Sleeve Gastrectomy with Duodenal Transit Bipartition (S-DTB): Preliminary Results and Technical Aspects of Its Metabolic Structure

Obesity is a significant and escalating health issue both in Brazil and globally, with over 650 million overweight adults worldwide. The treatment of obesity can be performed clinically, endoscopically or surgically;surgical treatment proves to be safe and more effective in terms of weight loss and long-term maintenance. Objective: This study aimed to monitor the progress of weight loss and comorbidity control in patients undergoing sleeve gastrectomy with duodenal bipartition. Methods: This pilot project involved 8 patients divided into 2 arms. In the first arm, patients underwent sleeve gastrectomy with Roux-en-Y duodenoileal transit bipartition (S-RYDITB), while in the second arm, patients underwent sleeve gastrectomy with Roux-en-Y duodenojejunal transit bipartition (S-RYDJTB). Both procedures involved Roux-en-Y reconstruction without duodenal exclusion. In S-RYDITB, the duodenal-ileal anastomosis was performed 300 cm from the ileocecal valve (ICV), creating a 250 cm common channel and a 50 cm alimentary channel. In S-RYDJTB, a biliopancreatic loop was created 200 cm from the angle of Treitz, with a 1 m alimentary channel. Results: Five patients underwent the procedures, with one undergoing S-RYDITB and four undergoing S-RYDJTB. No adverse events such as hospitalizations, readmissions, reoperations, fistulas, bleeding, pulmonary embolism, diarrhea, dumping syndrome, or hypoglycemia occurred during the study period. The mean length of hospital stay was 2 days. The average BMI decreased from 37.27 kg/m2 preoperatively to 29.48 kg/m2 after 6 months. The significant percentage of weight loss was 21.22%, with excess weight loss of 63.6%. Ninety-five percent remission of comorbidities, including hypercholesterolemia, hypertriglyceridemia, diabetes, hypertension, steatosis, and pre-diabetes. Two patients underwent sleeve gastrectomy with duodenal bipartition using a single anastomosis. Conclusion: Duodenal switch surgery has gained worldwide recognition for its safety and efficacy in treating obesity and its associated comorbidities. In efforts to maintain the positive outcomes of the classic technique while minimizing adverse effects such as malnutrition and diarrhea, modifications to the original procedure have been proposed. Among these adaptations, Sleeve gastrectomy with bipartition of duodenal transit (S-DTB) emerges as a promising variant, offering alternative strategies to optimize patients’ nutritional safety while preserving endoscopic access to the duodenum. Initial results of S-DTB, whether performed in Roux-en-Y or single anastomosis (loop) configuration without intestinal exclusions, demonstrate the procedure’s safety and effectiveness in managing obesity and its comorbidities.

Endoscopic radial incision and cutting method for adult congenital duodenal webs:A case report

BACKGROUND Congenital duodenal webs are rare in adults and can lead to various symptoms such as nausea,vomiting,and postprandial fullness.The treatment for this disease is mostly surgical.Endoscopic treatment techniques have been developed and attempted for this disease.Endoscopic radial incision and cutting(RIC)techniques are reportedly very effective in benign anastomotic stricture.This case report highlights the effectiveness and safety of endoscopic RIC as a minimally invasive treatment for adult congenital duodenal webs.CASE SUMMARY A 23-year-old female patient with indigestion was referred to a tertiary hospital.The patient complained of postprandial fullness in the epigastric region.Previous physical examinations or blood tests indicated no abnormalities.Computed tomography revealed an eccentric broad-based delayed-enhancing mass-like lesion in the second portion of the duodenum.Endoscopy showed an enlarged gastric cavity and a significantly dilated duodenal bulb;a very small hole was observed in the distal part of the second portion,and scope passage was not possible.Gastrografin upper gastrointestinal series was performed,revealing an intraduodenal barium contrast-filled sac with a curvilinear narrow radiolucent rim,a typical"windsock"sign.Endoscopic RIC was performed on the duodenal web.The patient recovered uneventfully.Follow-up endoscopy showed a patent duodenal lumen without any residual stenosis.The patient reported complete resolution of symptoms at the 18-month follow-up.CONCLUSION Endoscopic RIC may be an effective treatment for congenital duodenal webs in adults.

