EGS BTK_Episode9

Hi everyone, and welcome to our ninth episode in Emergency General Surgery. My name is Graeme Scalphorn Gross. We've got a great episode for you today, some really interesting cases, and I'm joined as always by Jordan Nada and Ashley Nadler. Hello. Hey. So we figured it was about time that we talked about one of the most dreaded emergency general surgery organs, the duodenum.

Yes, often in many cases referred to appropriately as the difficult duodenum. Yes, it really is, and there's many reasons for that. Part of it is that the incidence of duodenal catastrophes has decreased over time, although it doesn't always feel like that. And we've developed a better understanding and treatment for peptic ulcer disease, which caused the majority of duodenal surgical problems.

So, we have less training and exposure to duodenal surgical emergencies than we once had. Yeah, I totally agree, Ashley. A lot of the surgeries that used to be commonplace for acid control, like vagotomies, have fallen out of favor with the use of

PPIs. So most surgeons in practice now don't have any idea what selective vagotomy is, I can include myself as one of them.

And we rarely have to perform it because it's just not necessary anymore. Yeah, proton pump inhibitors have certainly done wonders, but, you know, we still have issues with H. pylori, NSAID use, associated alcohol and tobacco use, etc. Yeah, and it's also challenging to deal with a retroperitoneal organ that's intimate with the pancreas.

The insertion of the common bowel duct at the second portion of the duodenum can really limit management options in ways that we don't have to deal with in other regions of the small bowel. It also relies on a multidisciplinary approach to management and this can definitely be a good thing and I'm very thankful that we don't have to operate on every bleeding duodenal ulcer.

So, thank you to our colleagues from GI and from IR. It's good to recognize these challenges so we can prepare for when we do need to intervene surgically. And this also allows us to teach trainees about these rare operations that are still necessary in emergent settings when other non surgical

options have failed or aren't available or aren't appropriate for that particular scenario.

So let's get into a couple of cases to highlight the decision making and management around duodenal surgical emergencies. That sounds great. If it's all right, I'll do the first case. I had a relatively difficult case last week, not something that I've seen very often. And I'd really like to work through it with you guys and hear your pro tips for how you would have approached it.

Does that sound okay? Yeah, of course. That sounds great. Yeah, for sure. Hit it. Okay, great. So, I was called urgently down to the emergency department. All I knew was that we had a 57 year old male with an upper GI bleed. Jordan, I know that's not a lot of information, but as a trauma surgeon, I know you've also got a great approach to bleeding.

What would you be thinking about as you went to see this patient? Yeah, I gotta say, I feel like I'm in my element when we're talking about bleeding patients. So whenever I'm faced with a scenario with aggressive hemorrhaging, I'm thinking about three questions. So number one, and most pertinently, are they stable or

unstable?

Number two, where's the bleeding coming from? And number three, what do I have to do to stop it? I think that's a really nice and straightforward approach, Jordan. We talk a lot about stable versus unstable patients, and usually when I ask trainees about this, they tell me about the current vital signs.

Vital signs are really important, but so is the trend over time and the resuscitation they've had so far. And the physical exam findings, ultrasound findings, labs, and imaging data. So clearly we need a lot more information than we have here. Those are really great points. Ashley, can you tell me a bit more about how you would use your exam and labs and imaging and the early management of this patient with the upper GI bleed?

For sure. So, as I arrive at the bedside, in addition to reviewing the vitals, I wanna know how the patient looks. Did they look well? Did they look sick? Are they pale? Are they protecting their airway? Are they in respiratory distress? Is there any visible bleeding that I can see? You can use POCUS here.

It can be a great tool. Especially if you have some training from ICU or if you're familiar with it.

You can look for things like the IVC and see if it's flat. You can look at the left ventricle, see if it's hyperdynamic. You can see if there's ascites. You can see how distended the stomach is. Of course, there's a lot of fancier things you can do with an ultrasound, but that's beyond the scope of this discussion.

