Difficult Closures of the Duodenal Stump

PRIMARY closure of the duodenal stump following gastric resection for peptic ulcer disease usually poses no problem. However, when there is intense scarring or active ulceration with marked edema and inflammation, the closure and management of this difficult duodenum is of importance. Since the incidence of duodenal stump leakage is 1½% to 3%^1-3 and the mortality of this condition is approximately 50%,^1,2,4,5 every precaution should be taken to avoid this severe complication. Many different approaches have been used to manage this problem. Some prefer to avoid the difficult duodenal dissection and closure by such methods as the Devine and Bancroft antral exclusion techniques,^6,7 McKittrick's two-stage gastric resection,⁸ and the sleeve resection of Wangensteen.⁹ In many instances, however, the duodenal dissection is completed or nearly so before the difficulty of the closure can be evaluated. In this instance, several alternate methods of duodenal closure have been