Annals of Pediatric Surgery, Vol 2, No 3-4, July- October 2006, PP 139-150

Original Article

Comparison of Various Techniques for Repair of Large Duodenal wall Defects: an

Experimental Study
Ayman Elnemr

Department of Surgery, Faculty of Medicine, Tanta University.

Background/ Purpose: Duodenal defects still pose a formidable challenge to surgeons. The failure to repair them properly
may result in a high output duodenal fistula, which is catastrophic and may even be fatal. The aim of this study was to
compare the results of four different surgical techniques used for the repair of large duodenal defects in an experimental
model.
Methods: A duodenal defect including ≥ 50% of the circumference and constitutes about 6 cm in length was created in the
lateral wall of the second part of the duodenum in 40 healthy dogs. They were divided into 4 equal groups, each group 10
animals. Duodenal defects in animals of group I were repaired by primary duodenorraphy and used as a control. The
effectiveness of pedicled jejunal flap (group II), Roux-en-Y side-to-side duodenojejunostomy (group III), and expanded
polytetrafluoroethylene patch repair (group IV) techniques were investigated. Fifteen days were set as survival criteria.
Repair techniques were investigated on the basis of survival, radiological examination, and postmortem gross and histological
features.
Results: Six animals survived in group I, nine animals survived in each of group II and III, while no mortality was found in
group IV. No significant survival benefit was observed between group II, III, and IV, but they had better survival than group
I. Radiological examination showed ≤50% stenosis in the repaired duodenum in group I, while the duodenal passage was
well-maintained in group II, and IV. In group III, the passage of contrast media was demonstrated in both the duodenal and
the jejunal routes. At the time of autopsy, the vascular pedicles were found pulsating with no thrombosis in group II.
Postmortem examination after 2 weeks showed complete serosal and mucosal healing of the duodenojejunal anastomosis in
both group II and III. Complete serosal coverage of expanded polytetrafluoroethylene patch was observed after 2 weeks, while
complete mucosal healing did not occur even after 12 weeks.
Conclusion: The primary repair of large duodenal defects is risky, while the autologous pedicled jejunal flap or Roux-en-Y
duodenojejunostomy could be suitable and safe options. Expanded polytetrafluoroethylene patches can be used in only
selected situations.
Index Words: Duodenal defect, experimental, repair, Jejunal pedicled flap, Roux-en-Y, ePTFE patch

INTRODUCTION

S evere duodenal injuries are technically difficult

to repair and continue to pose a significant
challenge to surgeons. Although duodenal injuries are
uncommon and are found only in 5 % of all
laparotomies for trauma, they are associated with
high morbidity (up to 50%) and substantial mortality
rates (from 10.5% to 14%).1,2 large defects can be a
result of resection of primary duodenal tumors,
resection of locally advanced tumors of the right half
of the colon invading the duodenum, extirpation of
most of duodenal wall duo to congenital
megaduodenum, or iatrogenic duodenal injury
during operation on the right kidney.3-7

Correspondence to: Dr. Ayman Elnemr, Department of Surgery, Tanta University Hospital , P.O. Box 31527, Tanta, Egypt,
Phone: Office: +20 (40) 547-7744; Cellular: +20 (10) 6245403 E-mail: aymann1@yahoo.com