Yeah, for labs, I think it's important to make sure you have your basic stuff like a CBC, coags, fibrinogen, and then, of course, if they're available to you you might be able to make some use of things like rhodium and tag to know a little bit more about their coagulopathy. I think a blood gas and a lactate can be quite useful here to help guide your resuscitation or for signs of occult shock and of course, important to get a type and cross match.

And don't forget the value, of course, of history here. First and foremost, as consultants, our job is to confirm the diagnosis that we heard about on the phone. Upper versus lower GI bleeding can be a little bit difficult to sort out initially, especially if you have a brisk upper GI bleed but there are a number of clues that can help.

Frank hematemesis is pretty clear, but you might not always have that. So from there,

I'd want to know about previous episodes of upper GI bleed, any associated abdominal pain, risk factors for cirrhosis, previous endoscopy or banding, personal or family history of foregut malignancy, any previous surgeries, especially associated with the aorta, medication history, including NSAIDs or ASA.

I totally agree with both of you and, and such great points, I think, you know, one of the critical things for sick patients is that as you're obtaining all this information, you are simultaneously managing them, right? So, you're going to start your resuscitation with the information you have, and you're going to kind of go from there.

And then, as Jordan mentioned, if you have real time data like TAG or Rotem, this can be really nice to guide you, but from the beginning, you're just going to kind of start with a balanced approach. I also really liked the point about the history. You know, this can really tell you a lot about what type of bleed you might be dealing with.

And, and it's so different taking care of a patient with a history of cirrhosis and maybe esophageal varices

versus somebody with a bleeding gastric or doing the ulcer or a new cancer. For sure. For example, if I had a strong suspicion for esophageal varices, I'd be giving octreotide and ceftriaxone early.

If they were really unstable, I'd be thinking about, you know, Do I have a Blakemore tube available? In just about everyone, I'd be starting a proton pump inhibitor, and since my goal is to get them to an upper GI scope pretty quickly I would consider erythromycin if there's a lot of blood suspected in the stomach to help them with visualization.

And of course, they're bleeding, so they need things like good vascular access and to be in a safe setting and resuscitation, as Graham mentioned. Yeah, for sure. And I always enjoy, you know, hearing you talk about Blakemore tubes, you're the person who taught me how to place them and it's a procedure I've only had to do once, but I really heard your voice in my head as I was putting that traction on that tube and crossing my fingers, hoping for the best.

So, Jordan, you mentioned a bunch of labs that you would get. How would you use those to plan and then execute

your resuscitation? So yes, of course, in resuscitation, it's great to have some objective data and we talked a little bit about a gas and lactate, which can be very helpful. And you know, I've certainly had patients that look pretty good from the outset of things only to find out they have a base deficit of minus 10 and we're a lot further behind than we thought.

So part of resuscitation approach has to depend a little bit on their, you know, hemodynamic findings as well as their laboratory findings. The unstable patient, to my experience, gets a balanced resuscitation, whole blood if you have it. And if not, of course, a ratio approaching one to one to one, you're gonna also wanna add calcium in every six units or so.

Or so. In, in a patient who's a bit more stable, I'll transfuse to a hemoglobin greater than seven, platelets over 50 and FibroGen greater than one 50, or change that as you know, to your units as appropriate. There's some evidence for permissive hypertension and gastrointestinal bleeding, so you can keep that in mind, and we don't need to keep the numbers perfect from a hemodynamics standpoint, but you do want to keep them reasonable.

We're going to hold any home

anticoagulants, and reverse them if possible. Cirrhotic patients can be really tricky. You want to consider FFP, but it might not completely fix their coagulopathy. And of course, you know, uremia may also be an issue, so you want to consider whether or not patients could benefit from DDAVP as far as some platelet dysfunction.

Yes, you can never forget about those uremic platelets. I think those are really great transfusion targets and so important that you mentioned this is only relevant in fairly stable patients. The unstable patient gets resuscitated with blood. So one thing I always find tricky, and Jordan, maybe you can speak to this, is how do you decide when to intubate someone with an upper GI blade?

Yeah, so I can share my approach for sure, but I think the bottom line here is that it's tough. So we know patients who have an upper GI bleed who get intubated have worse outcomes, and probably a lot of that has to do with the fact that they're just sicker patients. Who knows? It's hard to tease out those details.