Duodenal-jejunal bypass improves hypothalamic oxidative stress and inflammation in diabetic rats via glucagon-like peptide 1-mediated Nrf2/HO-1 signaling

BACKGROUND Type 2 diabetes mellitus(T2DM)is often accompanied by impaired glucose utilization in the brain,leading to oxidative stress,neuronal cell injury and inflammation.Previous studies have shown that duodenal jejunal bypass(DJB)surgery significantly improves brain glucose metabolism in T2DM rats,the role and the metabolism of DJB in improving brain oxidative stress and inflammation condition in T2DM rats remain unclear.AIM To investigate the role and metabolism of DJB in improving hypothalamic oxidative stress and inflammation condition in T2DM rats.METHODS A T2DM rat model was induced via a high-glucose and high-fat diet,combined with a low-dose streptozotocin injection.T2DM rats were divided into DJB operation and Sham operation groups.DJB surgical intervention was carried out on T2DM rats.The differential expression of hypothalamic proteins was analyzed using quantitative proteomics analysis.Proteins related to oxidative stress,inflammation,and neuronal injury in the hypothalamus of T2DM rats were analyzed by flow cytometry,quantitative real-time PCR,Western blotting,and immunofluorescence.RESULTS Quantitative proteomics analysis showed significant differences in proteins related to oxidative stress,inflammation,and neuronal injury in the hypothalamus of rats with T2DM-DJB after DJB surgery,compared to the T2DM-Sham groups of rats.Oxidative stress-related proteins(glucagon-like peptide 1 receptor,Nrf2,and HO-1)were significantly increased(P<0.05)in the hypothalamus of rats with T2DM after DJB surgery.DJB surgery significantly reduced(P<0.05)hypothalamic inflammation in T2DM rats by inhibiting the activation of NF-κB and decreasing the expression of interleukin(IL)-1βand IL-6.DJB surgery significantly reduced(P<0.05)the expression of factors related to neuronal injury(glial fibrillary acidic protein and Caspase-3)in the hypothalamus of T2DM rats and upregulated(P<0.05)the expression of neuroprotective factors(C-fos,Ki67,Bcl-2,and BDNF),thereby reducing hypothalamic injury in T2DM rats.CONCLUSION DJB surgery improve oxidative stress and inflammation in the hypothalamus of T2DM rats and reduce neuronal cell injury by activating the glucagon-like peptide 1 receptor-mediated Nrf2/HO-1 signaling pathway.

Management of duodenal ulcer bleeding resistant to endoscopy:Surgery is dead!

Acute massive duodenal bleeding is one of the most frequent complications of peptic ulcer disease.Endoscopy is the first-line method for diagnosing and treating actively bleeding peptic ulcers because its success rate is high.Of the small group of patients whose bleeding fails to respond to endoscopic therapy,increasingly the majority is referred for embolotherapy.Indeed,advances in catheter-based techniques and newer embolic agents,as well as recognition of the effectiveness of minimally invasive treatment options,have expanded the role of interventional radiology in the management of hemorrhage from peptic ulcers over the past decade.Embolization may be effective for even the most gravely ill patients for whom surgery is not a viable option,even when extravasation is not visualized by angiography.However,it seems that careful selection of the embolic agents according to the bleeding vessel may play a role in a successful outcome.The role of the surgeon in this clinical sphere is dramatically diminishing and will certainly continue to diminish in ensuing years,surgery being typically reserved for patients whose bleeding failed to respond all previous treatments.Such a setting has become extremely rare.

