Postgastrectomy duodenal leak

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 trauma in adults" and "Management of 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].

●One study from Hong Kong, where gastric resection is still performed at a high volume, reported a duodenal leak rate of 7.7 percent after gastrectomy with duodenal exclusion (3.4 percent after elective surgery; 21 percent after emergency surgery) [7].

ETIOLOGY AND RISK FACTORS — Postgastrectomy duodenal leak primarily results from a disruption of the duodenal stump closure. The duodenal stump typically leaks at the suture/staple line due to inflammation, infection, ischemia, or tissue loss. Specific risk factors that predispose to a duodenal leak include [4-6,8]:

●Inadequate closure of the duodenal stump (eg, incomplete stapling due to tissue retraction during transection of the duodenum).

●Lack of manual suture reinforcement of a stapled duodenal stump [6,9].

●Devascularization (eg, during lymph node dissection).

●Cancer involvement of the resection line (ie, R1 or R2, as opposed to an R0 resection).

●Inflamed duodenal wall. Presence of a duodenal ulcer dramatically increases the risk of a postgastrectomy duodenal leak (32 versus 4 percent) [7].

●Local hematoma.

●Incorrect drain placement.

●Postoperative distention of the duodenum or afferent limb.

●Thermal injury to the duodenal wall from electrocautery or other advanced energy devices (eg, ultrasonic dissector or LigaSure).

●Older patients [4].

●Male patients [4].

●Patients with comorbid conditions, including heart disease, liver cirrhosis, malnutrition [6].

Neither the extent of the gastrectomy (subtotal versus total) nor the reconstructive technique (Billroth II versus Roux-en-Y) was predictive of a duodenal leak [4-6].

PREVENTION — In dealing with the duodenum, the adage "an ounce of prevention is worth a pound of cure" is well worth considering. Duodenal stump blowout is one of the most feared complications of gastric surgery. Thus, it always behooves the surgeon to do the best possible index procedure because the tissue will never be in a better condition at reoperation than at the index operation. It is equally important for the surgeon not to overestimate their own success rate and to prepare for complications upfront. Good contingency planning in case the operation fails can mean the difference between a controlled fistula and uncontrolled sepsis.

In the era of reliable medical acid suppression and H. pylori treatment, surgical management of peptic ulcer disease (PUD) is limited to the treatment of complications, such as bleeding or perforation [10-12]. As such, simple oversewing of a bleeding ulcer or closure of a perforated ulcer is preferred to a more elaborate procedure for the majority of gastric and duodenal ulcers. Definitive ulcer surgery, most commonly antrectomy, in the presence of significant duodenal scarring (due to PUD) frequently requires a gastrojejunostomy (Billroth II or Roux-en-Y), which closes the proximal end of the duodenum as a blind "stump." The creation of a duodenal stump predisposes to a leak, especially if the closure is difficult or tenuous. The best prevention for a duodenal stump leak is to avoid creating a duodenal stump in the first place. (See "Surgical management of peptic ulcer disease", section on 'Duodenal ulcer'.)

While most traditional surgical reconstructive techniques create a blind duodenal stump, a newer technique, "double tract reconstruction," anastomoses the remnant duodenum to a portion of the jejunum, creating a parallel pathway for decompression (figure 1) [13,14]. This newer technique and its variants may ameliorate some duodenal stump complications [15,16].

When creating a duodenal stump cannot be avoided, we suggest buttressing the duodenal stump closure with sutures. In elective gastric cancer resection, data suggest that when the duodenal stump is closed with a stapling device, manual oversewing of the staple line may lower the duodenal leak/fistula rate [6,9]. In a series of 1287 patients undergoing gastrectomy, the lack of stump reinforcement was a risk factor for leak at an odds ratio of 30 [6]. However, those data may not be extrapolative to PUD cases, especially when local tissue is too inflamed to tolerate suture buttressing. Limited data also support the use of biologic glue to buttress the duodenal stump closure.

