Abdominal wall defect with large duodenal disruption treated by a free tissue flap with a help of temporary expandable metallic stent
A 64-year-old man underwent emergency surgery after penetrating abdominal trauma. He had intra-abdominal exsanguinating bleeding, duodenal disruption, and multiple small bowel perforation. Duodenojejunostomy, the resection of about 150 cm of small bowel followed by anastomosis, and bleeding control were performed. Despite of repeated reanastomosis due to anastomosis failure, he developed sepsis and multiorgan failure. Therefore, he was referred to our institution 22 days after the first surgery. A surgical reexploration was performed and it revealed duodenojejunal disruption and multiple enteroenteric anastomosis failure; there was a large amount of bilestained fluid in the abdomen. Since less than 1 m of the small bowel remained, pyloric exclusion or pancreaticoduodenectomy could no longer be considered. Therefore, we performed enteroenterostomy and duodenal primary repair, and placed a feeding tube distal to the perforated duodenum. After massive irrigation, the multiple drain tube was placed.\nFortunately, after intensive care, the patient could be transferred to the general ward after ventilator weaning. Enteral feeding through the jejunal feeding tube worked well. However, due to severe retraction of the duodenum, a duodenal disruption gap that was approximately 5 cm long developed. This was associated with an abdominal wall defect (). It was impossible to close either the duodenum or the wall defect primarily. We decided to use a free flap to repair the abdominal wall defect. However, because of persistent leakage of gastric, bile, and pancreatic juice through the duodenal defect, the abdominal wall defect could not be repaired directly with a free flap.\nTherefore, the bile and pancreatic juices were diverted first by placing separate pancreatic duct and bile duct drainage tubes by endoscopic retrograde cholangiopancreaticography. Thereafter, the interventional radiologist placed a 16-mm diameter, 90-mm long covered expandable metallic stent (S&G Biotech, Seongnam, Korea) from the duodenal bulb to the jejunum. This successfully reestablished duodenal continuity. Bile and pancreatic juices were diverted through endoscopic nasobiliary drainage and endoscopic nasopancreatic drainage completely. The stent migrated downward 5 days after placement. It was removed through the abdominal defect without difficulty. A second stent was placed from the gastric antrum to the jejunum. It was 16 mm in diameter and 130 mm long (), and thus was much longer than the first stent. The stent was tightly sutured to the duodenum to prevent stent migration.\nSeven days after stent placement, the patient underwent debridement and closure of the abdominal wall defect with a free flap. Duodenostomy was performed by placing a drainage tube that decompressed the duodenum and prevented infection. Endoscopic images obtained 3 months after stent placement revealed a widely patent stent, although granulation tissue had formed above the stent. The stent was electively removed 112 days after placement by using a stent removal set. Stent placement and stent removal techniques have been described in detail previously []. The pancreatic duct and bile duct drainage tubes were removed 13 days after stent removal.\nThe patient was able to take food orally after stent removal. The abdominal wall defect had healed completely. A small enterocutaneous fistula was observed. On the 234 th postoperative day, an upper gastrointestinal water-soluble contrast study was performed and showed good passage of contrast with a small enterocutaneous fistula and no significant obstruction ().