As with any resuscitation, A and B are pretty important, and we have to do what we can to protect the airway. And intubation can definitely help to facilitate the endoscopy. And the important thing to

remember, too, is that when these patients get the bit of sedation they need for endoscopy, they're likely going to get a bit more uptunded, they're going to get more unstable, so that intubation sometimes becomes very important.

You have to expect these patients are going to have a full stomach. So in my hands, these patients would all get a rapid sequence intubation. And the airway can be expected to be bloody. They're likely to have bloody emesis that's going to be getting in your way. So make sure you have one or two suctions or even better to have ready.

And this is definitely a case where I would go direct to direct laryngoscopy rather than use a glide scope. Because if you get any blood on your glide scope, anyone who's experienced that will know your view is just completely lost. So many great pearls and such a scary situation when you're trying to intubate somebody and you can't see anything.

I like, you know, when you think about these patients and when you're at the foot of the bed I like to think of sort of having a court vision and really trying to, while we resuscitate, try to figure out where they're gonna go, what's their next step for this patient? And for a lot of these patients, it's really about localizing the bleeding.

And to do that, we need to do a

diagnostic study. So. Ashley, what are our options for these patients in terms of diagnostic studies to help us localize the bleeding? Yeah, you're exactly right. Localization is key in these patients. The standard of care here is to do an upper endoscopy and this can be diagnostic as well as therapeutic.

The timing of that is going to be dependent on institutional policies and culture. But the guidelines suggests that these should be done within 12 to 24 hours of the patient presenting with the bleed. Much longer than most of us want to sit around and wait with a sick patient, but there's reason for that.

Yeah, for sure. And I think there's a couple of important points here. So first the resuscitation is really important in order to facilitate a safe diagnostic study. And the other thing is that no study is perfect. And sometimes there's just too much clot burden for the endoscopist to definitively localize or treat a bleeding vessel.

You'll often see algorithms to talk about doing a second scope if the patient rebleeds after the first one. And I, but I think in those situations you need to talk to the endoscopist,

have a plan for what to do. If the patient continues to bleed or re bleeds as they may or may or may not feel like a second endoscopy is actually the best strategy for that particular patient.

And if you can, I also recommend being present for the endoscopy. Any information you can get with respect to localization can be super helpful down the road, especially if you're looking at surgical intervention for that patient. Thanks, Jordan. That's a great point. And I find it so important with these really sick patients to really manage them in a multidisciplinary way.

And this includes communication and being present in those conversations. IR angiography can also be diagnostic and therapeutic, but again, the patient needs to be stable enough to tolerate the trip to the interventional radiology suite. But hang on, Graham, wait, this is a surgical podcast, we've been talking for a while about the diagnosis and initial approach to upper GI bleeding, but we have not forgotten your case.

So, I assume you tried all this, but it did not stop the bleeding. Yeah, actually, you're absolutely right. And as fun as it's been to kind of nerd out about some

critical care and resuscitative tips and tricks yeah, we did all of those things. And and, you know, some of those things didn't work as you'll find out.

So this particular patient did not have any history or exam findings to suggest cirrhosis. They had a recent fairly heavy NSAID use. So our hypothesis was that we were dealing with with a bleeding ulcer. We tried endoscopy and had conversations with IR but the patient continued to bleed and and get sicker and sicker.

So, as a group, we decided that the best thing to do is just to head to the operating room. Yeah, it's probably worth mentioning that if you're in the operating room for an upper GI bleed in 2024, the patient's probably pretty sick. So, while we're all big fans of minimally invasive surgery, this patient's getting a laparotomy in my hands.

Now, what you're going to do at a laparotomy really depends a little bit on the information that you have to guide you. Hopefully, you have some sense of where the bleeding is actually coming from, at least stomach versus duodenum to help guide you. Graham, in your case, did you guys have any sense of

this?

Yeah, for sure. And I really appreciate you mentioning before trying to see the endoscopy if you're not the therapeutic endoscopist. I think just a picture is worth a thousand words and so much value in actually being there for these procedures. So what we saw was that there was a little bit of clot in the stomach, but we were pretty sure that most of the bleeding was actually coming from the duodenum.

