Intramural duodenal dissection for the treatment of bleeding duodenal ulcer

Abstract

Surgical treatment of bleeding duodenal ulcers refractory to endoscopic hemostasis remains a great challenge for general surgeons. Despite a marked decrease in the incidence of peptic ulcer disease over the last four decades, complications of duodenal ulcer still occur worldwide and often require emergency surgery [1]. Acute bleeding of a large peptic ulcer of the posterior duodenal wall represents a feared event and a clinical emergency whose initial therapeutic approach remains controversial. Although upper gastrointestinal endoscopy represents a reasonable first-line approach for diagnostic purposes, it is unlikely to achieve prompt hemostasis in unstable patients with large ulcers, and there is a risk of re-bleeding even with dual endoscopic treatments [2]. Interventional angiography and transarterial embolization (TAE) should only be considered in selected patients who are hemodynamically stable and in facilities where a hybrid operating room is available, but there is still low-quality evidence in support of this approach as a primary treatment [3–5]. However, in a recent single-center study including a systematic review and meta-analysis, the overall success rate was in favour of surgery (odds ratio 2.19), and the authors underscored the need to identify predictive criteria for recurrent bleeding after primary TAE [6]. In patients with refractory bleeding after repeated endoscopic or angioembolization attempts, open surgery with gastroduodenotomy and ulcer oversewn or gastroduodenal resection remains the therapeutic strategy of choice. However, securing the duodenal stump may be difficult in the presence of a large callous ulcer due to the difficulties in dissecting around the ulcer border. We describe a revisitation of the technique of antrectomy and duodenal stump closure that was originally described by Slattery in the 60s [7] and revisited by Meyer in the 90 [8].