Journal of Investigative Surgery, 22, 148153, 2009

C Informa Healthcare USA, Inc.

Copyright

ISSN: 0894-1939 print / 1521-0553 online
DOI: 10.1080/08941930802713068

SURGICAL TECHNIQUES

Comparison between Gallbladder Serosal

and Mucosal Patch in Duodenal Injuries
Repair in Dogs
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Seyed Vahid Hosseini,

Hamid Reza Abbasi, and
Hamid Rezvani
Gastroenterohepatology Research
Center, Colorectal Surgery
Department, Shiraz University of
Medical Sciences, Shiraz, Iran

Mohammad Vasei and

Mohammad Javad Ashraf
Pathology Department, Shiraz
University of Medical Sciences,
Shiraz, Iran

ABSTRACT
Background: One of the most challenging problems in clinical surgery is management of an extensive
duodenal injury. In its management, there are limitations in using jejunal serosal patch and other
conventional methods in specific conditions. This study was performed to compare treatment of large
duodenal defects by a gallbladder serosal patch and the gallbladder mucosal patch in a dog as an
animal model. Methods: A duodenal defect (2 cm, about 50% of the total circumference) was created in
the second portion of the duodenum in eight dogs. The animals were divided into two equal groups,
with group 1 undergoing serosal patch repair and group 2 undergoing mucosal patch repair. The
macroscopic and microscopic healing features of the gallbladder serosal and mucosal patch were
compared. Results: None of the dogs died due to surgical complications. The whole grafted area was
covered by neomucosa at the end of the third week in all animals with the gallbladder serosal patch
(group 1). In this group, the scar was small; no significant narrowing of lumen was noted and serosal
healing was uniformly complete. In histological examination, a complete coverage of the gallbladder
serosal patch by neomucosa consisting of columnar epithelium with short villous formations was
observed. In mucosal patch models (group 2), complete epitheliazation, mild fibrosis, and incomplete
repair were visible. In histological examination, severe inflammation was noticed too. Conclusion: In
patients with multiple trauma affecting upper gastrointestinal tracts, use of the gallbladder serosal
patch method is easy and reliable. So it may be considered in the surgical management of large
duodenal defects, which cannot be repaired by available conventional methods.
Keywords: Gallbladder serosal patch, Gallbladder mucosal patch, Duodenal defects, Repair

INTRODUCTION
Received June 22, 2008; accepted July 15, 2008.
Address correspondence to Dr. Seyed Vahid Hosseini, Gastroenterohepatology Research Center, Colorectal Surgery Department, Shiraz University of Medical Sciences, Shiraz, Iran. E-mail:
hoseiniv@sums.ac.ir

148

Duodenal injury is a challenging problem in clinical

surgery and is associated with significant morbidities
and mortalities [13]. Although duodenal injuries are
uncommon and are found only in 3.7% of all laparotomies that are performed after trauma, they are
technically difficult to repair [4, 5]. Approximately

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Comparison between Gallbladder Serosal and Mucosal Patch

7585% of all duodenal injuries can be safely repaired with primary repair or duodenorrhaphy [6].
However, primary closure of a large defect (>50%
of the circumference) may narrow the lumen of the
bowel or result in undue tension and subsequent suture line breakdown. Various technically demanding
treatment options such as Roux-en-Y duodenojejunostomy, pedicled grafts, duodenal resection with end-toend duodenoduodenostomy, diverticulization, pyloric
exclusion, Whipple procedure or application of a synthetic mesh, or jejunal serosal patching have been reported to be effective in the surgical management of
severe duodenal injuries [1, 712]. Using gallbladder
serosal and mucosal grafts for coverage and support
of duodenal defects may be an alternative method in
the treatment of high-risk patients. We conducted this
study to investigate the results of gallbladder mucosal
patch repair and gallbladder serosal patch methods in
severe duodenal defects in a dog as an animal model.

and the mucosa was exposed (mucosal patch) and

this mucosal surface was applied over the defect
of duodenum and secured with 3.0 absorbable PDS
sutures.

METHODS

Before sacrificing the animals, gastrophin was given

orally and fluoroscopy was performed to detect any
leakage. The animals were sacrificed after 3 weeks by
using an intravenous overdosage of potassium chloride. The animals were autopsied and checked for any
gross leakage at the site of anastomosis, and the needed
tissue samples of duodenum and gallbladder were also
histologically studied. The healing characteristics of the
gallbladder serosal patch or mucosal patch repair techniques were investigated too. A Fishers exact test was
used for statistical analysis and a p < .05 was considered significant.