Okay, well, that's really helpful to make your operative plan. This isn't an operation that any of us do all the time, and there's a lot of critical structures nearby. So it's good to have a few tricks in your toolbox. Yeah. I agree with Jordan, this patient is probably quite sick if you're in the operating room, and I'd ensure that I had a big incision to get a good exposure.

I'd also have my favorite upper abdominal retractor ready, and profuse bleeding in the duodenum is classically from a posterior ulcer that has eroded into the gastroduodenal artery. The basic approach is to make a longitudinal incision at the duodenal bulb, just distal to the pylorus, address the bleeding, and then close transversely.

obviously so easy.

Yeah, for sure. You make a great point. This is a really high risk area. You're probably quite close to the CBD. So there's a couple of things that you can do to try to get a sense of exactly where the area is that you're dealing with. So first you can cokerize the duodenum, which will allow you to palpate a little bit to feel the CBD from the backside of the duodenum.

If it's still difficult to tell you can place a pediatric feeding tube into the papilla. If you are into the papilla, if you can see it through the duodenotomy, which can make it a bit easier. One additional trick I like here if I'm really worried and I'm having trouble visualizing it is I can actually do a cholecystectomy and then feed like a Fogarty or a pediatric feeding tube down the cystic duct and out the ampula.

And that way I can leave that sitting in place and, you know, keep that visualized throughout whatever I'm doing to try to deal with that bleed repair, etc. With respect to stopping the bleeding, the typical teaching is a three point ligation, getting the gastroduodenal artery as well as its medial branch.

In reality, you're probably just doing a figure of eight

suture through the area that's bleeding and trying to go an appropriate depth to control the bleeding, but not so deep that you're potentially grabbing one of the, or grabbing the duct or any other critical structure. Yeah, the Goldilocks suture.

I totally agree. I love those tips and tricks and you know, anything you can do to help you you know, in these difficult cases, especially as Ashley mentioned, doing something we don't do all the time to get any clues about the anatomy. I think that really helps. So that's pretty much exactly what we did.

We, we co chorized we had the pediatric feeding tube in and we were able to identify the bleeding. We were lucky. Really just a simple figure of eight was all we needed to control the bleeding, but but actually what if that hadn't been enough for, or what if our patient was an extremist and you didn't think there was time to do all of these things any other tricks that you could do to stop bleeding in this area?

So one thing you could do is identify and control the proximal gastroduodenal artery at its origin right off the common hepatic. This is done by retracting the liver cephalad and pulling the duodenum

down. What this does is flatten out the hepatoduodenal ligament and there's a prominent lymph node that you should be able to identify there.

Right underneath that should be the common hepatic artery where it gives off the GDA. Since I don't do this every day, before ligating anything I would test clamp the GDA and make sure I still have blood flow to the liver. Yeah, very cool trick and definitely can be life saving. So this gives us a nice approach to the bleeding duodenal ulcer.

What if the ulcer is in the stomach? Graham, how would you approach this? A good question, Jordan. Again, hopefully if, especially if you were able to see the endoscopy you probably have a little bit of information about where in the stomach the bleeding is coming from and and what the underlying etiology actually is.

Now you do have a few tools in your toolbox here this could just be a gastrotomy and over sewing a simple bleeder as well as various types of resections, including wedge, entrectomy, distal gastrectomy. As we've said before, these patients tend to be sick, so, you know, probably less is more if it's going to work to stop the bleeding.

And a simple wedge of the greater curve is a

viable option, but you really do have to ensure that you actually include the ulcer. Resecting distal stomach is also doable, but It might take you a little bit longer and of course it's going to ultimately require reconstruction. Exactly, you have lots of options.

I ask for a gastroscope to be available in the operating room as it may help with intraoperative localization. Again, remembering that these patients are going to be sick, you don't have to do any reconstruction in the initial operation. Our job in these cases is to stop bleeding. If they've had a large resuscitation or they're on a lot of pressers, have a large base excess or lactate, it's completely reasonable to leave them open, go to the ICU for further resuscitation before you come back for definitive management.