Primary duodenorraphy for grade III duodenal
injury (disruption of 50%-75% of the circumference
without pancreatic or biliary injury) may narrow the
bowel or result in undue tension and subsequent
suture line breakdown. The resultant lateral duodenal
fistulas have a low rate of spontaneous closure. When
maximal non-operative management fails, operative
diversion and decompression of the duodenum can
simplify the management and reduce the mortality
rate to 7 %.8,9
Experimentally, various techniques have been
reported for repair of large duodenal defects. Kobold
and Thal10 described the use of a jejunal serosal patch
to close the duodenal defect in a canine model, and
found that the jejunal serosa exposed to the lumen
was completely covered with duodenal mucosa
within 8 weeks. Similarly, Astarcioglu et al11 used the
same method in rat model with 90% survival rate, and
complete coverage of jejunal surfaces with duodenal
neomucosa at 6 weeks. However, the clinical
application of this method is limited and the suture
line leaks.12-14In a canine model, Papachristou and
Fortner15 used a pedicled gastric flap, while
Katsikogiannis et al16 tried a pedicled gall bladder flap
with success, but further studies are needed to
validate these methods. In clinical practice, Roux-en-Y
duodenojejunostomy was performed in few case
reports with encouraging results.3-7 More radical
procedures like pyloric exclusion or diverticulization
of duodenum, and Billroth II procedure were reported
to be effective in repair of such defects, but they are
extensive and have complications such as marginal
ulceration at the gastrojejunostomy, and duodenal
fistula still occur.9,17-19
Aside from these challenging procedures, few
studies suggest that expanded
polytetrafluoroethylene (ePTFE) (Gore-Tex, W.L. Gore
& Associates, Inc. Flagstaff, Arizona, USA) graft may
be an acceptable membrane for repair of duodenal
defects. It provides mild tissue reaction with cellular
and tissue infiltration into the porous structure of the
graft.11,20 Establishment of neomucosa claimed to
occur11, but seems to demand confirmatory studies to
be conducted.
With these considerations in mind, we aimed to
compare the results of primary repair, full thickness
pedicled jejunal flap, Roux-en-Y side-to-side
duodenojejunostomy, and ePTFE patch repair
methods for reconstruction of large experimental
duodenal defects in a canine model.
Annals of Pediatric Surgery
Elnemr A
MATERIALS AND METHODS
A total of 40 healthy Mongrel dogs of both sex,
weighing 15±2 kg included in this study. All animals
received humane care in compliance with the
standard local guidelines. The dogs were kept at room
temperature and provided with free access to
standard chow and tap water prior to the experiment.
The animals were anaesthetized using 60 mg/kg
ketamine hydrochloride and medazolam 0.2 mg/kg
(intramuscular). During the procedure, lactated
Ringer’s solution (40–60 ml/kg of body weight) was
administered intravenously through a 22 G canula
fixed into the saphenous vein. Under aseptic
conditions, the abdomen was opened via a median
supraumbilical incision. A defect similar to grade III
duodenal injury9 was created in the antimesentric
border of the second part of the duodenum by
excision of an area covering ≥ 50% of its circumference
and extended about 6 cm in length (Fig. 1). To achieve
sufficient contact of duodenal contents with the
wound edges, we waited for 15 minutes.
The dogs were allocated at random into four
groups, each consisting of 10 dogs. In group I
(control), defects were repaired primarily in two
layers. A full thickness layer using continuous 3/0
coated polyglycolic acid sutures (Stericat Gutstring (P)
Ltd, New Delhi-110044) and interrupted seromuscular
sutures using 3/0 silk (Stericat Gutstring (P) Ltd, New
Delhi-110044) were performed (Fig. 2a,b). In group II,
a short loop from the proximal jejunum of equal
length with that of the duodenal defect was isolated
on its vascular pedicle. Then, a flap was created by
opening the segment along its antimesentric border,
and used as a full thickness flap to cover the duodenal
defect. The continuity of the gut was restored with an
end-to-end anastomosis (Fig. 3a,b,c). Each
anastomosis was created in two layers as previously
described. In group III, the jejunum was transected
about 20-25 cm from the duodenojejunal flexure, the
end of the distal jejunum was closed in two layers.
Defects were repaired by performing side-to-side
duodenojejunostomy and end-to-side
jejunojejunostomy (Fig. 4a,b,c). Each anastomosis was
created in two layers as in the previous groups. In
group IV, ePTFE patch® (vascular fabrication) was
secured to the defect by using 4/0 continuous
polypropylene suture (Prolene; Ethicon, Edinburgh,
Scotland) placed about 2 mm from the edge of the
prosthetic patch (Fig. 5a). In all groups, abdomens
140
 Elnemr A

