A Life Saving but Inadequately Discussed Procedure: Tube Duodenostomy—So Far the Known and Unknown Aspects

This article, with its peculiar title, presents the authors’ experience with 31 patients treated with tube duodenostomy (TD). Like most such retrospective studies, this one is a ‘‘mix bag’’ that includes three main groups of patients: (1) those who underwent ‘‘primary’’ TD ‘‘for possible insecure duodenal stump’’ following gastrectomy for complicated duodenal ulcers; (2) patients in whom the TD was inserted into the duodenal stump during reoperation for duodenal leaks (which occurred following gastrectomy) or when the gastrectomy was added during reoperation; (3) gastric cancer patients undergoing ‘‘extended duodenal resection to achieve a free distal margin’’ or those undergoing ‘‘palliative’’ gastrectomy in whom ‘‘duodenal infiltration did not allow secure duodenal stump closure.’’ Tube duodenostomy is a maneuver well known to anyone experienced with the gastric surgery of the ‘‘old good peptic ulcer days.’’ The role of TD, when inserted into the end of the duodenal stump, is to produce a controlled ‘‘end’’ duodenal fistula that eventually closes spontaneously after removal of the TD. Surgical texts, particularly the older ones, usually mention TD in the context of the ‘‘difficult’’ duodenal stump. Numerous publications from around the world had reported experience with TD as well as other options to deal with the ‘‘difficult’’ duodenum. The raison d’etre of this article, according to the authors, is as follows: ‘‘It is surprising that despite the good results reported by many authors with TD, it has not gained wide acceptance and is rarely used.’’ As is usually the case, however, solutions for rare problems are rarely used and thus do not seem to gain wide acceptance and are rarely reported. Moreover, at least in my own surgical environment, a ‘‘difficult’’ duodenal stump, in need of a ‘‘life saving’’ TD, has become a pleasant memory from the remote past (the 1980s), when I was an aggressive young surgeon. How is it possible, then, that whereas we had an opportunity to insert only one TD in the last 10 years the authors could come up with such an impressive series of 31 cases? A closer look at the reported patients provides a few explanations. Elective surgery for duodenal ulcer is now history. Even complicated ulcers in need of surgical treatment have become a rarity in our H2 antagonistor proton pump inhibitor-fed population. Heliocobacter pylori eradication, accidental or purposeful, has nearly eliminated peptic ulcer disease in developed countries. The authors, on the other hand, are still blessed with operations for perforated, bleeding, and obstructed duodenal ulcer—whatever the reasons for it. This seems to be true for the developing world in general. I believe that gastrectomy is rarely indicated when operating for complicated ulcers. My good friend A. Hirshberg likes to say: ‘‘In the era of Helicobacter pylori, doing a gastrectomy for peptic ulcer is like doing a lobectomy for pneumonia’’ [1]. The alternatives to gastrectomy in these situations are feasible even in the presence of gross duodenal ulceration. Clearly, the best way to avoid a ‘‘difficult duodenum’’ (thus the need for TD) is to avoid an unnecessary gastrectomy. Even in the rare situations that mandate an emergency gastrectomy for perforated duodenal ulcer, such as a giant ulcer, it is our experience that a ‘‘difficult duodenal stump’’ can be avoided with a Billroth I reconstruction [2, 3]. M. Schein (&) Marshfield Clinic, 906 College Avenue West Ladysmith, WI 54848, USA e-mail: mschein1@mindspring.com