Good stuff, and I think that's a good lead in to our second case, and I made sure I saved a bit of a doozy for us. So for this case, we've got a 41 year old woman. She's got a history of substance misuse, both alcohol and street drugs. She presents an extremist with a very limited history. Your

emergency medicine colleagues have been able to determine that they had several days of severe abdominal pain and have been self medicating with street drugs.

By the time you see the patient, they've been intubated they're quite tachycardic and on high dose vasopressors they had a chest x ray to verify the endotracheal tube placement and it shows massive free air. So Graham, what are you thinking about in this case? Yeah, I'm pressers and free air. So I'm certainly thinking this is a very sick patient.

And so they're going to need aggressive management. I would you know, as always think about the ABC's first and sounds like we're happy with the endotracheal tube and ventilation. I would, you know, see where they were at in their resuscitation. Of course, make sure that that's ongoing while adhering to the principles we talked about in the 1st case.

Given the concern with the free air, I'd start the broad spectrum antibiotics. I think peptazo is a great choice here or whatever the local agent of choice is. And, and I'm probably not going to waste time getting this patient a

CT scan. I recognize that, That's that's something that some people would do, but I think this patient needs to be in the operating room.

And if I was able to get a little more history from them, or I guess not them but some collateral history from perhaps anybody that knew them or was with them, anything about their medications, anything about risk factors, although it would be great to have you know, but it may not be possible.

I completely agree, Graham. People definitely talk about doing a CT for operative planning and there's some arguments to be made for that, but this patient is sick. They need an operation sooner rather than later. Further imaging isn't going to change that for me. As far as the approach for this operation, given the undetermined nature of the perforation and the severity of the presentation, I'd go directly to a laparotomy rather than considering a laparoscopic approach.

Yeah, that's exactly what I would do too. So, in this case, we get into the operating room, the patient continues to have escalating vasopressor requirements, and they're not even really requiring much of an anesthetic because they're so We do a generous laparotomy and there's a big gush of air

and lots of bilious fluid everywhere.

Not only that, there's extensive fibrinous changes throughout the abdomen and loculations all implying it's been building for a while. So we suction the area thoroughly and then we pretty quickly see the source. There's a massive perforated ulcer in the anterior duodenum. It looks like it's primarily D1 but involving D2 as well.

It's at least three or four centimeters in size. The tissue looks terrible. It's thick, it's angry looking. It feels woody to the touch. Graham, do you have any thoughts? Easy peasy, right? ? Yeah, just another day. Y well, at this point, you know, I mean, I think this is a really bad situation. We have a really sick patient with a really, you know, terrible pathology.

I think, you know, at this time, we just have to take it back to basic principles. We're here to get source control and, you know, this patient is super sick. I think it's obvious we're going to be performing damage control surgery here. What's going through my mind is what, what are my options? And you

know, like, how can I get this patient out of the operating room with source control as safely as possible.

Yep, that's the question. And what makes this problem both so challenging and so interesting? We don't need to do anything definitive, but we do need to get control of the ongoing sepsis if this patient is going to survive. We have a few options, which is usually the case when there's no perfect answer.

First of all, the involvement of D2 is scary. And no matter what we do, we need to make sure that we don't destroy the impula. All the same tips and tricks from the last case apply here too. If the area is directly next to the ampulla and it's involved, then there's no easy resection that we can do here.

And primary repair or a drainage procedure like a duodenostomy tube becomes key. Yeah, definitely. And if you do repair, you usually do an anostomy tube to control the defect, then you're also going to have to decide whether or not to add something like a pyloric exclusion or some sort of drainage procedure like a triple tube.

But truthfully, that decision can wait until you take the patient back later. Perfect is the enemy of good here, in my opinion.

So get this patient sepsis controlled. and deal with the other things later. So let's say in this particular case, I won't be too mean. So the ampula is not actually involved.

So closure or resection are both potential options. So what do you think we do then? Yeah. I mean, I think a lot of it depends on what the tissue looks like. And you know, you kind of led us to believe this tissue looks pretty bad, but you know, if possible, we could try to bring the duodenum together and repair.

