Laparoscopic repair of perforated duodenal ulcers is safe and effective in centers with experience and increasingly performed by laparoscopic surgeons. However, the role of laparoscopy for the management of large duodenal perforations (>1 cm) is unclear. To date, no experience has been reported with emergency laparoscopic repair of large perforations for gastroduodenal ulcers. The commonest reason for conversion to open surgery is a perforation size of more than 1 cm. This paper reports a case of a large duodenal perforation due to a nasogastric tube in a 26-year-old male who had undergone a tracheostomy, following a cut-throat injury. This large perforation was successfully diagnosed and repaired laparoscopically. This is probably the first paper in the English literature to report duodenal perforation due to a nasogastric tube in an adult and also the first report of a successful laparoscopic repair of a large duodenal perforation.
Laparoscopic repair of perforated duodenal ulcers is safe and effective in centers with experience and increasingly performed by laparoscopic surgeons. However, based on the existing literature, it is uncertain whether large duodenal perforations have been managed laparoscopically. Studies have shown that the commonest reasons for conversion from laparoscopic to open surgery is the finding of a large perforation (>1 cm) [
Duodenal perforations due to nasoenteral tubes are a recognized complication in pediatric patients [
A 26-year-old male had sustained a partial transverse tracheal transection following a cut-throat assault using a knife. There were no other significant findings on clinical examination and the abdomen appeared to be normal. The patient was initially managed by the “otorhinolaryngology team.” He underwent a neck exploration, followed by a primary suture repair of tracheal transection and a tracheostomy was also performed. A flexible polyvinyl nasogastric tube (14 Fr) was instituted for the purpose of enteral feeding. The patient also received intravenous antibiotics and proton pump inhibitors. The patient received feeds and seemed to be recuperating well until on the fifth POD (postoperative day) when he developed severe upper abdominal pain and distension with clinical features of peritonitis. The patient had no previous history suggestive of acid peptic disease. Laboratory investigations revealed borderline leucocytosis with elevated polymorphs, normal serum amylase, and lipase values. Plain erect abdominal radiograph was inconclusive. Ultrasonography revealed moderate intraperitoneal free fluid with dilated bowel loops. The patient was taken up for emergency diagnostic laparoscopy under general anesthesia.
The open technique of laparoscopic access was used. Three ports, namely, a 10 mm (umbilical port for the 30° videoscope) and two 5 mm ports in the right and left midclavicular line were used (working instruments). Laparoscopic evaluation revealed purulent peritonitis with the omentum localized over the first part of the duodenum and in the vicinity of the gall bladder. On lifting off the omentum, the nasogastric tube was seen perforating and protruding out from the first part of the duodenum and impacting on to the gall bladder (Figure
The nasogastric (NG) tube (white arrow) can be seen perforating the duodenum and impacting on the gall bladder.
The large duodenal perforation (white arrow) is clearly seen after withdrawing the NG tube. The site of impaction of the NG tube on the gall bladder is also seen (black arrow).
Repair of the large ulcer by primary suture (a) followed by onlay pedicled omentoplasty (b).
The insertion of a nasogastric tube is a common clinical procedure which is relatively simple and safe. Nevertheless, various unexpected and potentially lethal complications have been reported [
Laparoscopic repair of duodenal perforations has been studied extensively with respect to perforated duodenal ulcers. Various studies including the LAMA (
The commonly encountered duodenal ulcer perforations are 1 cm or smaller, and these perforations are the easiest to repair either by open or laparoscopic techniques when compared to larger perforations. The outcome in this subset is also better. However there has been some confusion regarding categorizing duodenal perforations based on their size. The term “giant perforations” has been randomly used by various authors to describe the size of perforations ranging anywhere between 0.5 cm to 2.5 cm. A more meaningful classification based on the size of perforations has been suggested by Gupta et al. [
Bertleff and Lange [
In the present case, laparoscopic primary suture closure followed by onlay pedicled omentoplasty was used to repair the large perforation. However certain aspects need mentioning. Here it is felt that the perforation was not due to a duodenal ulcer and that is probably the reason why the edges were not friable and the sutures could be easily placed without the risk of tearing or cutting through. Moreover this was a young patient (with no known previous major medical illness) and the surgical treatment was accomplished before 24 hours after the onset of symptoms. In the present case, the patient was already on antibiotics, and this would have reduced the local inflammation and sepsis thereby making the procedure simpler. Therefore it is not certain whether the same technique could be replicated in case of a large duodenal ulcer perforation with greatly inflamed and friable margins. In such cases it would probably make sense to use a laparoscopic omental plug or laparoscopic version of a Cellan-Jones repair (suturing pedicled omentum on top of perforation without primary suture closure) or even convert to an open procedure which would probably require resective gastroduodenal surgery based on the surgeon’s decision at that time. The factors associated with adverse outcomes after peptic ulcer perforations include older age, associated major medical illness, perforations of >24 hours duration, and delay in surgery beyond >12 hours after onset of symptoms [
Duodenal perforation secondary to nasogastric tubes is a rare complication in adults. Increasing awareness of potential complications associated with the insertion and maintenance of nasogastric tubes will facilitate early diagnosis and treatment. Laparoscopy is useful in the diagnosis and treatment of duodenal perforations and may be feasible for repairing large duodenal perforations. However, further research is needed to confirm the true benefits of laparoscopic repair for large or giant duodenal perforations.