Laparoscopic and endoscopic co-operative surgery for nonampullary duodenal tumors

AIM To assess the safety and feasibility of laparoscopic and endoscopic co-operative surgery(LECS) for early nonampullary duodenal tumors.METHODS Twelve patients with a non-ampullary duodenal tumor underwent LECS at our hospital. One patient had two mucosal lesions in the duodenum. The indication for this procedure was the presence of duodenal tumors with a low risk for lymph node metastasis. In particular, the tumors included small(less than 10 mm) submucosal tumors(SMT) and epithelial mucosal tumors, such as mucosal cancers or large mucosal adenomas with malignant suspicion. The LECS procedures, such as full-thickness dissection for SMT and laparoscopic reinforcement after endoscopic submucosal dissection(ESD) for epithelial tumors, were performed for the 13 early duodenal lesions in 12 patients. Here we present the short-term outcomes and evaluate the safety and feasibility of this new technique.RESULTS Two SMT-like lesions and eleven superficial epithelial tumor-like lesions were observed. Seven and Six lesions were located in the second and third parts of the duodenum, respectively. All lesions were successfully resected en bloc. The defect in the duodenal wall was manually sutured after resection of the duodenal SMT. For epithelial duodenal tumors, the ulcer bed was laparoscopically reinforced via manual suturing after ESD. Intraoperative perforation occurred in two out of eleven epithelial tumor-like lesions during ESD; however, they were successfully laparoscopically repaired. The median operative time and intraoperative estimated blood loss were 322 min and 0 mL, respectively. Histological examination of the tumors revealed one adenoma with moderate atypia, ten adenocarcinomas, and two neuroendocrine tumors. No severe postoperative complications(Clavien-Dindo classification grade Ⅲ or higher) were reported in this series, but minor leakage secondary to pancreatic fistula occurred in one patient.CONCLUSION LECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors.

Perforations of Gastro-Duodenal Ulcers in the Surgery Department “A” at the University Hospital Point G Bamako

The purpose of this study was to investigate the clinical and therapeutic aspects of peritonitis by perforation of gastric and duodenal ulcer. This was a retrospective and descriptive study over 8 years (2010-2018) which allowed to collect 54 cases of peptic ulcer. Included in the study were all patients with confirmed gastroduodenal perforation on histology or laparotomy. We collected 54 cases of peptic ulcer perforated s. The age group of 30 - 49 years was the majority. The male sex was dominant with 90.7% of cases;the clinical picture was dominated by abdominal contracture associated with pain in 74.07% of cases. X-ray of the abdomen without preparation (AWP) revealed in 87.03% of cases of pneumoperitoneum. The perforation was in 68.52% of cases on the gastric antrum and in 31.48% on the duodenum. The surgical procedure used was the bank of excision, and a suture reinforcement epiploic in 68.52% of cases, a simple suture made in 31.48% of cases, the disease was marked by a fistula (1.90%) and mortality was 5.55% of cases. The gastroduodenal ulcer perforation is potentially serious and responsible peritonitis whose surgical treatment involves the peritoneal toilet and sutures the puncture.

Transit Bipartition with Duodeno-Ileal Anastomosis, without Duodenal Exclusion, as a First Stage of Bariatric Surgery in Severely Obese Patients: Case Report

Obesity is a difficult disease to control;bariatric surgery is one of the tools used to treat obesity and its comorbidities. The present case was chosen because it concerns a very obese patient whose proposed surgery—duodenal switch—resulted in traoperatively difficult to the medical team because the esophagogastric junction could not be reached due to the presence of hepatomegaly. Due to this unfavorable condition, we decided to perform a duodeno-ileal anastomosis with gastric preservation and without duodenal exclusion. The patient has been under follow-up for 14 years. She has lost 55 kg and maintains the comorbidities controlled to date.

