Prospective Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jan 27, 2017; 9(1): 19-24
Published online Jan 27, 2017. doi: 10.4240/wjgs.v9.i1.19
Triple tube drainage for “difficult” gastroduodenal perforations: A prospective study
Nitin Agarwal, Nishant Kumar Malviya, Nikhil Gupta, Iqbal Singh, Sanjay Gupta
Nitin Agarwal, Department of Surgery and Renal Transplant, Postgraduate Institute of Medical Education and Research (PGIMER) and Dr. Ram Manohar Lohia Hospital, Delhi 110075, India
Nishant Kumar Malviya, Iqbal Singh, Sanjay Gupta, Department of Surgery, University College of Medical Sciences and Guru Tegh Bahadur Hospital, Delhi 110075, India
Nikhil Gupta, Department of Surgery, Post Graduate Institute of Medical Education and Research (PGIMER) and Dr RML Hospital, New Delhi 110001, India
Author contributions: All the authors contributed to the Manuscript.
Institutional review board statement: The study was reviewed and approved by the University College of Medical Sciences and associated GTB Hospital Institutional Review Board.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: None of the authors has any conflicts of interest or financial ties to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Dr. Nikhil Gupta, Associate Professor, Department of Surgery, Post Graduate Institute of Medical Education and Research (PGIMER) and Dr RML Hospital, B 406 Panchsheel Apartments, Plot 9, Sector 10, Dwarka, New Delhi 110001, India.
Telephone: +91-9810-592084 Fax: +91-1145-526090
Received: July 15, 2016
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.

Keywords: Peptic ulcer, Perforation peritonitis, APACHE, Triple tube drainage, Duodenostomy

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.