Gastric disconnection in the management of perforated giant duodenal ulcer

Giant duodenal ulcer is the most severe variant of peptic ulcer disease. Currently, however, no technical recommendations exist for the surgical management of perforation of these lesions. Due to the often extensive loss of duodenal substance, plication is impossible, pyloroplasty is hazardous, and duodenal closure is tenuous at best. In the absence of surgical precedent, it was thought that an ideal procedure would embody three principles: (1) defunctionalization of the upper gastrointestinal tract; (2) minimization of suture lines; and (3) control of potential fistula sites with tube enterostomies. As it finally evolved, the procedure of gastric disconnection became truncal vagectomy and antrectomy, along with tube gastrostomy, duodenostomy, and jejunostomy. Restoration of gastrointestinal continuity was deferred for 3 to 4 weeks after recovery. Four consecutive patients have been successfully managed by this technique. Gastric disconnection is physiologically sound and may prove to be superior to alternative techniques in this difficult condition.