Treatment for superficial non-ampullary duodenal epithelial tumors

Because of the low prevalence of non-ampullary duodenal epithelial tumors(NADETs),standardized clinical management of sporadic superficial NADETs,including diagnosis,treatment,and follow-up,has not yet been established.Retrospective studies have revealed certain endoscopic findings suggestive of malignancy.Duodenal adenoma with high-grade dysplasia and mucosal cancer are candidates for local resection by endoscopic or minimally invasive surgery.The use of endoscopic treatment including endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD),for the treatment for superficial NADETs is increasing.EMR requires multiple sessions to achieve complete remission and repetitive endoscopy is needed after resection.ESD provides an excellent complete resection rate,however it remains a challenging method,considering the high risk of intraoperative or delayed perforation.Minimally invasive surgery such as wedge resection and pancreas-sparing duodenectomy are beneficial for superficial NADETs that are technically difficult to remove by endoscopic treatment.Pancreaticoduodenectomy remains a standard surgical procedure for treatment of duodenal cancer with submucosal invasion,which presents a risk of lymph node metastasis.Endoscopic or surgical treatment outcomes of superficial NADETs without submucosal invasion are satisfactory.Establishing an endoscopic diagnostic tool to differentiate superficial NADETs between adenoma and cancer as well as between mucosal and submucosal cancer is required to select the most appropriate treatment.

History of Helicobacter pylori,duodenal ulcer,gastric ulcer and gastric cancer

Helicobacter pylori (H. pylori) infection underlies gastric ulcer disease, gastric cancer and duodenal ulcer disease. The disease expression reflects the pattern and extent of gastritis/gastric atrophy (i.e., duodenal ulcer with non-atrophic and gastric ulcer and gastric cancer with atrophic gastritis). Gastric and duodenal ulcers and gastric cancer have been known for thousands of years. Ulcers are generally non-fatal and until the 20th century were difficult to diagnose. However, the presence and pattern of gastritis in past civilizations can be deduced based on the diseases present. It has been suggested that gastric ulcer and duodenal ulcer both arose or became more frequent in Europe in the 19th century. Here, we show that gastric cancer and gastric ulcer were present throughout the 17th to 19th centuries consistent with atrophic gastritis being the predominant pattern, as it proved to be when it could be examined directly in the late 19th century. The environment before the 20th century favored acquisition of H. pylori infection and atrophic gastritis (e.g., poor sanitation and standards of living, seasonal diets poor in fresh fruits and vegetables, especially in winter, vitamin deficiencies, and frequent febrile infections in childhood). The latter part of the 19th century saw improvements in standards of living, sanitation, and diets with a corresponding decrease in rate of development of atrophic gastritis allowing duodenal ulcers to become more prominent. In the early 20th century physician’s believed they could diagnose ulcers clinically and that the diagnosis required hospitalization for “surgical disease” or for “Sippy” diets. We show that while H. pylori remained common and virulent in Europe and the United States, environmental changes resulted in changes of the pattern of gastritis producing a change in the manifestations of H. pylori infections and subsequently to a rapid decline in transmission and a rapid decline in all H. pylori-related diseases.

Gastroduodenal ulcer treated by pylorus and pyloric vagus-preserving gastrectomy

AIM To evaluate the curative effect of pylorus and pyloric vagus-preserving gastrectomy (PPVPG) on peptic ulcer.METHODS Treating 132 cases of GU and DU with PPVPG, and comparative studies made with 24 cases treated with Billroth Ⅰ (BⅠ) and 20 cases with Billroth Ⅱ (BⅡ); advantages and shortcomings evaluated.RESULTS Not a single death after PPVPG. No recurrence of the disorder in the subsequent follow-up for an average of 6.5 years. Curative effect (visik Ⅰ & Ⅱ) 97.7%. Acidity reduction similar to that found in BⅠ and BⅡ, but 97.7% of the BⅠ and all BⅡ cases having more than second degree intestinal fluid reflux, in contrast to 7.1% in PPVPG cases. Dumping syndrome occurred in the BⅠ and BⅡ cases, none in PPVPG cases. With regard to gastric emptying, food digestion, absorption, body weight and life quality, PPVPG proved to be superior to Billroth procedure.CONCLUSION PPVPG has the advantages of conventional Billroth gastrectomy in reducing acid, removing ulcer focus, and at the same time preserves the pylorus and pyloric vagus for maintaining the normal gastric physiological function. Dumping syndrome, intestinal fluid reflux and other complications of conventional gastrectomy may be avoided.