Of course, we try to patch anything over top of it to buttress. It's momentum is a great choice. I love using the falciform ligament. People describe using the June. And, you know, at that point, decide how confident you are in it and whether they're an exclusion is going to be going to be useful. We could also consider a resective procedure, and that may be the right move here given, you know, how big this thing is and the tissue that you were describing.

It really did sound like that duodenum was blown apart and that tissue sounded pretty terrible. I think you're right. Often these cases look like a bomb went off, and I don't think anything

is going to hold together here. If we can resect, then I think that We should perform an antrectomy and see if we're able to get healthy tissue to close on the distal end of the duodenum.

If we can't, then we can drain the distal end however you see fit, do a temporary abdominal closure and get out of the operating room. Don't feel the need to finish your reconstruction at this time. We can do that later. Yeah, that's exactly what I would suggest, suggest too. So, in this case, we did an antrectomy.

We leave an NG in the stomach on suction. The duodenal staple line looks okay, but the tissue is still pretty crummy, even as far distal as we can safely get. We put a couple of drains adjacent to it, and we do a temporary abdominal closure. We get the patient back to the ICU. We continue resuscitation and antibiotics, and over the course of about 48 hours, they improve quite a bit.

They come off pressers, and eventually we take them back to the OR. You open the abdomen back up and the duodenal staple line has started to de hiss a little bit with a little bit of associated bile leakage. What do we do now?

I think things were going so well. You couldn't just let us have this one, eh?

No, never. Oh boy. Well, yeah. Now we have to make a decision about what to do with this duodenum. And then what are we going to do about the reconstruction? There's lots of options that have been described, but I think we all agree that simple and safe is really key here. So. In my hands I'd I convert this duodenal stump into a duo ostomy tube.

And at that point, if I think it's safe, the contamination wasn't too bad. The patient's doing well hemodynamically. I convert this to a B two with a gastro de ostomy ruin wise. Also another option here, but that does that in additional anastomosis. And this s field is already sounding pretty high risk.

Yep, I agree. Simple and safe is the way to go. This gets the patient out of trouble, minimizes your number of staple lines remaining at risk, and gives them the best possible chance. It's important to remember at this point that you need to also think about early nutrition of these patients. So you can

consider putting in a feeding, triginostomy, distal to the GJ, and asthmosis.

And as they recover, you need to remember H. pylori eradication, as well as addictions and social services involvement. Yeah, great job guys with a, with a complex case, and I want to reiterate that these, with these patients, there's no absolutely right answer in my opinion. These are tough, complex, controversial cases but there certainly are safer and less safe options.

So I think we have to make the best decision that we can from amongst those options for the patient that's in front of us. And that brings us to the game portion of the session. Woohoo! The best part. Yes, and I'm very excited that I actually get to host the game for once. So, this game is called Drain or Pain.

Yes, I love it because it's absolutely a trick. The duodenum always leads to pain. That is correct, and so get ready for your scenarios. So, the first scenario is an 80 year old comorbid woman in hemorrhagic

shock from an upper GI bleed who's failed two endoscopies for control. Let's go to Graham. Great.

Okay. Well, luckily we touched on some of these principles in the first case. We're going to do resuscitation while we're doing physical exam history. We're going to talk to our colleagues to see where this bleed might be. We're going to talk to IR to see if that's an option. If they're too sick for IR, they're going to go to the operating room.

And I sure hope I have some sense of where this is so that I know where to make my incision. Gordon.

Yeah, fair enough. I think in this case, especially assuming this is a pretty multi comorbid 80 year old. If there is a good IR option, which is most likely to be the case, if it's in the or more likely to be the case, if it's in the duodenum, I'd certainly want to try to get them stabilized with resuscitation and entertain that.

If that's unlikely to be successful or they're too unstable for that to be an option, then they get an operation, you know, assuming that's in keeping with their goals and they get this

over sewed and likely not any resective procedure if I can avoid it. Okay, great. So now we'll go on to the next patient, a 68 year old man.

