A Case of Myxoma after Surgery for Giant Duodenal Ulcer Perforation with a Choledochoduodenal Fistula

Abstract

A 51-year-old man presented with a 10-day history of severe epigastric pain. CT showed free air, irregular wall thickness of the duodenal bulb, and abscess formation. The operative findings were giant perforation of the duodenal bulb, the wall of which was almost defected, accompanied by a choledochoduodenal fistula. The descending duodenum was transected (duodenal diverticulization), and antrectomy by the Billroth II procedure and cholecystectomy with biliary drainage were performed. A part of the mucosa of the duodenal ulcer was left behind because it was strongly adhered to the head of the pancreas. Three months later, a myxoma appeared in the same area. Percutaneous drainage of the myxoma and injections of drug such as ethanol and OK-432 failed. Mucosal ablation using an endoscope and a urologic device through the drainage fistula was successful for stopping mucus outflow, and the lesion shrank. Giant duodenal ulcer perforation has high morbidity and mortality because it causes severe peritonitis, and there are no standard surgical procedures. Duodenal diverticulization and biliary drainage are among the useful surgical procedures, but it is important to remove as much of the ulcer lesions as possible, since remnants of the mucosa can cause myxoma.