Published online Jan 27, 2017. doi: 10.4240/wjgs.v9.i1.19
Peer-review started: July 16, 2016
First decision: August 26, 2016
Revised: October 7, 2016
Accepted: November 1, 2016
Article in press: November 3, 2016
Published online: January 27, 2017
To prospectively study the outcome of difficult gastroduodenal perforations (GDPs) treated by triple tube drainage (TTD) in order to standardize the procedure.
Patients presenting to a single surgical unit of a tertiary hospital with difficult GDPs (large, unfavourable local and systemic factors) were treated with TTD (gastrostomy, duodenostomy and feeding jejunostomy). Postoperative parameters were observed like time to return of bowel sounds, time to start enteral feeds, time to start oral feeds, daily output of all drains, time to clamping/removal of all drains, time for skin to heal, complications, hospital stay, and, mortality. Descriptive statistics were used.
Between December 2013 and April 2015, 20 patients undergoing TTD for GDP were included, with mean age of 44.6 ± 19.8 years and male:female ratio of 17:3. Mean pre-operative APACHE II scores were 10.85 ± 3.55; most GDPs were prepyloric (9/20; 45%) or proximal duodenal (8/20; 40%) and mean size was 1.83 ± 0.59 cm (largest 2.5 cm). Median times of resumption of enteral feeding, removal of gastrostomy, removal of duodenostomy, removal of feeding jejunostomy and oral feeding were 4 d (4-5 IQR), 13 (12-16.5 IQR), 16 (16.25-22.25 IQR), 18 (16.5-24 IQR) and 12 d (10.75-18.5 IQR) respectively. Median hospital stay was 22 d (19-26 IQR) while mortality was 4/20 (20%).
TTD for difficult GDP is feasible, easy in the emergency, and patients recover in two-three weeks. It obviates the need for technically demanding and riskier procedures.
Core tip: Generalised peritonitis secondary to hollow viscous perforation is common in India, with poor outcomes in many patients. Gastroduodenal perforations (GDPs), commonly treated by pedicled omental patch repair, have high leak rates and consequent high mortality, especially with advancing age, large perforations, and other systemic insults. Described strategies for leakage like jejunal patches or grafts, or pyloric exclusion are actually fraught with more risk. To emphasize minimizing time and skill, the concept of damage control from trauma is extrapolated and triple tube drainage is proposed for sick and difficult GDP patients. This study is prospective and demonstrates the ease and utility of this procedure, in an attempt to standardize it.