Multiple studies suggest that suture reinforcement of the duodenal stump is as important in laparoscopic gastrectomy as in open gastrectomy for prevention of duodenal stump leak [17,18]. In a series of 965 patients who underwent laparoscopic gastrectomy for cancer, duodenal stump leak occurred less frequently in the reinforcement than in the non-reinforcement group (0.67 versus. 5.71 percent) [19]. Furthermore, only one reinforced patient but all non-reinforced patients who developed a leak required surgical re-exploration. Newer techniques have been proposed to reinforce the duodenal stump staple line laparoscopically, which is technically more challenging to perform than in open surgery [9,20,21].

Prophylactic duodenostomy tubes can be used selectively in patients with a challenging duodenal closure to decompress the duodenum [2,22]. Prophylactic biliary diversion undertaken at the time of the index operation has also been associated with decreased postoperative complications [23]. (See 'Decompressive duodenostomy tube' below and 'Biliary diversion' below.)

CLINICAL MANIFESTATION — Patients with a duodenal leak typically present with severe abdominal pain, fever, and/or hemodynamic instability (tachycardia or hypotension). In those who still have an indwelling surgical drain near the duodenal stump, the effluent may increase in volume and/or become bilious or bloody.

DIAGNOSIS — A postgastrectomy duodenal leak should be suspected in patients who present with suggestive signs or symptoms, especially when accompanied by fever and/or leukocytosis, and who have undergone gastric surgery in the recent past. (See 'Clinical manifestation' above.)

A duodenal leak typically occurs after a Billroth II or Roux-en-Y gastrojejunostomy; leakage after a gastroduodenostomy (Billroth I) is rare. (See "Partial gastrectomy and gastrointestinal reconstruction", section on 'Gastrointestinal reconstruction'.)

The onset of postgastrectomy duodenal leak is usually delayed. In the two largest series, patients presented with a leak at a median of five (1 to 12 days) and seven days (0 to 22 days) after surgery, respectively [4,5].

Stable patients suspected of having a duodenal leak should undergo abdominopelvic computed tomography (CT), preferably with oral contrast, which can usually diagnose the leak. Unstable patients require immediate surgical exploration, where diagnosis is often made intraoperatively.

MANAGEMENT — The principles of treating a postgastrectomy duodenal leak are:

●Resuscitation of the patient and management of sepsis. (See "Antimicrobial approach to intra-abdominal infections in adults", section on 'High-risk community-acquired infections'.)

●Drainage of fluid collections.

●Control of fistula with diversion of intestinal, biliary, and pancreatic fluid.

●Optimization of nutrition and wound care.

These principles can be accomplished by medical, endoscopic, radiologic, or surgical interventions. For each individual patient, the best approach is determined by the patient's physiologic condition (ie, stable versus unstable) and the character of the leak (eg, the volume of drainage and the size of the defect) as detailed below.

In the absence of high-quality studies such as randomized trials, no one intervention can be considered superior in managing duodenal leak. However, a conservative, or nonoperative, approach is preferred for initial (first six weeks) management of stable patients. Surgical intervention is required for unstable patients or when conservative management fails (algorithm 1).

Unstable patients — An uncontrolled duodenal leak is a surgical emergency. Patients who present with diffuse peritonitis, intra-abdominal hemorrhage, major wound dehiscence, uncontrolled sepsis, clinical deterioration, or multiorgan failure/shock should receive broad-spectrum antibiotic coverage and undergo immediate surgical exploration.

If the defect is small, primary closure of the duodenum can be attempted. A primary duodenal repair should be buttressed with either healthy, vascularized adjacent biologic tissue, such as the omentum, serosal (outside) wall of jejunum, or fibrin sealant.

Unstable patients cannot tolerate extensive procedures. They often present with large duodenal defects or tenuous local tissues that make primary or even tissue patch closure unfeasible. Such patients may also have physiologic derangements that call for damage control measures. For such patients, an end duodenostomy tube may be beneficial in controlling the leak.