were closed with interrupted 2/0 silk sutures after one animal died in postoperative day 3. All animals
putting tube drains near the anastomotic sites. survived in group IV. In group II, III, IV, the survival
rate was much better than in the control group, but
The animals were returned to their cages after the
the difference was statistically significant in survival
operation. Cefotaxime sodium, 100 mg/kg per day
time only between control group and Group IV
intramuscularly, was administered to the animals for
(P<0.05). Among groups II, III, and IV, there was no
5 days after the operation. Oral fluid was resumed on
statistically significant difference in survival rate
the second day, and then gradual alimentation after
(P>0.05). The cause of death in all nonsurvivors was
the third postoperative day. Drains were removed
abdominal sepsis due to anastomotic leakage. Until
after 48 hours. Fifteen days were set as survival
the survivors were sacrificed, they had eaten well and
criteria.
had displayed no unusual behavior. Only one animal
All animals had an upper gastrointestinal contrast had wound infection.
study 15 days postoperatively. After the dogs were
Upper Gastrointestinal contrast study
anaesthetized (5~7 mg/kg intravenous thiopental
sodium), 14 G Ryle tube was inserted into the Upper gastrointestinal roentgenographic series on
stomach. A volume of 300~500 ml of thin barium the 15th postoperative day demonstrated about 50%
sulfate was introduced, and then serial X-ray films stenosis of the repaired duodenum in the survivors of
were taken. group I (Fig. 2C). In group II, a well maintained
passage through the reconstructed duodenum
Gross and histological examinations of the
without stenosis was found (Fig 3d). In group III, a
repaired defects were carried out after 2 weeks for
smooth passage of the contrast media through both
group I, II, III, and after 2, 12 weeks for group IV.
the duodenal route and the jejunal route was
Through sacrification under an intravenous overdose
observed (Fig. 4d). In group IV, a filling defect with an
of thiopental sodium (total of 1 gm/animal), the
ulcer niche was observed at the repair site which
abdomen was entered using the same antiseptic
seems to be the result of the extruded prosthesis in the
precautions as at the initial operation. Both aerobic
lumen (Fig. 5B).
and anaerobic cultures were taken on peritoneal
cavity entry. The abdominal cavity was examined Gross examinations
with respect to the presence of leakage, abscesses and
At the time of autopsy, intraabdominal adhesions
adhesions. The animals in group II were initially
were identified particularly on the right upper
given anesthetic dose of thiopental sodium to examine
quadrant close to the repair sites. In group I, II, and
the vascular pedicle for visible pulsations or
III, minor adhesions could be separated easily from
thrombosis, and then were sacrificed. Intraluminal
the repaired duodenum. Only significant adhesions at
cultures were taken in group IV. After death, repaired
the site of the repair were noted in 3 animals of group
segments of the duodenum were excised and fixed in
IV. There was no leakage or abscess seen in the
10 % formalin prior to processing through paraffin-
peritoneum in all groups.
embedded blocks. Cross-sections 4 µm of the
anastomotic sites and ePTFE patch sites were taken In control group, all survivors showed healed
and stained with hematoxylin and eosin for light suture line, patent but narrowed duodenum (Fig. 2D).
microscopic examination. The internal diameter of the duodenum at the site of
repair was ≤50% of the distal duodenum. In group II,
All the nonsurvivors were explored to define the
the vascular pedicles of the jejunal flaps appeared
exact cause of death. All data were analyzed using a
intact and pulsating with no thrombosis. The jejunal
Fisher exact test for paired observations, with P < 0.05
flaps were found to be in place with strong integrity
for significant levels.
into the duodenal serosa (Fig. 3E). On gross
examination there was no evidence of focal
RESULTS hemorrhage or ulceration of the flaps. The structure
and thickness of the flaps remained unchanged. Also,
Survival studies
complete healing of the suture line between the
Survival rates of all groups are shown in Table 1. jejunal and duodenal mucosa was obvious after 2
In the primary repair group (control), 4 animals died weeks (Fig. 3F). Patency of the repaired duodenum
in the postoperative days 3, 4, 4 and 5. In group II, one was excellent for those animals.
animal died in the postoperative day 4. In group III,

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Fig 1. Marking a 6 cm longitudinal defect in the lateral Fig 2. Primary duodenorraphy: (A) Large
wall of the 2nd part of duodenum (about 50% of its duodenal defect was created.
circumference).

B C D

Fig 2 B-D. Primary duodenorraphy: (B) operative photograph showing a severely narrowed duodenum after repair arrows).
(C) Upper gastrointestinal contrast study 2 weeks postoperatively showing narrowing of the repaired duodenum (arrows).
(D) Postmortem examination of the repair sites after 15 days showing narrowed duodenum (arrows).

Annals of Pediatric Surgery 142

 Elnemr A

A B
Fig. 3. The full thickness pedicled jejunal flap: (A) A jejunal loop of equal length to the duodenal defect was isolated
based on its vascular pedicle. (B) The flap was prepared by opening the segment along its antimesentric border.

C D
Fig. 3. (C) The full thickness flap anastomosed to the duodenal defect, and the continuity of the gut was restored with an
end-to-end anastomosis. (D) Upper gastrointestinal contrast study 2 weeks postoperatively showing a well maintained
duodenal passage without stenosis (arrows).

E F
Fig. 3. (E) Complete serosal healing between the jejunal flap and the duodenum. (F) Healing of the suture line between
the mucosa of jejunal flap and duodenal mucosa is clear.
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 Elnemr A

A B C

Fig. 4. A side-to-side duodenojejunostomy and an end-to-side jejunojejunostomy: (A) Distal jejunal limb was closed at its
end then opened along its antimesentric border. (B) Both anastomoses are completed. (C) Diagram illustrating Roux-en-Y
anastomosis.

