Postgastrectomy duodenal leak
- Betty J Tsuei, MD
Betty J Tsuei, MD
- Professor of Surgery
- University of Cincinnati
- Jason Schrager, MD
Jason Schrager, MD
- Assistant Professor of Surgery
- University of Cincinnati
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 .
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".)
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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- ETIOLOGY AND RISK FACTORS
- CLINICAL MANIFESTATION
- Unstable patients
- Stable patients
- - Initial management of stable patients
- Controlling sepsis
- Controlling fistula
- Optimizing nutrition
- - Subsequent management of stable patients with persistent leak
- Small defect
- Large defect
- Adjunctive measures
- - Paraduodenal drain
- - Decompressive duodenostomy tube
- - Jejunostomy tube
- - Biliary diversion
- Postoperative care
- - Antibiotics
- - Nutrition
- - Drain management
- MORBIDITY AND MORTALITY
- SUMMARY AND RECOMMENDATIONS