Duodenostomy (or duodenal) tubes (DTs) were popularized in the 1950s and come in a variety of forms. One study reported using 22 French Pezzer drains as end DTs with good results [2]. The end DT was historically placed through the resected end of the duodenum and is primarily used when the stump cannot be safely closed. Placement of the end DT requires mobilization of enough posterior duodenum for purse-string sutures but conceptually may be more manageable than complicated alternative repairs that unstable patients would not tolerate.

Several series have documented very low leak rates with the use of end DT, and typically the tube can be removed in three weeks [2,24]. However, the use of end DT deliberately creates a chronic duodenal fistula and introduces the potential for uncontrolled leak around the tube [23]. Thus, end DT should be reserved as an option of last resort for unstable patients with a duodenal leak. If a chronic duodenal fistula forms, additional elective surgery is required to close it. (See 'Subsequent management of stable patients with persistent leak' below.)

An alternative strategy is to close the defect to one's best ability and insert a lateral DT. A lateral DT in theory decompresses the duodenum and facilitates the healing of the repair. Lateral DT was used more commonly in the era when gastric surgery was the primary treatment for ulcer disease [25-27]. Lateral DTs can also be used in more stable patients and are discussed in detail in that section. (See 'Decompressive duodenostomy tube' below.)

Commonly used adjunctive measures, such as paraduodenal drain, duodenostomy tube, feeding jejunostomy tube, and biliary diversion, can be used at the surgeon's discretion after primary repair or control of the leak to facilitate healing and reduce the risk of recurrence. These measures are discussed in detail below. (See 'Adjunctive measures' below.)

Stable patients — Initial treatment of a postoperative duodenal leak in a stable patient is nonoperative, which heals the leak in 25 to 75 percent of patients [1]. For the rest who have a persistent duodenal leak/fistula in spite of nonoperative management, a delay before the reoperation makes the reoperation easier by reducing inflammation.

The optimal length of nonoperative management is debated. We prefer to wait three to six months before reoperation, provided that patients are stable and can tolerate enteral feeding. A patient's physiology is also important in determining the timing of reoperation. As an example, a patient who is living independently at home with a well-drained fistula can tolerate a reoperation earlier than one who is debilitated living in a nursing home.

Initial nonoperative management of postgastrectomy duodenal leaks is widely practiced and may have contributed to the decrease in mortality from 40 to 16 percent since the 1980s [1,4,5,8].

Initial management of stable patients

Controlling sepsis — Sepsis, when present, should be aggressively treated with appropriate antibiotics and percutaneous (radiology-guided) drainage of any intra-abdominal abscesses.

Controlling fistula — Drainage from the duodenum, which contains caustic biliary and pancreatic secretions, must be adequately controlled and diverted away from the body:

●Patients with low-volume duodenal leak (<200 mL/day) can be managed by diverting output with an existing paraduodenal drain or placing new drains percutaneously. Over the ensuing weeks or months, the leak may taper off or stop. Patients can be managed expectantly as long as their physiology allows. There have also been case reports of successful closure of low-volume duodenal leaks with radiologic or endoscopic interventions (eg, fibrin glue) [28-30].

●Moderate- (200 to 500 mL/day) or high-volume (>500 mL/day) duodenal leaks call for proactive management because they can be detrimental to the patient's physiology (eg, dehydration, malnutrition) and keep patients hospitalized. The patency of all existing tubes, including the paraduodenal drain, T-tube, and duodenostomy tube, should be ascertained to help reduce or divert leakage. Prolonged high drain output should also prompt investigation and elimination of other potential contributing factors such as corticosteroid use and distal bowel obstruction. Early postoperative percutaneous, transhepatic biliary diversion in such patients can further reduce the volume of duodenal leaks and promote closure. (See 'Biliary diversion' below.)

