bouveret's Syndrome: Case Report and Review of the Literature

              Bouveret's syndrome is defined as gastric outlet obstruction caused by duodenal impaction of a large gallstone which passes into the duodenal bulb through a cholecystogastric or cholecystoduodenal fistula. Initial attempts at endoscopic retrieval with or without mechanical or extracorporeal lithotripsy should be performed as first-line treatment, though success rates with endoscopic treatment are variable. We describe a case of Bouveret's Syndrome in an elderly patient that was successfully treated with endoscopic extraction combined with mechanical lithotripsy, and review the literature on this uncommon condition.
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                Author and article information

                Journal
                Ann Surg Innov Res
                Ann Surg Innov Res
                Annals of Surgical Innovation and Research
                BioMed Central
                1750-1164
                2012
                8 August 2012
                : 6
                : 6
                Affiliations
                [1 ]Department of General and Visceral Surgery, Klinikum-Vest, Knappschaftskrankenhaus, Recklinghausen, Germany
                Article
                1750-1164-6-6
                10.1186/1750-1164-6-6
                3432014
                22873823
                60a6315c-67db-45b0-af33-09c8076d5fee
                Copyright ©2012 Büsing et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 16 January 2012
                : 13 July 2012
                Categories
                Case Report

                Surgery
                duodenal defect,bouveret’s syndrome,gastroduodeno-plasty
                Surgery
                duodenal defect, bouveret’s syndrome, gastroduodeno-plasty

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