448 Case Study of a Giant Duodenal Perforation: Where Is the Ampulla?M E Bin Mohamed Ebrahim, C Lim
Concurrent duodenal and gallbladder perforation is a rare finding. Whilst cholecystoduodenal fistulas have been observed in literature, massive duodenal perforation with gallbladder erosion has not been recorded. We present the case of a 77-year-old female who was found to have a giant duodenal perforation (measuring 10cmx5cm) with an associated gallbladder perforation as well. On patient’s first presentation, a Computed Tomography of the abdomen was performed due to abdominal pain and constipation. Images showed pneumoperitoneum and intra-abdominal free fluid. Upon performing an explorative laparotomy, findings of duodenal and gallbladder perforations were observed. Distal gastrectomy, cholecystectomy and gastrojejunostomy were performed. Due to uncertainty of the location of the ampulla to the ulcer edges, a cholangiogram catheter was advanced into the Ampulla of Vater via the Cystic Duct to definitively identify it prior to D1/D2 stapling. Gastrograffin study was conducted on Day-5, showing good contrast flow. No major events occurred during her post operative recovery. The main concern is inadvertent stapling of D1/D2 together with the ampulla. The passage of a catheter down the Cystic Duct, into the Common Bile Duct and through the ampulla is a definitive way to locate its position. In addition, Common Bile Duct patency with cholangiography can be ensured. Intra-operative improvisation such as advancing a cholangiogram catheter into the ampulla would assist surgeons in safely resecting proximal duodenum especially when it encroaches on the D1/2 junction.