Somatostatin and its analogs (eg, octreotide, pasireotide) have been used in enterocutaneous fistulas [31] and pancreatic fistulas [32]. The general consensus is that they decrease fistula output but have little effect on the rate of fistula closure [31]. Although it may be intuitive to use somatostatin or one of its analogues to treat postgastrectomy duodenal leaks, there are no high-quality data to support or reject that practice.

Optimizing nutrition — In patients who have an enteral access route distal to the duodenal leak (eg, a feeding jejunostomy tube), enteral nutrition is preferred to total parenteral nutrition (TPN). In patients with a high-volume duodenal leak, however, it is reasonable to put patients on TPN for a short time to determine if ceasing enteral feeding would reduce or stop the duodenal leak. If not, enteral feeding should resume. In patients who have an ileus that precludes enteral feeding, we typically wait for seven days before initiating TPN, unless the patient is already nutritionally depleted. (See 'Nutrition' below.)

Subsequent management of stable patients with persistent leak — Stable patients with a duodenal leak that has not closed despite an adequate trial of nonoperative treatment require further intervention, either operatively or endoscopically.

Operative intervention — At elective reoperation, the duodenal defect is closed or controlled. Choices of primary and adjunctive procedures are tailored to the conditions of the duodenum and patient, according to surgeon experience and preference.

Small defect — In most stable patients with a small defect in the duodenum, primary closure of the defect can be accomplished.

A primary duodenal repair should be buttressed with healthy, vascularized adjacent biologic tissue, such as the omentum, serosal (outside) wall of jejunum, or fibrin sealant.

Large defect — In stable patients with a duodenal defect that is too large to close primarily, there are two options that both require the use of a loop of healthy, vascularized jejunum:

●The Thal patch technique uses the serosal (outside) wall of a loop of jejunum to patch the duodenal defect [33]. It is equally efficacious at the index surgery and the reoperation [34].

●Roux-en-Y drainage, or duodenojejunostomy, anastomoses a roux limb of jejunum and sutures directly to the duodenal defect in an end-to-side or side-to-side fashion. In a retrospective series of 62 matched patients treated for penetrating peptic ulcer between 1990 and 2007 at a single institution, patients who underwent duodenojejunostomy (ie, Roux-en-Y drainage) had lower mortality (5 versus 16 percent) and duodenal leak rate (15 versus 29 percent) compared with those who underwent distal gastrectomy and Nissen closure [35].

Endoscopic intervention — In patients who are high risk for operative intervention, endoscopic therapy may be an alternative option. Endoscopic clipping, first utilized for closure of gastrointestinal perforation, has expanded to include endoscopic treatment of colonic and bariatric surgery leaks and full-thickness gastrointestinal defects created during natural orifice transluminal endoscopic surgery.

In a study that examined the use of endoscopic therapy for postgastrectomy anastomotic leaks in patients with gastric cancer [36], while the vast majority of the esophageal or gastric leaks were successfully closed with endoscopic techniques, only 60 percent of the duodenal or jejunal leaks were completely closed with endoscopic clipping or stenting. All 18 of the duodenal leaks were treated with clipping; the difficulty of approaching this region may have contributed to the lower success rate. The anatomic challenges of reaching the duodenum given the presence of Billroth II or Roux-en-Y reconstruction may limit the ability to employ endoscopic methods of repair, even for the most skilled of technicians. This need for advanced endoscopy and its associated equipment might limit the applicability of this modality to only experienced centers.

Adjunctive measures — In treating duodenal leak, one or more adjunctive measures are commonly employed along with the primary procedure to reduce complications or improve nutrition. Commonly used adjunctive measures include paraduodenal drain, duodenostomy tube, feeding jejunostomy tube, and biliary diversion.

Paraduodenal drain — Adequate external drainage of the duodenal stump is required in upper gastrointestinal surgery, regardless of whether duodenal closure or resection is performed. Closed suction drains are most commonly used. Drains should be placed in the most dependent position and avoid direct contact with any existing suture lines. In some cases, multiple periduodenal drains may be necessary.

