Pakistan Journal of Medical Sciences

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ISSN 1681-715X

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CASE REPORT

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Volume 22

October - December 2006

Number 4


 

Abstract
PDF of this Article

Laparoscopic Management of Perforation of a
Marginal Ulcer Following Anterior Gastrojejunostomy

Muthukumaran Rangarajan1, Chinnusamy Palanivelu2,
Madhupalayam Velusamy3, Rangasamy Senthilkumar4

ABSTRACT

Marginal ulcer is a well-known complication following gastrojejunostomy, especially if vagotomy is not done or is incomplete and in anterior gastrojejunostomies. We report a case of marginal ulcer perforation in a 45-year old male who presented with peritonitis and a history of undergoing surgery for peptic ulcer disease 20 years back. Diagnostic laparoscopy revealed extensive soiling and a 1.5cm perforation on the efferent loop of an anterior gastrojejunostomy. Laparoscopic closure was done. There are only few reports of similar conditions published in the literature. With experience, it is feasible to use laparoscopy for the management of uncommon acute conditions like this one.

KEY WORDS: Marginal ulcer, Perforation, Efferent loop, Laparoscopy.

Pak J Med Sci October - December 2006 Vol. 22 No. 4 474-476


1. Dr. Muthukumaran Rangarajan,
Registrar in Surgical Gastroenterology

2. Dr. Chinnusamy Palanivelu,
Director

3. Dr. Madhupalayam Velusamy Madankumar,
Registrar in Surgical Gastroenterology

4. Dr. Rangasamy Senthilkumar
Registrar in Surgical Gastroenterology

1-4: GEM Hospital, 45-A,
Pankaja Mill Road,
Ramnathapuram,
Coimbatore – 641045,
INDIA.

Correspondence:
Dr. Muthukumaran Rangarajan
E-Mail: rangy68@gmail.com

* Received for Publication: March 25, 2006

* Accepted: May 25, 2006


BACKGROUND

Anastomotic site ulceration (marginal ulcer) is a known complication of gastrojejunostomy (GJ) for peptic ulcer disease.1 It may also appear in the stomach or duodenum. It can even occur in the anterior GJ being performed for malignancy.2 Recurrence can only mean that the ulcer diathesis persists or a defective mucosal barrier– the hypersecretory state has not been corrected sufficiently by the previous operation. Recurrence is sometimes the direct result of alcohol or drug abuse by the patient, even after the first surgery. The causes are incomplete vagotomy; G-cell hyperplasia; gastrinoma; inadequate resection; retained antrum; carcinoma and hypercalcemia. Incomplete vagotomy is the most common cause of recurrent ulceration, incidence is 20% after truncal vagotomy.3 This can be reduced by baring the abdominal esophagus, which will also take care of the so-called criminal nerve of Grassi. The incidence is less in selective vagotomy. Less commonly, recurrent ulcers present with bleeding or perforation. Generally, medical management can be tried for recurrent ulcers. Perforation, bleeding, obstruction and intractability of the recurrent ulcer require surgery. Marginal ulcers require repeat resection, repeat vagotomy or both.4

CASE REPORT

The patient was a 45-year old male presenting with features of acute abdomen and peritonitis. He had undergone laparotomy for peptic ulcer disease 20 years ago; details were not known. On examination, he had tachycardia; hypotension; dehydration; tachypnea; oliguria; abdomen was rigid; rebound tenderness present; absent bowel sounds and a midline scar almost three inches below the xiphisternum was seen. The lab values showed anemia; mildly deranged electrolytes; elevated urea levels; liver function was normal including prothrombin time. On laparoscopy, there was extensive soiling of the peritoneal cavity with inflammatory flakes and bilious fluid (Fig-1). This was sucked out and a thorough saline wash was given. The small and large bowels were carefully inspected and found to be normal. On the anterior surface of the stomach, an isoperistaltic GJ anastomosis was seen. A 1.5cm perforation was found in the efferent loop of the jejunum at the anastomotic site (Fig-2). A pedicled strip of omentum was mobilized up to the perforation site and anchored with interrupted 20 vicryl intracorporeal sutures (Fig-3). The stitches were placed all around the perforation by taking seromuscular bites on the bowel and the omentum. Five such sutures were necessary to complete the omental patch. Air was pushed forcibly through the nasogastric tube and the sutured area was inspected for any leak by checking for air bubbles in a pool of saline. The postoperative period was uneventful. The nasogastric tube was removed on the 3rd postoperative day (POD), oral liquids were allowed on the 4th POD, patient started taking soft diet on the 5th POD, the drainage tube was removed after USG showed no intra-abdominal collection on the 6th POD and the patient was discharged on 7th POD.