We have a perforated ulcer at the first part of the duodenum, his heart rate is 110 and his blood pressure is 130 over 90. Graham? So the first thing I'm thinking about is this patient doesn't sound that sick. And so I really think that we have all options on the table here. My preference would be to do a minimally invasive procedure if I can.

And then depending on the size of the ulcer and what the tissue looked like, I'm probably some sort of patch procedure using momentum or falciform, depending on how those tissues looked great. Yeah, I agree. It sounds like they're maybe a little bit tachycardic, but otherwise pretty close to human.

I mean, it dynamically normal. So with ongoing resuscitation, antibiotics, PPI I would plan to approach this laparoscopically and I, I do personally even with a, you know, if there's a small hole in

D1, I like to close this primarily and then patch over top is my personal preference. And I do that laparoscopically in this case, unless I had some reason not to.

Okay, great. We have finally a stable patient, a 72 year old woman who's stable and has a contained appearing duodenal perforation. Jordan, why don't you go first? Okay. Yeah, you know, these, these can be challenging if I think it would depend a little bit on what exactly we mean by a, you know, contained appearing.

Duodenal perforation. If this is like a, you know, retroperitoneal perforation that's relatively small, I might try to treat that non operatively with MPO for a number of days, followed by a swallow study to make sure there's no active leak in antibiotics and PPI. If this is like an anterior ulcer that presents in a very delayed fashion and is walled off again, I might take the same approach.

And again, you know, assume that this has mostly walled itself off already

and try to treat this non operatively, give them time, antibiotics, PPI, and then a delayed scan with PO contrast. If I think this is just a you know, still a relatively early perforation that's just partially contained, then my approach, I think, would be similar to our last patient to laparoscopically approach this and close it and patch it.

Depends a little bit on the details of this one. Yeah, I agree. I mean, I think that not every duodenal perforation necessarily requires operative management, and I certainly not operated on, especially posterior perforations before. And just like I said, Jordan drained and, and kind of observed them you know, if it's anterior, and this is sort of the beginning of something that's going to make the patient really sick.

It's, it's hard to know with just the snapshot. So, I'd want this patient to have antibiotics. I'd want, you know, them to be NPO with a NG tube in place, and I'd want them in a monitored setting so that I can keep an eye on them. Okay, great. And our

last case, I can't help myself. We talked a bit about gastric bleeding.

But let's talk about a 76 year old man with a 2cm perforation of the gastric antrum. Let's say he's stable. All right. I wasn't sure which one of us you were torturing with this one. So yeah, you know, that's that's tough if I might approach this initially laparoscopically, but if I get in there and I see there's this big ulcer there I'm, and it's in the gastro gantrum I'm likely feeling that this is It's going to need a resective procedure rather than just being something that can be closed and patched.

So in my hands, personally, I'd likely convert to a laparotomy, do an antrectomy and given that he's stable, I'd do an immediately or immediate resection with a B2 or a Roux en Y depending on the circumstances. Great. Graham. Yeah I always struggle with with this sort of scenario because so much of it depends on what you think the underlying etiology is.

And you know, especially if you're worried about

malignancy and what the tissues around it are. And I really think this is hard because I don't want to set the patient up for you know, not being able to do a future cancer surgery, but I really think I have to treat the problem at hand.

And that problem is, is the perforation. So. You know, as Jordan said if if the hole is too big to close primarily in patch you know, it's, it's and it's not a place that I can wedge, then I'm probably going to need to do a resection. And, you know, I, as we always talk about it. You know, the cat sort of out of the bag.

It wants these if it is cancer, it wants these things are perforated. So, I'm not going to do a D two in the middle of the night, of course or in my hands at all. But but I want to do what I can do to control the contamination. That's why I'm in the operating room. Great. Thank you both for the thoughtful answers for some tough cases.

I think they are all painful and we didn't use a lot of drain so successful overall. So thank you all for listening to our episode and I'm going to declare Graham as the winner. It's there. Wow. I think that's the first time in nine episodes.

So it feels good. It feels good. Thanks everyone for listening.

Thank you, Jordan and Ashley as always and dominate the day