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Background: Despite advances in the medical management of peptic ulcer disease, duodenal ulcer (DU)perforation remains a common surgical emergency. Most DU perforations are small and can be managedwith omental patch repair. However, occasionally the surgeon may encounter a giant perforation notamenable to this. Giant DU perforations are defined as u003e 2cm. They are associated with high leak rates andmortality. Prognosis in elderly patients are particularly poor because of advanced age and comorbidities.Furthermore, there are no specific recommendations for their management despite a variety of repairtechniques being described. Here, we aim to describe a novel technique used to treat such patients, especiallythose of advanced age, in our institution and to review the current literature.Case presentation: Four patients with giant DU perforation underwent emergency laparotomy and repairwith our duodenojejunostomy technique at our hospital. Post-operatively, patients were monitored clinicallyand radiologically and discharged when well and tolerating diet. The mean age of the patients was 67 yearswith an equal gender distribution. The average Charlson Comorbidity Index (CCI) score was 3 (moderatelysevere). All presented with peritonitis and two had concomitant bleeding. There were two anterior and twoposterior ulcers. One was a revision repair after a leak post laparoscopic omental patch repair for the initialperforation. In all cases, the duodenojejunostomy repair technique was used. Post-operative recovery wasuneventful for all except one who developed pneumonia. In particular; there were no anastomotic leaks,intra-abdominal collections, gastric outlet obstructions or mortalities.Conclusion: Giant DU perforation remains a challenge to the general surgeon, particularly so in elderlypatients with multiple comorbids. A review of the current literature suggests a myriad of surgical techniquesbut no perfect solution. Some suggested techniques include omental patch with pyloric exclusion, controlledtube duodenostomy, jejunal pedicled graft or serosal patch, gastric disconnection and partial gastrectomy.Here, we propose that isolated duodenojejunostomy can be a quick, safe and novel solution that ensuresdefinitive repair of giant ulcer perforation in a single setting in the high-risk patient.

Duodenojejunostomy, an Old Technique but Novel Solution for Giant Duodenal Perforations - A Report of Four Cases and Review of Literature