Endoscopic therapy for weight loss: Gastroplasty, duodenal sleeves, intragastric balloons, and aspiration

A new paradigm in the treatment of obesity and metabolic disease is developing. The global obesity epidemic continues to expand despite the availability of diet and lifestyle counseling, pharmacologic therapy, and weight loss surgery. Endoscopic procedures have the potential to bridge the gap between medical therapy and surgery. Current primary endoscopic bariatric therapies can be classified as restrictive, bypass, spaceoccupying, or aspiration therapy. Restrictive procedures include the USGI Primary Obesity Surgery Endolumenal procedure, endoscopic sleeve gastroplasty using Apollo Over Stitch, Trans Oral GAstroplasty, gastric volume reduction using the ACE stapler, and insertion of the TERIS restrictive device. Intestinal bypass has been reported using the EndoB arrier duodenal-jejunal bypass liner. A number of space-occupying devices have been studied or are in use, including intragastric balloons(Orbera, Reshape Duo, Heliosphere BAG, Obalon), Transpyloric Shuttle, and Sati Sphere. The Aspire Assist aspiration system has demonstrated efficacy. Finally, endoscopic revision of gastric bypass to address weight regain has been studied using Apollo Over Stitch, the USGI Incisionless Operating Platform Revision Obesity Surgery Endolumenal procedure, Stomaphyx, and endoscopic sclerotherapy. Endoscopic therapies for weight loss are potentially reversible, repeatable, less invasive, and lower cost than various medical and surgical alternatives. Given the variety of devices under development, in clinical trials, and currently in use, patients will have multiple endoscopic options with greater efficacy than medical therapy, and with lower invasiveness and greater accessibility than surgery.

Life threatening bleeding from duodenal ulcer after Roux-en-Y gastric bypass: Case report and review of the literature

Acute upper gastrointestinal bleeding is a rare, but serious complication of gastric bypass surgery. The inaccessibility of the excluded stomach restrains postoperative examination and treatment of the gastric remnant and duodenum, and represents a major challenge, especially in the emergency setting. A 59-year-old patient with previous history of peptic ulcer disease had an upper gastrointestinal bleeding from a duodenal ulcer two years after having a gastric bypass procedure for morbid obesity. After negative upper endoscopy finding, he was urgently evaluated for gastrointestinal bleeding. At emergency laparotomy, the bleeding duodenal ulcer was identified by intraoperative endoscopy through gastrotomy. The patient recovered well after surgical hemostasis, excision of the duodenal ulcer and completion of the remnant gastrectomy. Every general practitioner, gastroenterologist and general surgeon should be aware of growing incidenceof bariatric operations and coherently possible complications after such procedures, which modify patient's anatomy and physiology.

Perforation associated with endoscopic submucosal dissection for duodenal neoplasm without a papillary portion

AIM To investigate predictors of perforation after endoscopic resection(ER) for duodenal neoplasms without a papillary portion.METHODS This was a single-center, retrospective, cohort study conducted between April 2003 and September 2014. A total of 54 patients(59 lesions) underwent endoscopic mucosal resection(EMR)(n = 36) and endoscopic submucosal dissection(ESD)(n = 23). Clinical features, outcomes, and predictors of perforation were investigated.RESULTS Cases of perforation occurred in eight(13%) patients(95%CI: 4.7%-22.6%). Three ESD cases required sur-gical management because they could not be repaired by clipping. Delayed perforation occurred in two ESD cases, which required surgical management, although both patients underwent prophylactic clipping. All patients with perforation who required surgery had no postoperative complications and were discharged at anaverage of 13.2 d after ER. Perforation after ER showed a significant association with a tumor size greater than20 mm(P = 0.014) and ESD(P = 0.047).CONCLUSION ESD for duodenal neoplasms exceeding 20 mm may be associated with perforation. ESD alone is not recom-mended for tumor treatment, and LECS should be con-sidered as an alternative.