Although paraduodenal drains do not prevent leaks, they can both detect and control a duodenal leak: bile staining or increased output from a drain may be the earliest sign of a duodenal leak; a well-positioned drain can control a small leak by diverting the drainage externally, which prevents the onset of sepsis or diffuse peritonitis.

Decompressive duodenostomy tube — In contrast to the end DT, a decompressive DT functions to divert biliary and pancreatic secretions, decrease the intraluminal pressure in the duodenal stump, and decrease the potential for a duodenal stump leak.

A decompressive DT provides internal drainage in the face of a duodenal stump leak and diverts flow away from the leak. While paraduodenal drains can prevent sepsis from undrained collections, internal drainage may allow the leak to heal without further surgical intervention. (See 'Initial management of stable patients' above.)

A decompressive DT can be placed laterally or retrograde. The lateral DT is placed through the lateral wall of the second portion of the duodenum. The retrograde DT enters the intestinal tract just distal to the ligament of Treitz and courses retrograde to drain the duodenum [37].

Pezzer-type tubes are most commonly used for end and lateral DTs. We frequently use red rubber catheters with additional side holes as retrograde DTs. We typically cut off the tip of the red rubber catheter to allow guidewire-based radiographic manipulation of the tube when necessary. The largest-sized tube that does not cause obstruction should be selected.

In our practice, we prefer the retrograde DT to the lateral DT because it provides the same drainage without placing another incision in an inflamed duodenum. The technique of placing a retrograde DT is almost identical to that of placing a jejunostomy tube, except that the tube is directed retrograde toward the duodenum, rather than anterograde toward the jejunum. Fortunately, this technique is familiar to all surgeons regardless of their experience with the difficult duodenum. Additionally, removal of a retrograde DT is also straightforward: after allowing adequate time for the tract at the skin level to mature (typically six weeks), the tube is simply pulled out.

Percutaneously placed duodenostomy tubes have been described in case reports [38,39] and have also been used to treat postgastrectomy duodenal leak [40]. Although the number of patients undergoing percutaneous DT placement has been small, the technique may be feasible in the hands of an experienced radiologist and provide an alternative to surgical intervention.

High-quality evidence for or against decompressive DT use is limited [2,23,24]; there has been no randomized trial on the subject. However, we frequently use retrograde duodenal decompression prophylactically in an effort to prevent stump blowout because of the devastating nature of such a complication. While DTs did not consistently reduce intraluminal pressure in the literature, we have found that decompressive DTs do decrease paraduodenal drain output and lead to their earlier removal in patients with duodenal leaks.

Jejunostomy tube — As with any critically ill patient, adequate nutrition must be provided to overcome the catabolic state, and a reliable enteral feeding access should be established at the time of the definitive surgery. Options of providing enteral nutrition to patients with a duodenal leak include jejunostomy tube (JT), combined gastric (decompression) and jejunal (feeding) tube, and nasojejunal tube.

●In most cases, standard JT placement can be safely performed and provides enteral access distal to the duodenum. As mentioned previously, we often use the retrograde DT for decompression, a procedure that can readily be combined with JT placement in a slightly more distal location.

●In cases where gastric drainage is required (eg, a Billroth I reconstruction or a Graham patch repair of a perforated duodenal ulcer), the use of a combined gastric and jejunal tube (eg, Moss tube) may eliminate the need for a separate enterotomy. In these combination tubes, the gastric lumen is usually placed to gravity drainage or venting, while the jejunal lumen is used for enteral feeding.

●Another option for enteral nutrition is the use of a nasojejunal feeding tube. However, because patients with a duodenal leak often require tube feeding for an extended period of time (eg, up to one year), a JT placed at the index operation often provides for greater patient comfort than a nasal tube.

Reports on potential morbidities of feeding tubes placed at the time of complex foregut operations have been mixed. While some series associated feeding tubes with nothing more than a slightly longer operative time, others showed complication rates of 14 percent [41,42]. JT-related complications can range from local wound issues to intestinal obstruction and volvulus necessitating reoperation.

