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Postgastrectomy duodenal leak

Authors
Betty J Tsuei, MD
Jason Schrager, MD
Section Editor
David I Soybel, MD
Deputy Editor
Wenliang Chen, MD, PhD

INTRODUCTION

If the head of the pancreas were the surgical "soul," the duodenum could be considered the "cradle" of that soul. The duodenum plays an important role in containing and regulating the flow of hepatic bile, pancreatic enzymes, and gastric acid. Not surprisingly, complications arising in the duodenum, such as a leak, can be challenging to manage.

A duodenal leak most frequently occurs from one of three sources: perforated peptic ulcer disease (PUD), traumatic injury, and postsurgical suture or staple line dehiscence. In the past, a duodenal leak was most commonly caused by a perforated duodenal ulcer due to the high prevalence of PUD. In contemporary practice, PUD is less common, and a duodenal leak is more likely to result as the complication of an upper gastrointestinal surgery. In a 2013 meta-analysis of 42 studies, 48 percent of duodenal leaks were a result of surgical complication; only 13 percent were caused by perforated ulcers [1].

This topic will discuss the etiology, clinical manifestation, diagnosis, and management of duodenal leaks that occur after gastric or other upper gastrointestinal surgeries. Duodenal leaks due to perforated PUD and duodenal trauma are discussed in other topics. (See "Surgical management of peptic ulcer disease" and "Management of duodenal and pancreatic trauma in adults".)

EPIDEMIOLOGY

Postgastrectomy duodenal leak, sometimes referred to as duodenal stump blowout, is an infrequent but potentially devastating complication of gastric surgery.

In the era of gastrectomy for peptic ulcer disease, duodenal leak occurred after gastric surgery in 1 to 3 percent of patients [2,3]. Most contemporary studies only included patients undergoing gastrectomy for cancer because elective peptic ulcer surgery has become rare due to widespread use of proton pump inhibitors, eradication of Helicobacter pylori, and endoscopic treatment of ulcer complications (eg, bleeding). In the three largest studies, duodenal leak occurred in 1.1, 1.8, and 2.5 percent of patients, respectively, after gastrectomy for cancer [4-6].

                           
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Literature review current through: Nov 2017. | This topic last updated: Mar 08, 2017.
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References
Top
  1. Babu BI, Finch JG. Current status in the multidisciplinary management of duodenal fistula. Surgeon 2013; 11:158.
  2. Isik B, Yilmaz S, Kirimlioglu V, et al. A life-saving but inadequately discussed procedure: tube duodenostomy. Known and unknown aspects. World J Surg 2007; 31:1616.
  3. Jones RC, McClelland RN, Zedlitz WH, Shires GT. Difficult closures of the duodenal stump. Arch Surg 1967; 94:696.
  4. Kim KH, Kim MC, Jung GJ. Risk factors for duodenal stump leakage after gastrectomy for gastric cancer and management technique of stump leakage. Hepatogastroenterology 2014; 61:1446.
  5. Cozzaglio L, Coladonato M, Biffi R, et al. Duodenal fistula after elective gastrectomy for malignant disease : an italian retrospective multicenter study. J Gastrointest Surg 2010; 14:805.
  6. Orsenigo E, Bissolati M, Socci C, et al. Duodenal stump fistula after gastric surgery for malignancies: a retrospective analysis of risk factors in a single centre experience. Gastric Cancer 2014; 17:733.
  7. Aurello P, Sirimarco D, Magistri P, et al. Management of duodenal stump fistula after gastrectomy for gastric cancer: Systematic review. World J Gastroenterol 2015; 21:7571.
  8. Bashinskaya B, Nahed BV, Redjal N, et al. Trends in Peptic Ulcer Disease and the Identification of Helicobacter Pylori as a Causative Organism: Population-based Estimates from the US Nationwide Inpatient Sample. J Glob Infect Dis 2011; 3:366.
  9. Lau JY, Sung J, Hill C, et al. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 2011; 84:102.
  10. Wang YR, Richter JE, Dempsey DT. Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to 2006. Ann Surg 2010; 251:51.
  11. Lal P, Vindal A, Hadke NS. Controlled tube duodenostomy in the management of giant duodenal ulcer perforation: a new technique for a surgically challenging condition. Am J Surg 2009; 198:319.
  12. Burch JM, Cox CL, Feliciano DV, et al. Management of the difficult duodenal stump. Am J Surg 1991; 162:522.
  13. Prigouris S, Michas P. Duodenostomy. Am J Surg 1949; 138:69.
  14. Dardik I, Dardik H, Shumofsky E, Gliedman ML. Lateral T-tube duodenostomy. Duodenal stump management and manometrics. Arch Surg 1973; 107:89.
  15. Ng EK, Chung SC, Li AK. Controlled duodenostomy for difficult duodenal stump. Aust N Z J Surg 1995; 65:345.
  16. Welch CE, Rodkey GV, von Ryll Gryska P. A thousand operations for ulcer disease. Ann Surg 1986; 204:454.
  17. Granata A, Curcio G, Ligresti D, et al. Overtube-assisted over-the-wire stent placement to treat a post-surgical duodenal leak. Endoscopy 2016; 48 Suppl 1:E220.
  18. Yang HY, Chen JH. Endoscopic fibrin sealant closure of duodenal perforation after endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2015; 21:12976.
  19. Wadhwa V, Leeper WR, Tamrazi A. Percutaneous BioOrganic Sealing of Duodenal Fistulas: Case Report and Review of Biological Sealants with Potential Use in Interventional Radiology. Cardiovasc Intervent Radiol 2015; 38:1036.
  20. Davis KG, Johnson EK. Controversies in the care of the enterocutaneous fistula. Surg Clin North Am 2013; 93:231.
  21. Rahbour G, Siddiqui MR, Ullah MR, et al. A meta-analysis of outcomes following use of somatostatin and its analogues for the management of enterocutaneous fistulas. Ann Surg 2012; 256:946.
  22. KOBOLD EE, THAL AP. A simple method for the management of experimental wounds of the duodenum. Surg Gynecol Obstet 1963; 116:340.
  23. Jones RJ, Samson PC, Dugan DJ. Current management of civilian thoracic trauma. Am J Surg 1967; 114:289.
  24. Vashist YK, Yekebas EF, Gebauer F, et al. Management of the difficult duodenal stump in penetrating duodenal ulcer disease: a comparative analysis of duodenojejunostomy with "classical" stump closure (Nissen-Bsteh). Langenbecks Arch Surg 2012; 397:1243.
  25. Stone HH, Garoni WJ. Experiences in the management of duodenal wounds. South Med J 1966; 59:864.
  26. Sun Z, Shenoi MM, Nussbaum DP, et al. Feeding jejunostomy tube placement during resection of gastric cancers. J Surg Res 2016; 200:189.
  27. Nussbaum DP, Zani S, Penne K, et al. Feeding jejunostomy tube placement in patients undergoing pancreaticoduodenectomy: an ongoing dilemma. J Gastrointest Surg 2014; 18:1752.
  28. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med 2015; 372:1996.
  29. Bardsley DW, Coakley WT, Jones G, Liddell JE. Electroacoustic fusion of millilitre volumes of cells in physiological medium. J Biochem Biophys Methods 1989; 19:339.