DISCUSSION

In the 1920’s, it was Dragstedt who championed the modern treatment of peptic ulcer surgery by introducing the vagotomy, which was based on a better understanding of the vagal drive for acid secretion in the stomach. In the 1940s and 1950s, the most common operations performed for peptic ulcers were truncal vagotomies with pyloroplasties and antrectomies. In the 1960s, recognition of complications such as postvagotomy diarrhea led to development of the proximal gastric vagotomy, which could obviate these problems and the need for a gastric-emptying procedure. Today, these operations can be performed using open or minimally invasive techniques. In India, GJ is still the most commonly performed drainage procedure following vagotomy. Our patient had a history of laparotomy that was done for peptic ulcer disease 20 years ago. Details of the previous surgery were not available. In all probability, vagotomy may not have been done for this patient, as the laparotomy incision was too low to accommodate a vagotomy. The anteriorly placed GJ is probably another reason why an ulcer developed at the anastomotic site that later perforated. Another fact that has to be remembered is the possibility of carcinoma developing at the anastomotic site – the so-called ‘stump carcinoma’. This is known to occur anytime after 17 years following GJ. Gastroscopy has a unique place in studying post-operative stomachs. It is probably the procedure of choice in diagnosing anastomotic ulcer. In a study of 63 patients, 19% anastomotic ulcer was seen in 12 cases.5 It was interesting to note that the anastomotic ulcers were all found to be on the jejunal side of the GJ. Scarring due to marginal ulceration can cause afferent loop syndrome in a patient with GJ, marginal ulcers can also occur following surgery for afferent loop syndrome.6 A Nigerian study on acute abdomen also reported perforation of stomal ulcer at the GJ site.7 In a rare situation, one patient developed a marginal ulcer perforation 16 months after pyloric exclusion with GJ (for duodenal trauma).8 Laparoscopy in the management of hollow viscus perforation has been well documented. This type of marginal ulcer perforation treated with laparoscopy is probably among the first few in the literature. We can conclude that this is more proof of the role of laparoscopy in the surgery for hollow viscus perforation, even in the presence of peritonitis.

REFERENCES

1. Fernandez LR, Alvarez SJ, Fuerte S, Limones M, Lopez Herrero J. Perforation from gastrojejunostomy: 2 cases Rev Esp Enferm Dig 1994; 86(4):779-80.

2. Poole GV, Howe HR, Myers RT. Perforated marginal ulcer after palliative gastrojejunostomy. South Med J 1983; 76(7):928-9.

3. Humphrey CS, Cuschieri A. The Stomach and Duodenum. In.: Cuschieri A, Giles GR, Moosa AR eds, Essential Surgical Practice. 2 ed., chapt.67, England:Butterworth International 1988; pp. 955-88.

4. Dempsey DT. Reoperative Gastric Surgery and Postgastrectomy Syndromes. In: Zuidema GD, Yeo CJ eds, Stomach and Duodenum, Shackelfords Surgery of the Alimentary Tract, 5 ed., Vol.2, Chapt.12, Philadelphia:W.B.Saunders Company 2002;178-84.

5. Ng EKW, Leung WK, To KF, Wong SKH. The role of early endoscopic follow up after simple closure of perforated duodenal ulcer: A prospective study. Ann Coll Surg Hong Kong 2002; 6(3):71-6.

6. Tsutsui S, Kitamura M, Shirabe K. Afferent loop syndrome due to scarring of a stomal ulcer following a Billroth II gastrectomy. Endoscopy 1995; 27(5): 410.

7. Adesunkanmi ARK, Ogunrombi O. Unusual causes of acute abdomen in a Nigerian hospital. W African J Med 2003; 22(3):264-6.

8. Jen-Feng F, Ray-Jade C Lin, Being-Chuan L. Controlled Reopen Suture Technique for Pyloric Exclusion: J Trauma Injury Infection Critical Care 1998; 45(3):593-6.


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