D E F
Fig. 4. A side-to-side duodenojejunostomy and an end-to-side jejunojejunostomy: (D) Upper gastrointestinal contrast study
2 weeks postoperatively showing smooth passage of the contrast media through the duodenal route and the jejunal route.
(E, F) Postmortem examination of the repair sites after 2 weeks showing complete serosal healing of the Roux-en-Y
anastomosis as well as complete healing of the suture line between the jejunal and duodenal mucosa of the Roux-en-Y
anastomosis.

Annals of Pediatric Surgery 144

 Elnemr A

A B C
Fig. 5. An ePTFE patch repair: (A) ePTFE patch is sutured to the duodenal defect by continuous Prolene 4/0. (B) Upper
gastrointestinal contrast study 2 weeks postoperatively showing a filling defect with an ulcer niche (arrow) at the repair site.
(C) Postmortem examination after 2 weeks, the patch is completely covered by serosal layer from the duodenum (arrows).

D E F

Fig 5. An ePTFE patch repair: (D) Postmortem examination after 2 weeks, the mucosa crept on the patch (arrow) only for about
a 2 mm from the patch edge. (E,F) After 12 weeks, the patch was still attached but extruded into the lumen from its center and
the mucosa folded over (arrow) toward the middle for a distance of about 5 mm. On removal of the patch, the central area
became the base of what appeared to be a punched-out ulcer.

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A
Fig 6. Complete anastomotic healing with a clear regional
specializations of both duodenal (arrow) and jejunal
(notched arrow) mucosae in the full thickness pedicled
jejunal flap and Roux-en-Y repairs (H&E staining; × 40).
B
Fig 7. In ePTFE patch repair, the outer layer of ePTFE
patches (arrow) was covered by mesothelial-like cells)
(H&E staining; × 40).

In the Roux-en-Y group, complete anastomotic
healing between the jejunal and duodenal serosa as
well as mucosa was observed after 2 weeks (Fig.
4E&F). Gross inspection revealed no particular lesions
such as ulceration or shrinkage in both duodenal and
jejunal sides of the repair. In ePTFE patch group, there
was no patch failure in the form of detachment or
migration. Serosal surface healing was complete by 2
week (Fig. 5C). Also, patches had creeping mucosa at
the margin of well-sealed patch edges for a distance
about 2 mm (Fig. 5D). After 12 weeks, the patches
were still attached but extruded into the lumen from
its center. Heaping mucosa at the margins of the
insert folded over toward the middle for a distance of
5 mm (Fig. 5E), and thus a mucosal clump from the
opposite side was grown toward the center of the
patch. On removal of the patch, the central area
became the base of what appeared like a punched-out
ulcer (Fig. 5F).
Histological examinations
On histological examination of the transverse
sections, the repair sites in the survivors of the control
group showed complete healing with normal mucosal
and serosal continuity of the duodenum. In the full
thickness pedicled jejunal flap and Roux-en-Y groups,
complete anastomotic healing with a clear regional
specializations of both duodenal and jejunal mucosae
was observed (Fig. 6). In ePTFE patch group, the outer
layer of ePTFE patches was covered by a layer of
mesothelial-like cells after 2 weeks. On the lumen
side, there was no mucosal overgrowth beyond the
heaped-up edge (Fig. 7).
Bacteriological culture
In group IV, heavy pure growth of E-coli was
detected from the swabs taken from the mucosa at the
defect edge in 6 animals. All peritoneal cultures had
no growth.
Table 1, Fifteen-day survival rates of the animals in
each group
Group No. of animals survived at 15 days (%)
I 6/10 (60%)
II 9/10 (90%)
III 9/10 (90%)
IV 10/10 (100%)
Group I = 2-layer primary duodenorraphy; Group II =
pedicled jejunal flap; Group III = Roux-en-Y side-to-side
duodenojejunostomy; Group IV = ePTFE patch repair.
Difference was statistically significant in survival time
only.

