Publication:

Ray’s rule of half - governs deployment of tube duodenostomy - a lifesaving procedure to manage stale and macerated duodenal perforation: a prospective study of 22 cases in 20 years

Background Tube decompression of the duodenum is an old but an underutilized technique known to decrease morbidity and mortality in patients with difficult to manage duodenal perforation. Tube duodenostomy surpasses all other elaborate and risky techniques of management of perforation or breach of duodenum in very sick patients.

Methods We have used tube duodenostomy in 22 cases over 20 years, as a desperate mode of management, in large, old macerated duodenal perforation. All our cases had >0.5 cm, macerated, more than 12 hours old perforation in the second part of duodenum. We observed an interesting pattern that duodenal perforation more than half a centimetre in diameter and more than half a day old were best managed by just tube duodenostomy. Same lesion of duodenum were managed by Graham’s omental patch, by other hospital elsewhere, had life threatening complication (duodenal blow out) which invariably ended in fatality.

Results Patients with large and old macerated duodenal perforation often present with hemodynamic instability and sepsis. Complex procedures in an unstable patient are associated with adverse outcomes. In patients with significant comorbidities and instability the damage control principle of trauma surgery is gaining popularity. Tube duodenostomy technique described in this paper ‘click-fits’ well with that principle-it is a life saver and a game changer.

Conclusions Application of tube duodenostomy, instead of executing complex procedures involving surgical gymnasties, in an unstable patient provides an opportunity to stabilize the patient, converting an impending catastrophe to a future scheduled surgery, which has favourable outcomes.