Yagi Shusuke, Ida Satoshi, Ohashi Manabu, Kumagai Koshi, Hiki Naoki, Sano Takeshi, Nunobe Souya
Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan.
Department of Upper Gastrointestinal Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
Surg Case Rep. 2019 Nov 5;5(1):169. doi: 10.1186/s40792-019-0738-y.
What type of reconstruction procedure should be applied is one of the important issues in surgery for gastric cancer. We have several options for reconstruction procedure after distal gastrectomy. The Billroth II and Roux-en-Y reconstruction have a duodenal stump while the Billroth I does not have it, which is the biggest structural difference in these procedures. An increase in intraduodenal pressure due to the formation of duodenum stump occasionally causes severe complication such as duodenal stump leakage; however, a duodenal diverticulum perforation after the Roux-en-Y reconstruction has not yet been reported. Herein, we report two cases of a perforated duodenal diverticulum after gastrectomy with the Roux-en-Y reconstruction.
The first case was a 66-year-old man who presented to our hospital with an acute onset right-upper-quadrant abdominal pain. He had undergone laparoscopic distal gastrectomy with the Roux-en-Y reconstruction for the early gastric cancer 15 months before. A large periampullary diverticulum had been detected during the checkup before the gastrectomy. Abdominal contrast-enhanced CT showed a retroperitoneal fluid collection with gas present at the second part of the duodenum. Therefore, a perforated duodenal diverticulum with abdominal abscess was diagnosed, and an emergency laparotomy was performed. Pancreaticoduodenectomy was performed because of severe duodenal inflammation and surrounding tissue damage. The second case was a 52-year-old man who had undergone open distal gastrectomy for locally advanced gastric cancer. Multiple non-ampullary duodenal diverticula had also been identified during the preoperative checkup. On the 2nd postoperative day, he presented with a sudden-onset abdominal pain with peritoneal irritation signs, and intestinal fluid was identified through the intraperitoneal drainage tube placed in a suprapancreatic site during his previous gastrectomy. Therefore, an emergency laparotomy was performed. During laparotomy, a perforated diverticulum at the second part of the duodenum was detected. The perforated duodenum diverticulum was directly sutured with drainage of the retroperitoneal space.
It is necessary to recognize that the Roux-en-Y reconstruction after gastrectomy for gastric cancer patients with duodenal diverticulum might cause a perforation of the diverticulum.
在胃癌手术中，应采用何种重建手术方式是一个重要问题。远端胃切除术后的重建手术有多种选择。毕罗Ⅱ式和 Roux-en-Y 重建术有十二指肠残端，而毕罗Ⅰ式没有，这是这些手术方式最大的结构差异。十二指肠残端形成导致十二指肠内压力升高偶尔会引起严重并发症，如十二指肠残端漏；然而，Roux-en-Y 重建术后十二指肠憩室穿孔尚未见报道。在此，我们报告 2 例 Roux-en-Y 重建胃切除术后十二指肠憩室穿孔病例。
第一例是一名 66 岁男性，因突发右上腹疼痛入院。15 个月前他因早期胃癌接受了腹腔镜远端胃切除术并 Roux-en-Y 重建。在胃切除术前检查时发现一个较大的壶腹周围憩室。腹部增强 CT 显示十二指肠第二部有气体存在的腹膜后积液。因此，诊断为十二指肠憩室穿孔伴腹部脓肿，行急诊剖腹手术。由于严重的十二指肠炎症和周围组织损伤，进行了胰十二指肠切除术。第二例是一名 52 岁男性，因局部进展期胃癌接受了开放远端胃切除术。术前检查也发现多个非壶腹十二指肠憩室。术后第 2 天，他突然出现腹痛并伴有腹膜刺激征，通过上次胃切除术中放置在胰上区的腹腔引流管引出肠液。因此，行急诊剖腹手术。剖腹手术中，发现十二指肠第二部一个穿孔的憩室。对穿孔的十二指肠憩室直接缝合并引流腹膜后间隙。
对于有十二指肠憩室的胃癌患者，胃切除术后行 Roux-en-Y 重建术可能导致憩室穿孔，必须予以认识。
