Use of an occlusive dressing for 2 weeks reduces the incidence of sternal wound infections

The problem of distal duodenal obstruction is relatively uncommon but of considerable morbidity to the patients in which it occurs. How best to overcome such obstruction remains the subject of debate, with most opting for the more traditional gastrojejunal bypass procedure. Duodenojejunostomy is presented here as a valid alternative to consider when deciding how best to palliate such patients. Obstruction of the distal duodenum is usually caused by extrinsic compression either by a carcinoma of the uncinate process of the pancreas or by retroperitoneal lymphadenopathy. However, chronic duodenal ileus may also develop from benign processes such as congenital malrotations, duodenal diverticulae, duodenal stenosis, annular pancreas; and acquired lesions such as superior mesenteric aneurysm, peptic ulceration and radiation-induced stricture. The main symptoms are vomiting, biliary reflux and epigastric pain with consequential malnutrition, weight loss and malaise. Experience with duodenojejunostomy at Royal North Shore Hospital has been favourable, with five cases over the last 3 years proving suitable for the bypass procedure and all showing marked improvement in symptoms. All cases used a Roux-en-Y loop of jejunum with either side-to-side or end-to-side anastomosis onto the second or third parts of the duodenum. Patients were generally able to tolerate an oral diet within 4–5 days and discharge from hospital usually occurred within 1 week of surgery. Postoperatively, one patient with a large liposarcoma of the retroperitoneum invading the 4th part of the duodenum, developed an enterocutaneous fistula. The surgical anastomosis was not involved and remained patent and functioning. The fistula healed with a short course of total parenteral nutrition. The patient survived 12 months following discharge and was reported by the palliative care team 2 weeks prior to his death as pain free, tolerating a soft diet with a normal bowel habit. The other four patients have been followed up for over 6 months and found to be free of bilious vomiting and tolerating sufficient diet to maintain their weight. The superiority of duodenojejunostomy over gastrojejunostomy in terms of symptom control was most clearly demonstrated in a 66-year-old man who underwent both procedures, 1 year apart. Suffering duodenal obstruction from a metastatic colonic carcinoma, he had a gastrojejunostomy formed in 2001. Although initially controlling his symptoms, within a year he had redeveloped problems of vomiting, diarrhoea, weight loss and malaise. A revision of the bypass was made, bringing the jejunal anastomosis to the 3rd part of the duodenum and closing the original gastric stoma site. Following this second procedure and to date, his symptoms have improved considerably. Patients undergoing bypass surgery tend to be unwell, for a combination of factors. As a direct consequence of their vomiting and poor oral intake, they rapidly become malnourished. Those with malignancy are even more cachexic and do not tolerate surgical intervention well. They usually have locally advanced or widespread metastatic disease at the time of presentation. Therefore the decision to operate needs to take into account the ease of the procedure and how successful it is likely to be in terms of palliating the symptoms for the patient. The role of gastro-enterostomy has been controversial. Delayed gastric emptying is the major cause of morbidity in these patients and its incidence ranges between 30% and 60%. 1 It has been argued that patients can be stratified on their clinical status so that on the basis of a reasonable expected survival period they should be offered prophylactic gastro-enterostomy in addition to other bypass procedures such as choledochojejunostomy. 2,3 The problem is that in a substantial proportion, the patient still suffers from delayed gastric emptying, the pathophysiology of which is poorly understood. The relatively poor outcome following gastro-enterostomy has prompted others to use gastric antrectomy and Billroth type-2 reconstruction. 4 However, gastric antrectomy remains a formidable procedure in these patients. The better tolerated gastroenterostomy is a favoured approach in gastric outlet obstruction, but its role in distal duodenal obstruction is questionable. 5