This experiment was done on eight hybrid dogs, weighing 2030 kg, in the animal research laboratory of Shiraz
University of Medical Sciences. The reason pigs were
not used was the unavailability of the animal in the
country and the similarity of the gastrointestinal tract
of dogs with humans. The procedures and the handling
of the animals were reviewed and approved by the research and ethics committee of Shiraz University of
Medical Sciences in accordance with the Principles of
Laboratory Animal Care formulated by the National
Society for Medical Research and the Guide for the
Care and Use of Laboratory Animals published by
the National Institutes of Health (NIH publication 85
23, revised 1985, Washington, D.C.: U.S. Department of
Health and Human Services).
All procedures were carried out under aseptic conditions. The protocols for anesthesia, postoperative care,
and sacrifice were identical for all animals. Anesthesia was induced by intravenous injection of sodium
thiopental (15 mg/kg). After endotracheal intubation,
the animals were maintained on controlled ventilation with halothane and 100% oxygen. Normal saline
was given intravenously throughout the operative procedure at a rate of 10 ml/kg/h. In supine position,
through midline laparatomy incision, the gallbladder
and the second portion of duodenum were found. The
proximal and distal ends of duodenum were secured
by a traumatic vascular clamp to prevent leakage. A
50% full-thickness defect of circumference was made
on the second portion of the duodenum in all animals
identically. In group 1 (four dogs), while the cystic
artery was preserved, the cystic duct was ligated. An
incision was made on the fundus of the gallbladder

In the other four dogs (group 2), the outer peritoneal

layer of gallbladder (serosal patch) was applied over
the duodenal defect and sutured circumferentially by
using a 3.0 absorbable PDS suture. After hemostasis
and irrigation, abdominal cavity was closed in layers
with a running suture of 0 nylon for fascia, a running
3.0 chromic suture for the subcutaneous plane, and a
3.0 nylon suture for skin in all animals.
Cefazolin (40 mg/kg) was administered intravenously
before induction of anesthesia and also for postoperative care (10 days). Animals were housed in individual
cages. The animals did not have access to oral feeding at the first postoperative day but received fluid on
the second day. All animals were allowed to have oral
feeding after the third day.

RESULTS
All dogs survived until they were sacrificed and the
short-term survival rates in both groups were identical. There was no evidence of leakage or peritonitis
in all animals and the patches were well fixed. Fluoroscopy with gastrophin swallowing revealed no sign
of leakage in any of the subjects. Serosal surface healing was complete in group 1 macroscopically but in
group 2, the mucosal patches had an undergrowth
of mucosa with partial patch separation without any
leakage. Figures 1 and 2 show the gross view of the
site of repair with mucosal patch. The duodenal wall
defect margin was somehow thicker in group 2 due
to severe inflammation. A few adhesion bands were
also noted in the peritoneum. No evidence of leakage,
abscess, fistula, or obstruction was found in group 2.
In group 1, a complete coverage of duodenal neomucosa on the gallbladder surfaces was observed. In this
group, no evidence of leakage, abscess, fistula, or obstruction was found (Figures 3 and 4). Pathological
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S. V. Hosseini et al.

Figure 1. Gross view of the site of repair with mucosal

patch.

Figure 2. Transverse section of the site of repair with

mucosal patch.

comparison of both groups was shown in Table 1. In

histological evaluation, smooth muscle formation was
complete and a mild chronic inflammatory reaction
was found. Additionally, a complete coverage of the
mucosal grafts by neomucosa consisting of columnar
epithelium with villous formation was observed. The
scar was small; no significant narrowing of lumen was
noted and serosal healing was uniformly complete with
mild fibrosis (Figure 5).

noted and serosal healing was incomplete. In histological evaluation, smooth muscle formation was nearly
complete and a severe inflammatory reaction was also
found. Additionally in group 2, complete coverage of
the mucosal grafts by neomucosa consisting of columnar epithelium with villous formation was observed
(Figure 6).

Histological study confirmed these gross observations.