Annals of Pediatric Surgery 146

 Elnemr A

DISCUSSION treated with primary closure especially with large

defects.
In cases of duodenal trauma, the second portion is
injured most commonly, in 35%-45%, while the third To the best of our knowledge, only few reports in
and fourth portions are each injured in approximately the literature about the use of open pedicled small
15%, and the first portion in <10%. Multiple injuries intestinal grafts for repair of alimentary tract defects.
are seen in the remaining.1, 21-23 Experimentally, Walley and Goco31 proposed many
methods to correct this problem such as
In a recent report including 222 patients with
duodenojejunostomy, serosal patching, pedicled flap
duodenal injuries, Blocksom et al24 reported that 70%
from the ileum or jejunum, and pedicled gastric flap.
of the patients had grade III injuries according to
They concluded that the choice of procedure must be
American Association for Surgery for Trauma
tailored to the nature of the defect, the amount of
(AAST).9 In other case series, most of the duodenal
tissue lost and the amount of peritoneal
wounds are grades II and III.25, 26 Experimentally, Oh
contamination. Mokhov, 32 described a technique to
et al18 created defects of 4 cm2 in various segments of
patch defects with the jejunum, but the details were
canine abdominal alimentary tract (stomach,
not available. Clinically, Littmann et al33 used jejunal
duodenum, small bowel, and colon). In this study, a
flap to enlarge localized duodenal stenosis in a case of
large duodenal defect (similar to grade III of duodenal
chronic pancreatitis. Also, Ishiguro et al34 successfully
injury scale9) was created in the lateral wall of second
used pedicled ileal flap to repair large duodenal
part of duodenum involved ≥ 50% of its
defect after right hemicolectomy for right colon cancer
circumference and extended for 6 cm in its
invading the duodenum in one patient.
longitudinal axis. Also, it may simulate the defect left
after resection of primary duodenal tumors or tumors In the current study, a full thickness pedicled
of the surrounding organs invading the second jejunal flap was tailored to reconstruct a large defect
portion of the duodenum. created in the lateral wall of the second part of the
duodenum. This well-vascularized flap augments the
Segmental resection and primary end-to-end
blood supply to the suture line and hastens the
duodenoduodenostomy is usually feasible when
process of healing. Moreover, this method does not
dealing with injuries to the first, third and fourth
create a nonanatomical bypass and has fewer
portions of the duodenum. This may be technically
intestinal anastomoses than other complex techniques.
difficult when dealing with an injury to the second
In this group, only one animal (10%) died due to
portion since the ampulla of Vater and the intimate
gangrene and anastomotic disruption at the cranial
relationship of the duodenum to the pancreas may
end of the graft. This may be due to entrapment of the
limit adequate mobilization.17, 23 Primary repair has
terminal feeding vessels of the jejunal flap by the
been used successfully in 70%–85% of duodenal
sutures. All the survivors in this experimental group
wounds.24,26 However, duodenal fistula constitutes a
had a strong integrity of the suture line, normal
major cause of morbidity and mortality in patients
thickness and structure of flap. The inner surface of
treated with primary repair. The overall incidence of
the graft showed no gross lesions. The internal
fistula formation is reported to be 2%–16%. 17,25,27,28 In
diameter of the reconstructed duedenum was larger
a series reported by Timaran and colleagues,29
than or similar to the diameter of the proximal and
duodenal fistula was reported in 3.9% of patients
distal segments as detected by radiological and gross
treated with primary repair. The mortality rate was
examinations.
reported to be 5.3% in their study.
To date, there is no available published data in
For primary repair, a 2-layer closure technique is
English to compare with our results of the jejunal
accepted generally by most surgeons.17,21,28,29 In this
pedicled flap in the repair of large duodenal defects.
work, the 2-layer closure of the defect severely
However, Gupta et al35 reported no ulceration or scar
compromised the lumen, and led to 40% mortality
stenosis in 20 animals using ileal flaps to cover gross
duo to suture line disruption and peritonitis. This is in
defects in the duodenal wall. They also found that
parallel with the results of Astarcioglu et al11 and
healing was good and the ileal mucosa retained its
Saygun et al30 who reported 50 % mortality in rats
villi and other features on microscopic examination.
treated by primary repair. So, it can be clearly said
In this work, we preferred the proximal jejunal flap
that some problems cannot be resolved in cases
over the ileal flap for some aspects related to the

