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Hosseini2009 PDF
Hosseini2009 PDF
Hosseini2009 PDF
SURGICAL TECHNIQUES
ABSTRACT
Background: One of the most challenging problems in clinical surgery is management of an extensive
duodenal injury. In its management, there are limitations in using jejunal serosal patch and other
conventional methods in specific conditions. This study was performed to compare treatment of large
duodenal defects by a gallbladder serosal patch and the gallbladder mucosal patch in a dog as an
animal model. Methods: A duodenal defect (2 cm, about 50% of the total circumference) was created in
the second portion of the duodenum in eight dogs. The animals were divided into two equal groups,
with group 1 undergoing serosal patch repair and group 2 undergoing mucosal patch repair. The
macroscopic and microscopic healing features of the gallbladder serosal and mucosal patch were
compared. Results: None of the dogs died due to surgical complications. The whole grafted area was
covered by neomucosa at the end of the third week in all animals with the gallbladder serosal patch
(group 1). In this group, the scar was small; no significant narrowing of lumen was noted and serosal
healing was uniformly complete. In histological examination, a complete coverage of the gallbladder
serosal patch by neomucosa consisting of columnar epithelium with short villous formations was
observed. In mucosal patch models (group 2), complete epitheliazation, mild fibrosis, and incomplete
repair were visible. In histological examination, severe inflammation was noticed too. Conclusion: In
patients with multiple trauma affecting upper gastrointestinal tracts, use of the gallbladder serosal
patch method is easy and reliable. So it may be considered in the surgical management of large
duodenal defects, which cannot be repaired by available conventional methods.
Keywords: Gallbladder serosal patch, Gallbladder mucosal patch, Duodenal defects, Repair
INTRODUCTION
Received June 22, 2008; accepted July 15, 2008.
Address correspondence to Dr. Seyed Vahid Hosseini, Gastroenterohepatology Research Center, Colorectal Surgery Department, Shiraz University of Medical Sciences, Shiraz, Iran. E-mail:
hoseiniv@sums.ac.ir
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7585% of all duodenal injuries can be safely repaired with primary repair or duodenorrhaphy [6].
However, primary closure of a large defect (>50%
of the circumference) may narrow the lumen of the
bowel or result in undue tension and subsequent suture line breakdown. Various technically demanding
treatment options such as Roux-en-Y duodenojejunostomy, pedicled grafts, duodenal resection with end-toend duodenoduodenostomy, diverticulization, pyloric
exclusion, Whipple procedure or application of a synthetic mesh, or jejunal serosal patching have been reported to be effective in the surgical management of
severe duodenal injuries [1, 712]. Using gallbladder
serosal and mucosal grafts for coverage and support
of duodenal defects may be an alternative method in
the treatment of high-risk patients. We conducted this
study to investigate the results of gallbladder mucosal
patch repair and gallbladder serosal patch methods in
severe duodenal defects in a dog as an animal model.
METHODS
This experiment was done on eight hybrid dogs, weighing 2030 kg, in the animal research laboratory of Shiraz
University of Medical Sciences. The reason pigs were
not used was the unavailability of the animal in the
country and the similarity of the gastrointestinal tract
of dogs with humans. The procedures and the handling
of the animals were reviewed and approved by the research and ethics committee of Shiraz University of
Medical Sciences in accordance with the Principles of
Laboratory Animal Care formulated by the National
Society for Medical Research and the Guide for the
Care and Use of Laboratory Animals published by
the National Institutes of Health (NIH publication 85
23, revised 1985, Washington, D.C.: U.S. Department of
Health and Human Services).
All procedures were carried out under aseptic conditions. The protocols for anesthesia, postoperative care,
and sacrifice were identical for all animals. Anesthesia was induced by intravenous injection of sodium
thiopental (15 mg/kg). After endotracheal intubation,
the animals were maintained on controlled ventilation with halothane and 100% oxygen. Normal saline
was given intravenously throughout the operative procedure at a rate of 10 ml/kg/h. In supine position,
through midline laparatomy incision, the gallbladder
and the second portion of duodenum were found. The
proximal and distal ends of duodenum were secured
by a traumatic vascular clamp to prevent leakage. A
50% full-thickness defect of circumference was made
on the second portion of the duodenum in all animals
identically. In group 1 (four dogs), while the cystic
artery was preserved, the cystic duct was ligated. An
incision was made on the fundus of the gallbladder
RESULTS
All dogs survived until they were sacrificed and the
short-term survival rates in both groups were identical. There was no evidence of leakage or peritonitis
in all animals and the patches were well fixed. Fluoroscopy with gastrophin swallowing revealed no sign
of leakage in any of the subjects. Serosal surface healing was complete in group 1 macroscopically but in
group 2, the mucosal patches had an undergrowth
of mucosa with partial patch separation without any
leakage. Figures 1 and 2 show the gross view of the
site of repair with mucosal patch. The duodenal wall
defect margin was somehow thicker in group 2 due
to severe inflammation. A few adhesion bands were
also noted in the peritoneum. No evidence of leakage,
abscess, fistula, or obstruction was found in group 2.
In group 1, a complete coverage of duodenal neomucosa on the gallbladder surfaces was observed. In this
group, no evidence of leakage, abscess, fistula, or obstruction was found (Figures 3 and 4). Pathological
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S. V. Hosseini et al.
noted and serosal healing was incomplete. In histological evaluation, smooth muscle formation was nearly
complete and a severe inflammatory reaction was also
found. Additionally in group 2, complete coverage of
the mucosal grafts by neomucosa consisting of columnar epithelium with villous formation was observed
(Figure 6).
Level of
epitheliazation
Type of
inflammation
Site of graft
Level of fibrosis
150
Gallbladder
mucosal patch
Gallbladder
serosal patch
Complete
epitheliazation
Severe
inflammation
Incomplete repair
Mild fibrosis
Complete
epitheliazation
Mild chronic
inflammation
Complete repair
Complete fibrosis
DISCUSSION
The duodenum is infrequently injured owing to its protected retroperitoneal location [13]; duodenal injury is
reported to be the reason for 3.7% of all laparotomies for
trauma [14] and is rarely an isolated injury [15]. After
the surgical treatment of duodenal injuries, mortality
and morbidity mostly depend on the development of
anastomotic leakage and subsequent abdominal sepsis
[13]. Improvements in surgical methods not only will
decrease morbidity and control the complications of
the duodenal wound but will also increase the survival
rates.
The optimal management of severe duodenal injury
(SDI) remains controversial.
Although primary repair can be performed in some
duodenal injuries, the majority require more complex
surgical interventions. In rare circumstances and for
catastrophic injuries of the pancreatoduodenal region,
pancreatoduodenectomy is unavoidable [16, 17]. Up to
now, several materials such as serosal grafts, human
amniotic membrane, lyophilized dura, Teflon, Dacron,
and ePTFE grafts have been tried for repair of gastric
and intestinal defects, with successful results [2024].
Kobold and Thal [11] for the first time used a jejunal serosal patch to close the duodenal defect in
a canine model. In this method, the serosa-to-serosa
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S. V. Hosseini et al.
Figure 6. Section of gallbladder mucosal patch graft showing severe inflammation, incomplete repair, and mild fibrosis.
Arrows: (a) Gallbladder mucosa, (b) area of inflammation, and (c) duodenal mucosa. (H & E, 25)
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