Use of jejunal serosal patch and pyloric exclusion in the management of complex duodenal injury

BACKGROUND

Duodenal injuries are relatively rare but remain a management challenge with a high incidence of postoperative complications. Guidelines from the World Society of Emergency Surgery and American Association for the Surgery of Trauma favour a primary repair for less-complex injuries, but the management of more complex duodenal trauma remains controversial with varying techniques supported, including pyloric exclusion, omental or jejunal patch closure, gastrojejunostomy and pancreatoduodenectomy. We describe the techniques used in one case of complex duodenal trauma.

TECHNIQUE

The duodenum is approached via a standard laparotomy with Kocherisation. Primary repair of the duodenal perforations is performed using a 3/0 polydioxanone suture (PDS), followed by mobilisation of a loop of mid-jejunum against the area of duodenal trauma over the primary repair as a jejunal serosal patch. The antimesenteric jejunal serosal border is sutured to the serosa of the duodenum (serosa only) using a 3/0 PDS. Pyloric exclusion is then performed through an anterior gastrostomy, to control the volume of gastric juice entering the duodenum. The pylorus is sutured closed using an absorbable suture followed by closure of the anterior gastrostomy using a GIA stapling device.

The Potential of Mesothelial Cells in Tissue Engineering and Regenerative Medicine Applications

Injury to the serosa through injurious agents such as radiation, surgery, infection and disease results in the loss of the protective surface mesothelium and often leads to fibrous adhesion formation. Mechanisms that increase the rate of mesothialisation are therefore actively being investigated in order to reduce the formation of adhesions. These include intraperitoneal delivery of cultured mesothelial cells as well as administration of factors that are known to increase mesothelial proliferation and migration. An exciting alternative that has only recently received attention, is the possible role of mesothelial progenitor cells in the repair and regeneration of denuded serosal areas. Accumulating evidence suggests that such a population exists and under certain conditions is able to form a number of defined cell types indicating a degree of plasticity. Such properties may explain the extensive use of mesothelial cells in various tissue engineering applications including the development of vascular conduits and peripheral nerve replacements. It is likely that with the rapid explosion in the fields of tissue engineering and regenerative medicine, a greater understanding of the potential of mesothelial progenitor cells to repair, replace and possibly regenerate damaged or defective tissue will be uncovered.

A serosa-searing apparatus for producing gastric ulcer in rats

Chronic ulcer models produced by serosa-searing method are very similar histologically to the ulcer healing process occurring in humans. In an effort to produce a serosa-searing chronic ulcer model in rats, we devised a new balance-type apparatus. This searing apparatus is capable of changing adequately both temperature and duration of time. Furthermore, the pressure which serves to bring the searing iron tip into contact with the stomach serosa surface can also be precisely changed. Optimal conditions for reproducing the serosa-searing ulcer model were at 65 degrees C and in 5 sec. Moreover, in order to evaluate the effects of pressure, various pressure levels (A: 5 g, 17.68 g/cm2; B: 10 g, 35.37 g/cm2; C: 15 g, 53.05 g/cm2; D: 20 g, 70.74 g/cm2; E: 25 g, 88.42 g/cm2; F: 30 g, 106.10 g/cm2; G: 35 g, 123.79 g/cm2 (+/- 1 g, 0.149 g/cm2)) of 5-sec duration at 65 +/- 0.1 degrees C were used. Macroscopically, gastric mucosal lesions were most clearly observed in a pressure-related manner 7 days after the procedure. Histologically, definite deep ulcerations (UI-III or UI-IV) were observed at pressure level C (15 g, 53.05 g/cm2) or more. The highest incidence (87%) of histological gastric ulcers (UI-IV) was observed in pressure level E (25 g, 88.42 g/cm2). The healing process was observed at 40 to 60 days postoperatively. At 100 days after the procedure, recurrences were observed both macroscopically and histologically. In conclusion, this new apparatus is very useful for reproducing a chronic ulcer model for observing the healing and recurrence process.