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native bowel characteristics and function; during right nephrectomy for xanthogranuloma [In
compatibility of the wall thickness of the duodenum press].
and jejunum, such as the collagen content and elastic
In some experimental studies concerning the
properties which are nearly similar in both, 36and the
treatment of gastric and intestinal defects, ePTFE
minimal differences in the intraluminal milieu
patches have been tried with successful results.11,20, 42
between the duodenum and jejunum when compared
Expanded polytetrafluoroethylene is an inert
to the ileum.37 The loop from proximal jejunum was
biomaterial and impermeable to secretions. Because of
easily accessible, and its vascular pedicle was long
its pore size of 10 to 20 µm, fibrocollagenous tissues
enough for its transferring to the injured duodenum.
can hardly ingrow through these pores.12 When using
The terminal straight arteries were easily visible
this particular material, no significant leaks have been
because the mesenteric fat does not reach that far into
reported to date. Complete resurfacing of ePTFE
the mesentery. Interestingly, there is extensive
patch by serosa has been observed to occur within a
communication between submucosal plexuses formed
few days after its insertion as replacement for full-
by short and long vessels that supplied the jejunal not
thickness duodenal defects. Even when a patch has
the ileal wall.38 Moreover, Anthony et al39 found that
partial separation, the covering mesothelial layer
the vascularity score of the jejunal antimesenteric
remains intact and is reliably confining to luminal
margin was significantly higher than that of the ileum
contents.20,42, 43 This study supports these results as a
(jejunal = 8.6 (0.6); versus ileal = 6.6 (0.2), giving an
complete resurfacing by serosa has been observed to
overall impression that the jejunal antimesenteric
occur after 2 weeks (when the first animal was
margin was more vascular than that of the ileum. This
sacrificed) of ePTFE patch insertion.
aids in more safe and rapid healing of the
anastomosis. Thoroughness of mucosal growth over the luminal
side of the ePTFE patch, however, cannot be
Another alternative technique for closure of large
substantiated. Careful review of prior reports failed to
duodenal defects is Roux-en-Y duodenojejunostomy.
disclose accurate details. Indeed, there was no actual
In the Roux-en-Y group of this experiment, complete
mucosal resurfacing over the ePTFE prostheses in
anastomotic healing was observed at 15 days in all
what was displayed in their microscopic
survivors (90%). This is in accordance with the results
illustrations.11, 42 After their work using different
of Astarcioglu et al11 who found complete anastomotic
Fabrics of ePTFE, Oh et al20 stated that heaping
healing in 17 out of 20 (85%) rats after 15 days. No
mucosa at the margins of the insert seemed to fold
other experimental work or case series for comparison
over toward the middle for a distance of 5 mm, and
was found. The main advantage of these techniques is
thus a mucosal clump from the opposite side was met
the usage of autologue tissues, with double blood
toward the center of the patch, thereby giving an
supply to the anastomotic line from both the
illusion of complete luminal healing by mucosal
duodenal and jejunal sides. However, multiple
overgrowth. Mucosa never extended more than 5 mm
anastomoses prolong the operating time and may be
beyond its supporting vascularized bed. To prevent
associated with increased risk of anastomotic
this abutment, we used a bigger patch (6×2 cm), thus
problems. In the clinical practice, no large case series
obviating such a false impression. The patches have
was found but only sporadic case reports used this
remained in position as placed, yet eventually led to
technique. Fujiwara et al3 used this double-tract
patch extrusion into duodenal lumen. Similar to the
anastomosis with a Roux-en-Y loop to repair
results of Oh et al 20 mucosa never extended more
extensive duodenal defect caused by a wide resection
than 5 mm beyond its supporting vascularized bed in
of a tubulovillous adenoma of the second part of the
our own preparations. As a result, with this bigger
duodenum in one patient. Also, Lee et al40 used this
prosthesis the central area became the base of what
technique for repair of posterior perforation of
appeared to be like a punched-out ulcer on patch
duodenal diverticulitis in one patient. Goh et al41
removal. It therefore appears that ePTFE, as currently
described this technique after partial duodenectomy
fabricated, is not the matrix for mucosal area
for a case of gastrointestinal stromal tumor involving
expansion, yet the fact that a synthetic prosthesis can
the second and third portion of the duodenum.
be accepted into bowel wall and has some durability
Recently, we successfully applied this technique for
is at least a major step forward. Perhaps some future
repair of a duodenal defect after excision of high
fabrications may permit the desired growth of mucosa
output duodenal fistula caused by duodenal injury
to occur.

