can anyone tell me what they would use for this conversion to bladder drain for a duod leak ???
PREOPERATIVE DIAGNOSIS(ES): STATUS POST PANCREAS TRANSPLANT WITH RECURRENT
DUODENAL LEAK.
POSTOPERATIVE DIAGNOSIS(ES): STATUS POST PANCREAS TRANSPLANT WITH RECURRENT
DUODENAL LEAK.
PROCEDURES PERFORMED:
1. EXPLORATORY LAPAROTOMY.
2. CONVERSION TO BLADDER-DRAINED PANCREAS ALLOGRAFT.
3. PRIMARY REPAIR OF ALLOGRAFT DUODENAL PERFORATION.
4. ABDOMINAL WASHOUT.
ANESTHESIA: General.
INDICATION FOR PROCEDURE: The patient is a 61-year-old gentleman status post
simultaneous kidney and pancreas transplant, which was complicated by duodenal
leak. He was reexplored on March 04, 2011, and at that time, we performed
excision of the perforation site in the donor duodenum, primary repair, and
omentoplasty. On the morning of March 07, 2011, an obvious leak was noted due
to increased output of pancreatic exocrine secretions from the drain. We
therefore recommended reexploration with an attempt at conversion to bladder
drainage or pancreatectomy. The patient was competent and understood the
ramifications of the exploration. He wishes for us to proceed with the
operation.
DESCRIPTION OF PROCEDURE: The patient was taken from the floor to the
operating room and placed on the operating room table in the supine position.
General anesthesia was induced without hemodynamic instability. The abdomen
was prepped and draped in the standard surgical fashion. The abdomen was
entered through the previous midline incision.
On exploration, we immediately noted that the pancreas donor duodenum had a
recurrent leak from the same site from his previous exploration. The tissues
in the area were very inflamed. The pancreas itself continued to look viable
and had good flow to the pancreatic body and tail. The duodenum was then
mobilized as best as possible, and the bladder was also fully mobilized. We
were unable to, however, bring the donor duodenum to the bladder without
tension.
We elected to leave the donor duodenojejunostomy intact. Instead, we divided
the bowel in 2 separate places in order to leave a long length of jejunum
attached to the donor duodenum. The resulting blind ends were then
reapproximated, and an enteroenterostomy was then fashioned in order to
reestablish enteral continuity. That anastomosis was performed in 2 layers
with a running 4-0 PDS suture as well as running 4-0 Prolene suture. The
mesenteric defect was closed at the end of the procedure to avoid internal
herniation. This then gave us a blind loop near the jejunum just off the donor
duodenum. This was oversewn with a running 4-0 Prolene suture. The other
blind loop of jejunum was then anastomosed to the bladder. This anastomosis
was performed again in 2 layers with an inner layer of 3-0 PDS suture as well
as an outer layer of 3-0 PDS suture. We felt that this was the best option due
to the fact that the compromised donor duodenum was now drained into the
bladder. We filled the bladder with methylene blue, and there was no leak. We
also noted that the donor duodenum felt when the methylene blue saline was
placed, which showed us that we had a patent anastomosis.
44130 ?????????
PREOPERATIVE DIAGNOSIS(ES): STATUS POST PANCREAS TRANSPLANT WITH RECURRENT
DUODENAL LEAK.
POSTOPERATIVE DIAGNOSIS(ES): STATUS POST PANCREAS TRANSPLANT WITH RECURRENT
DUODENAL LEAK.
PROCEDURES PERFORMED:
1. EXPLORATORY LAPAROTOMY.
2. CONVERSION TO BLADDER-DRAINED PANCREAS ALLOGRAFT.
3. PRIMARY REPAIR OF ALLOGRAFT DUODENAL PERFORATION.
4. ABDOMINAL WASHOUT.
ANESTHESIA: General.
INDICATION FOR PROCEDURE: The patient is a 61-year-old gentleman status post
simultaneous kidney and pancreas transplant, which was complicated by duodenal
leak. He was reexplored on March 04, 2011, and at that time, we performed
excision of the perforation site in the donor duodenum, primary repair, and
omentoplasty. On the morning of March 07, 2011, an obvious leak was noted due
to increased output of pancreatic exocrine secretions from the drain. We
therefore recommended reexploration with an attempt at conversion to bladder
drainage or pancreatectomy. The patient was competent and understood the
ramifications of the exploration. He wishes for us to proceed with the
operation.
DESCRIPTION OF PROCEDURE: The patient was taken from the floor to the
operating room and placed on the operating room table in the supine position.
General anesthesia was induced without hemodynamic instability. The abdomen
was prepped and draped in the standard surgical fashion. The abdomen was
entered through the previous midline incision.
On exploration, we immediately noted that the pancreas donor duodenum had a
recurrent leak from the same site from his previous exploration. The tissues
in the area were very inflamed. The pancreas itself continued to look viable
and had good flow to the pancreatic body and tail. The duodenum was then
mobilized as best as possible, and the bladder was also fully mobilized. We
were unable to, however, bring the donor duodenum to the bladder without
tension.
We elected to leave the donor duodenojejunostomy intact. Instead, we divided
the bowel in 2 separate places in order to leave a long length of jejunum
attached to the donor duodenum. The resulting blind ends were then
reapproximated, and an enteroenterostomy was then fashioned in order to
reestablish enteral continuity. That anastomosis was performed in 2 layers
with a running 4-0 PDS suture as well as running 4-0 Prolene suture. The
mesenteric defect was closed at the end of the procedure to avoid internal
herniation. This then gave us a blind loop near the jejunum just off the donor
duodenum. This was oversewn with a running 4-0 Prolene suture. The other
blind loop of jejunum was then anastomosed to the bladder. This anastomosis
was performed again in 2 layers with an inner layer of 3-0 PDS suture as well
as an outer layer of 3-0 PDS suture. We felt that this was the best option due
to the fact that the compromised donor duodenum was now drained into the
bladder. We filled the bladder with methylene blue, and there was no leak. We
also noted that the donor duodenum felt when the methylene blue saline was
placed, which showed us that we had a patent anastomosis.
44130 ?????????