Endoscopic mucosal resection with circumferential mucosal incision of duodenal carcinoid tumors

Duodenal carcinoids are a rare form of neuroendocrine tumors, and tend to invade the submucosa during the early stage. Endoscopic treatment is generally recommended for duodenal carcinoids less than 10 mm in diameter. Although a few reports have described the use of endoscopic resection of duodenal carcinoids, there are no published studies on endoscopic mucosal resection with circumferential mucosal incision (EMR-CMI). We performed EMR-CMI for 5 cases of duodenal carcinoids in the duodenal bulb. The mean tumor diameter was 4.6 ± 1.8 mm. Although all of the tumors were located in the submucosa, R0 resection was performed without complication in each case. EMR-CMI may thus be a safe and effective treatment for duodenal carcinoids less than 10 mm in diameter.

Investigation of the factors influencing surgical treatment of duodenal gastrointestinal stromal tumors

BACKGROUND Duodenal gastrointestinal stromal tumor(DGIST)is a rare tumor with a specific anatomic site and biological characteristics.As the incidence of lymph node metastasis is very low,the main treatment method is surgery.Two main surgical techniques(local resection and Whipple)are performed in patients with DGISTs.The critical question is which surgical technique to choose.AIM To identify factors influencing the choice of surgery for DGISTs.METHODS The clinicopathological data of patients with DGISTs who underwent surgery between January 1999 and January 2021 were analyzed.We used the Student’s ttest or Mann-Whitney U-test and theχ2 test or Fisher’s exact test to determine the differences between the two groups of patients.Furthermore,we used logistic analysis to identify the relevant factors and independent factors related to the type of surgery.The Kaplan-Meier method was used to analyze the patient’s survival information and Cox regression analysis was performed to determine prognostic risk factors.RESULTS Overall,86 patients were analyzed,including 43 men(50%)and 43 women(50%).We divided the patients into two groups based on surgical technique(local resection or Whipple surgery).There were no differences in the age,mitotic figures,and complications between the two groups;however,the tumor size,tumor location,risk grade,postoperative hospital stay,and abdominal drainage time were significantly different.Based on univariate logistic analysis,the Whipple procedure was chosen if the tumor size was≥5.0 cm,the tumor was located in the descending part of the duodenum,or the risk grade was medium or high.In our research,the five-year overall survival rate of patients was more than 90%.We also describe two DGIST patients with liver metastases at first diagnosis and analyzed their management in order to provide advice on complicated cases.CONCLUSION The Whipple procedure was performed if the primary tumor was in the descending part of the duodenum,tumor size was≥5.0 cm,or the tumor risk grade was medium or high.

Laparoscopic partial cystectomy with mucosal stripping of extraluminal duodenal duplication cysts

Duodenal duplication cysts are rare congenital anomalies.Duodenal duplication should be considered in the differential diagnosis of patients who present with abdominal symptoms with cystic structures neighboring the duodenum.Here,we present an 8-year-old girl with a duodenal duplication cyst treated with partial cystectomy with mucosal stripping performed laparoscopically.Laparoscopic surgery can be considered as a treatment option for duodenal duplication cysts,especially in extraluminal locations.

Pancreas sparing duodenectomy in the treatment of primary duodenal neoplasms and other situations with duodenal involvement

Background:There are no clearly defined indications for pancreas-preserving duodenectomy.The present study aimed to analyze postoperative morbidity and the outcomes of patients undergoing pancreaspreserving duodenectomy.Methods:Patients undergoing pancreas-preserving duodenectomy from April 2008 to May 2020 were included.We divided the series according to indication:scenario 1,primary duodenal tumors;scenario 2,tumors of another origin with duodenal involvement;and scenario 3,emergency duodenectomy.Results:We included 35 patients.Total duodenectomy was performed in 1 patient of adenomatous duodenal polyposis,limited duodenectomy in 7,and third+fourth duodenal portion resection in 27.The indications for scenario 1 were gastrointestinal stromal tumor(n=13),adenocarcinoma(n=4),neuroendocrine tumor(n=3),duodenal adenoma(n=1),and adenomatous duodenal polyposis(n=1);scenario 2:retroperitoneal desmoid tumor(n=2),recurrence of liposarcoma(n=2),retroperitoneal paraganglioma(n=1),neuroendocrine tumor in pancreatic uncinate process(n=1),and duodenal infiltration due to metastatic adenopathies of a germinal tumor with digestive hemorrhage(n=1);and scenario 3:aortoenteric fistula(n=3),duodenal trauma(n=1),erosive duodenitis(n=1),and biliopancreatic limb ischemia(n=1).Severe complications(Clavien-Dindo≥IIIb)developed in 14%(5/35),and postoperative mortality was 3%(1/35).Conclusions:Pancreas-preserving duodenectomy is useful in the management of primary duodenal tumors,and is a technical option for some tumors with duodenal infiltration or in emergency interventions.