Annals of Pediatric Surgery 148


Brown et al, 44 and Bleichrodt et al, 45 claimed that
this material is not suitable to use in contaminated
environment because of the high risk of infection-
induced patch dehiscence. On an experimental basis,
some series reported no infections secondary to
ePTFE grafts.11,20,42 Therefore, in this work,
intraluminal swabs and excised grafts revealed heavy
pure growth of E-coli in 60%. So, it is a major concern
and should be investigated in future studies.
In this experimental study, we have compared the
results of 4 different methods (primary repair,
pedicled jejunal flap, Roux-en-Y duodenojejunostomy,
and ePTFE patch) for the repair of experimental large
duodenal wall defects in dogs. It is well known that
the application of experimental data in clinical
practice may be difficult. However, we believe that
the pedicled jejunal flap and Roux-en-Y
duodenojejunostomy can be applied safely. A possible
clinical applications of ePTFE for a duodenal patch
include closing of the difficult duodenal stump, and
replacement of sizeable areas of traumatized
duodenal wall. The use of different fabrics of
synthetic patches should be further explored
experimentally. Hopes for some changes in
fabrication of the material can provide a matrix for
mucosal overgrowth.
CONCLUSION
The primary repair is risky, while the autologous
pedicled jejunal flap and Roux-en-Y
duodenojejunostomy could be suitable and safe
options in the repair of traumatic and postsurgical
large duodenal defects. Expanded
polytetrafluoroethylene patches can be only used in
selected situations.
REFERENCES
1. Morton JR, Jordan GL Jr: Traumatic duodenal injuries.
Review of 131 cases. J Trauma 8:127-139, 1968
2. Donohue JH, Crass RA, Trunkey DD: The management
of duodenal and other small intestinal trauma. World J Surg
9:904-913, 1985
3. Fujiwara H, Yamasaki M, Nakamura S, et al:
Reconstruction of a large duodenal defect created by
resection of a duodenal tubulovillous adenoma using a
double-tract anastomosis to a retrocolic Roux-en-Y loop:
report of a case. Surg Today 32:824-827, 2002
4. Endo M, Ukiyama E, Yokoyama J, et al: Subtotal
duodenectomy with jejunal patch for megaduodenum
149
Elnemr A
secondary to congenital duodenal malformation. J Pediatr
Surg 33:1636-1640, 1998
5. Dimitrov V, Dudunkov Z: The use of a new method for
the restoration of duodenal passage following the partial
extirpation of its wall in treating locally advanced tumors of
the right half of the colon. Khirurgiia (Sofiia) 43:92-95, 1990
6. Dziri C, Horchani A, Ben Ayed H, et al: Duodenal risk
in difficult nephrectomies for lithiasic pyonephrosis. Tunis
Med 60:336-338, 1982
7. Kim CJ, Kato K, Yoshiki T, et al: Intractable
duodenocutaneous fistula after nephrectomy for stone
pyonephrosis: report of a case. Hinyokika Kiyo 49:547-450,
2003
8. Malangoni MA, Madura JA, Jesseph JE: Management of
lateral duodenal fistulas: a study of fourteen cases. Surgery
90:645-651, 1981
9. Moore EE, Cogbill TH, Malangoni MA, et al: Organ
injury scaling. II: Pancreas, duodenum, small bowel, colon
and rectum. J Trauma 30:1427-1429, 1990
10. Kobold EE, Thal AP: A simple method for the
management of experimental wounds of the duodenum.
Surg Gynecol Obstet 116:340-344, 1963
11. Astarcioglu H, Kocdor MA, Sokmen S, et al:
Comparison of different surgical repairs in the treatment of
experimental duodenal injuries. Am J Surg 181:309-312, 2001
12. Wynn M, Hill DM, miller DR, et al: Management of
pancreatic and duodenal trauma. Am J Surg 150:327-332,
1985
13. McInnis WD, Aust JB, Cruz AB, et al: Traumatic injuries
of the duodenum: a comparison of 1° closure and the jejunal
patch. J Trauma 15:847-853, 1975
14. Ivatury RR, Gaudino J, Ascer E, et al: Treatment of
penetrating duodenal trauma: primary repair vs. repair
with decompressive enterostomy/serosal patch. J Trauma
25:337-341, 1985
15. Papachristou DN, Fortner JG: Reconstruction of
duodenal wall defects with the use of a gastric "island" flap.
Arch Surg 112:199-200, 1977
16. Katsikogiannis N, Iachino C, Viotti A, et al:
Experimental use of a pedicle gallbladder graft for the
repair of large duodenal defects. Pathologica 89:54-58, 1979
17. Ivatury RR, Nallathambi M, Gaudino J, et al:
Penetrating duodenal injuries. Analysis of 100 consecutive
cases. Ann Surg 202:153-158, 1985
18. Berne CJ, Donovan AJ, Yellin AE: Duodenal
‘diverticulization’ for duodenal and pancreatic injuries. Am
J Surg 127:503-507, 1974
19. Martin TD, Felicano DV, Mattox KL, et al: Severe
duodenal injuries. Treatment with pyloric exclusion and
gastrojejunostomy. Arch Surg 118:631-635, 1985
Vol 2, No 3-4, July - October 2006