The outer layer of the mucosal patches was covered
progressively by a layer of mesothelial cells. In the inner layer, columnar epithelial cells with typical regenerative pattern were seen. There was some granulation
tissue with new angiogenesis, immature mesenchymal tissue, and smooth muscle proliferation after 3
weeks. However, the neomucosa had no goblet cell
or villous formation. Furthermore, serosa, scar and
fibrosis, and neomucosa covered the defect site. The
scar was small; no significant narrowing of lumen was
Table 1. Comparison between the gallbladder serosal and
mucosal patch

Level of
epitheliazation
Type of
inflammation
Site of graft
Level of fibrosis

150

Gallbladder
mucosal patch

Gallbladder
serosal patch

Complete
epitheliazation
Severe
inflammation
Incomplete repair
Mild fibrosis

Complete
epitheliazation
Mild chronic
inflammation
Complete repair
Complete fibrosis

DISCUSSION
The duodenum is infrequently injured owing to its protected retroperitoneal location [13]; duodenal injury is
reported to be the reason for 3.7% of all laparotomies for
trauma [14] and is rarely an isolated injury [15]. After
the surgical treatment of duodenal injuries, mortality
and morbidity mostly depend on the development of
anastomotic leakage and subsequent abdominal sepsis
[13]. Improvements in surgical methods not only will
decrease morbidity and control the complications of
the duodenal wound but will also increase the survival
rates.
The optimal management of severe duodenal injury
(SDI) remains controversial.
Although primary repair can be performed in some
duodenal injuries, the majority require more complex
surgical interventions. In rare circumstances and for
catastrophic injuries of the pancreatoduodenal region,
pancreatoduodenectomy is unavoidable [16, 17]. Up to
now, several materials such as serosal grafts, human
amniotic membrane, lyophilized dura, Teflon, Dacron,
and ePTFE grafts have been tried for repair of gastric
and intestinal defects, with successful results [2024].
Kobold and Thal [11] for the first time used a jejunal serosal patch to close the duodenal defect in
a canine model. In this method, the serosa-to-serosa

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Comparison between Gallbladder Serosal and Mucosal Patch

Figure 3. Gross view of the site of repair with serosal patch.

anastomosis between the edges of duodenal defect and

jejunum is performed. Binnington et al. [20] found that
neomucosa grows on colonic surfaces that are patched
over jejunal defects. The main advantage of this technique is the usage and availability of autolog tissues in
the surgical field.
Recently, polytetrafluoroethylene (PTFE) patches have
been tested experimentally for the repair of defects
of the gastrointestinal tract. Ozlem et al. [25] repaired large duodenal defects in rabbits by an ePTFE

Figure 4. Transverse section of the site of repair with serosal

patch.

(Gore-Tex) soft-tissue patch graft. In addition, ePTFE

patches were used in the repair of experimentally induced large duodenal defects in rats [1], and in defects of various segments of abdominal alimentary tract
(stomach, duodenum, small bowel, and colon) as well
as in a bladder dome in a canine model [27]. Possibly
more immediate as well as more promising applications of ePTFE for a bowel patch include closing of
the difficult duodenal stump, replacement of sizeable

Figure 5. Section of gallbladder serosal patch graft showing

complete epitheliazation and dense fibrosis (complete
repair). Arrows: (a) Gallbladder mucosa, (b) area of fibrosis,
and (c) duodenal mucosa. (H & E, 25)

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S. V. Hosseini et al.

Figure 6. Section of gallbladder mucosal patch graft showing severe inflammation, incomplete repair, and mild fibrosis.
Arrows: (a) Gallbladder mucosa, (b) area of inflammation, and (c) duodenal mucosa. (H & E, 25)

areas of traumatized duodenal wall, and perhaps small

bowel stricturoplasty [27].
In this experimental study, we compared the results of
two different methods (gallbladder serosal patch and
gallbladder mucosal patch) for the repair of large duodenal defects. We achieved the same results as Astarcioglu et al. [1]. The neomucosa covered the serosal
patch at the third operative week without any sign of
foreign body reaction, infection-induced patch dehiscence, or intestinal adhesion. It was a columnar epithelium with villous formation. The serosal patches
uniformly allowed mucosal proliferation beneath and
eventually led to patch extrusion into bowel lumen.
The short-term survival rates were comparable; none
of the dogs in both groups experienced early death. But
the gallbladder mucosal patches did not achieve complete repair. While in serosal patches we found chronic
mild inflammation and complete fibrosis, in mucosal
patches severe inflammation with mild fibrosis was observed.
In conclusion, the use of synthetic and organic patches
for the alimentary tract repair is obtaining considerable importance. The present surgical experiment clearly shows that a gallbladder serosal patch
can function, at least for short periods of time, as
a reliable barrier against the escape of intestinal
contents.
152

In this study we showed that gallbladder serosal patch

was more suitable with better outcome in comparison
to gallbladder mucosal patch. This shows that gallbladder can be a potential source for repair of large
duodenal injuries. Additional studies should be done
on neomucosal absorptive function, use of gallbladder
serosal patch for repair of larger duodenal injuries, or
the possibility of using gallbladder serosal patch as a
substitute for a short segment of small bowel.

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