Post-bulbar duodenal ulcer with anterior perforation with kissing ulcer and duodenocaval fistula:A case report and review of literature

BACKGROUND A post-bulbar duodenal ulcer(PBDU)is an ulcer in the duodenum that is distal to the duodenal bulb.PBDU may coexist with a synchronous posterior ulcer in rare occurrences,resulting in a kissing ulcer(KU).Duodenocaval fistula(DCF)is another uncommon but potentially fatal complication related to PBDU.There is limited knowledge of the scenarios in which PBDU is complicated by KU and DCF simultaneously.CASE SUMMARY A 22-year-old man was admitted to the emergency department with abdominal pain,stiffness,and vomiting.The X-ray showed pneumoperitoneum,suggesting a perforated viscus.Laparotomy revealed a KU with anterior perforation and a DCF.After Kocherization,venorrahphy was used to control caval bleeding.Due to the critical condition of the patient,only primary duodenorrahphy with gastrojejunostomy was performed as a damage control strategy.However,later,the patient developed obstructive jaundice and leakage,and two additional jejunal perforations were detected.Due to the poor condition of the duodenum and the involvement of the ampulla in the posterior ulcer,neither primary repair nor pancreatic-free duodenectomy and ampull-oplasty/ampullary reimplantation were considered viable;therefore,an emergency pancreaticoduodenectomy was performed,along with resection and anastomosis of the two jejunal perforations.The patient had a smooth recovery after surgery and was discharged after 27 d.CONCLUSION The timely diagnosis of PBDU and radical surgery can aid in the smooth recovery of patients,even in the most complex cases.

Exposed endoscopic full-thickness resection for duodenal submucosal tumors: Current status and future perspectives

Exposed endoscopic full-thickness resection(EFTR),with or without laparoscopic assistance,is an emergent natural orifice transluminal endoscopic surgery technique with promising safety and efficacy for the management of gastrointestinal submucosal tumors(SMTs)arising from the muscularis propria(MP),especially of the gastric wall.To date,evidence concerning duodenal exposed EFTR is lacking,mainly due to both the technical difficulty involved because of the special duodenal anatomy and concerns about safety and effectiveness of transmural wall defect closure.However,given the non-negligible morbidity and mortality associated with duodenal surgery,the recent availability of dedicated endoscopic tools for tissue-approximation capable to realize full-thickness defect closure could help in promoting the adoption of this endosurgical technique among referral centers.The aim of our study was to review the current evidence concerning exposed EFTR with or without laparoscopic assistance for the treatment of MP-arising duodenal SMTs.

达芬奇Xi手术机器人辅助单孔腹腔镜治疗早产低体重儿十二指肠梗阻:全球首例报道(附手术视频)

本文报道了2023年4月武汉大学中南医院小儿外科应用达芬奇Xi手术机器人辅助单孔腹腔镜治疗新生儿十二指肠梗阻1例,术中同时完成两处异位胰腺病灶切除。患儿胎龄35-1w,剖宫产,出生体重2090 g,出生后50 h进行手术。手术机器人操作时间76 min,术中出血量约5 ml,术后6 d试进水,术后8 d开奶,并逐步恢复至母乳喂养,间断复查腹部彩超3次,未见明显异常,术后16 d痊愈出院。