20. Oh DS, Manning MM, Emmanuel J, et al: Repair of full-
thickness defects in alimentary tract wall with patches of
expanded polytetrafluoroethylene. Ann Surg 235:708-711,
2002
21. Corley RD, Norcross WJ, Shoemaker WC: Traumatic
injuries of the duodenum: a report of 98 patients. Ann Surg
181:92-98, 1975
22. Flint LM Jr, McCoy M, Richardson JD, et al: Duodenal
injury: analysis of common misconceptions in diagnosis and
treatment. Ann Surg 191:697-701, 1980
23. Ivatury RR. Duodenal injuries: Small but lethal lesion.
Cir Gen 25:59-65, 2003
24. Blocksom JM, Tyburski JG, Sohn RL, et al: Prognostic
determinants in duodenal injuries. Am Surg 70:248-255,
2004
25. Ivatury RR, Nassoura ZE, Simon RJ, et al: Complex
duodenal injuries. Surg Clin North Am 76:797-812, 1996
26. Weigelt JA. Duodenal injuries: Surg Clin North Am
70:529-539, 1990
27. Cogbill TH, Moore EE, Feliciano DV, et al: Conservative
management of duodenal trauma: a multicenter
perspective. J Trauma 30:1469-1475, 1990
28. Nassoura ZE, Ivatury RR, Simon RJ, et al: A prospective
reappraisal of primary repair of penetrating duodenal
injuries. Am Surg 60:35-38, 1994
29. Timaran CH, Martinez O, Ospina JA: Prognostic factors
and management of civilian penetrating duodenal trauma. J
Trauma 47:330-335, 1999
30. Saygun O, Topaloglu S, Avsar FM, et al: Reinforcement
of the suture line with an ePTFE graft attached with
histoacryl glue in duodenal trauma. Can J Surg 49:107-112,
2006
31. Walley BD, Goco I: Duodenal patch grafting. Am J Surg
140:706-708, 1980
32. Mokhov EM: Replacement of defects in the duodenal
wall with a small intestine graft. Vestn Khir Im I I Grek
119:40-43, 1977
33. Littmann K, Krause U, Eigler FW: Enlargement surgery
of duodenal stenosis caused by chronic pancreatitis with a
pedicled open jejunal graft. Chirurg 53:109-111, 1982
34. Ishiguro S, Moriura S, Kobayashi I, et al: Pedicled ileal
flap to repair large duodenal defect after right
hemicolectomy for right colon cancer invading the
duodenum. Surg Today 34:386-388, 2004
Annals of Pediatric Surgery
Elnemr A
35. Gupta AKA, Garq BK, Kansal YK, et al: Open pedicle
grafts of ileum for the repair of large duodenal defects. An
experimental study. Br J Surg 3:241–244, 1976
36. Storkholm JH, Villadsen GE, Jensen SL, et al:
Mechanical properties and collagen content differ between
isolated guinea pig duodenum, jejunum, and distal ileum.
Dig Dis Sci 43: 2034-2041, 1998
37. Kararli TT: Comparison of the gastrointestinal
anatomy, physiology, and biochemistry of humans and
commonly used laboratory animals. Biopharm Drug Dispos
16:351-380, 1995
38. Anthony A, Dhillon AP, Pounder RE, et al: Ulceration
of the ileum in Crohn's disease: correlation with vascular
anatomy. J Clin Pathol 50:1013-1017, 1997
39. Anthony A, Pounder RE, Dhillon AP, et al: Vascular
anatomy defines sites of indomethacin induced jejunal
ulceration along the mesenteric margin. Gut 41:763–770,
1997
40. Lee VT, Chung AY, Soo KC: Mucosal repair of posterior
perforation of duodenal diverticulitis using Roux loop
duodenojejunostomy. Asian J Surg 28:139-141, 2005
41. Goh BK, Chow PK, Ong HS, et al: Gastrointestinal
stromal tumor involving the second and third portion of the
duodenum: Treatment by partial duodenectomy and Roux-
en-Y duodenojejunostomy. J Surg Oncol 91:273-275, 2005
42. Ozlem N, Erdogan B, Gültekin S, et al: Repairing great
duodenal defects in rabbits by ePTFE patch. Acta Chir Belg
99:17-21, 1999
43. Caga T, Gurer F: Polytetrafluoroethylene patch grafting
for closure of stomach defects in the rat. Br J Surg 80:1013–
1014, 1993
44. Brown GL, Richardson JD, Malangoni MA, et al:
Comparison of prosthetic materials for abdominal wall
reconstruction in the presence of contamination and
infection. Ann Surg 201:705-711, 1985
45. Bleichrodt RP, Simmermacher RK, van der Lei B, et al:
Expanded polytetrafluoroethylene patch versus
polypropylene mesh for the repair of contaminated defects
of the abdominal wall. Surg Gynecol Obstet 176:18-24, 1993
ACKNOWLEDGMENTS
The author wishes to thank Dr. Amr Elbadry, (Lecturer of
Radiology, Tanta University) for assistance in barium meal
examination, Dr Amr Elsebaey (consultant pathologist in
the Army Forces) for histological examination of the
specimens, and Dr. Abu Elfetoh Elanany (Lecturer of
Bacteriology, Tanta University) for making the
bacteriological cultures.
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