Biliary diversion — While low-volume duodenal leaks can typically be managed with external drains and DTs without biliary diversion, high-volume leaks may require biliary diversion to promote eventual sealing.

Biliary diversion can be accomplished with several maneuvers. Most commonly, percutaneous transhepatic cholangiographic (PTC) tubes are the treatment of choice as accessing the biliary tree via the duodenum is not feasible. Biliary drainage via cholecystostomy tube is possible but less ideal.

Biliary diversion can also be helpful in preventing high-volume duodenal leaks in patients who undergo a difficult duodenal closure. The decision to perform prophylactic biliary diversion is made by the surgeon intraoperatively based on several patient and technical factors:

●Prophylactic biliary diversion should be reserved for patients who are prone to develop a high-volume duodenal leak. Patients with poor baseline nutritional and/or function status, often characterized by a history of recent weight loss and nonindependent living, are at a high risk of developing such a leak. Severe inflammation and poor-quality tissue of the duodenum also predict a large leak and call for prophylactic biliary diversion when feasible.

●In the patient with a normal-appearing portal region, a standard T tube placed in the common bile duct can serve to divert bile from the duodenum. Care must be taken to avoid injury to the normal-sized duct. If the gallbladder is intact, tracing the cystic duct to the confluence with the common bile duct can assist with T tube placement.

●Biliary diversion in the postcholecystectomy patient with a markedly inflamed portal region, however, is much more difficult. Guidewire placed retrograde via the common bile duct through the dome of the liver is required during the operation, which can be converted to a PTC drain either intraoperatively or postoperatively by the interventional radiologist. Without the guidewire, it can be difficult to access a nondilated biliary system percutaneously. Biliary diversion via PTC tube is a technically challenging procedure that requires commensurate local expertise of surgeon and radiologist.

In patients with biliary diversion, which provides a source of minimally contaminated bile, bile refeeding is feasible and may assist in preventing long-term nutritional complications. However, an established enteral feeding access, such as a JT, is required for bile refeeding, as oral ingestion of bile is rarely tolerated.

Endoluminal vacuum therapy — The use of negative pressure wound therapy in the treatment of soft tissue wounds and injury has prompted interest in the use of this modality for gastrointestinal leaks and fistula. Primarily described for the use in treatment of esophageal and rectal defects, there is now additional literature describing the use of endoscopically placed foam or film covered suction catheters for the treatment of duodenal leak [43]. (See "Endoluminal vacuum therapy (EVAC/EVT)".)

Postoperative care — Once a duodenal leak has been closed or controlled surgically, early postoperative management should focus on treating sepsis with antibiotics, providing nutritional support, and managing various drains and tubes.

Antibiotics — Patients with sepsis from the duodenal leak should be treated with broad-spectrum antibiotics and possibly antifungals. In most cases, we stop antibiotics 24 hours after surgery. We do not alter this practice when temporary abdominal closure is used. A short course of antibiotics after definitive control of the infectious source has been associated with equivalent outcomes to longer courses of antibiotics [44]. The choice and duration of antibiotic therapy are discussed in detail in another topic. (See "Antimicrobial approach to intra-abdominal infections in adults".)

Nutrition — In patients who can tolerate it, enteral feeding should be started as soon as possible after surgery. We do not require stool passage before initiating tube feeds and often will start "trophic" tube feeding at a low rate as soon as resuscitation is complete. Patients who had extensive lysis of adhesions at the time of operation may develop a prolonged ileus, which may preclude enteral feeding for a longer period of time.

When enteral nutrition is not feasible or not tolerated, total parenteral nutrition should be used. Patients with baseline short bowel syndrome, profound preoperative malnutrition, and other underlying comorbidities (eg, known malignancy or inflammatory bowel disease) are candidates for early initiation of total parenteral nutrition.

Drain management — After surgical repair of a duodenal leak, patients often have multiple drains and tubes that require specific management (see 'Adjunctive measures' above):

●Nasogastric tubes should be placed on low wall suction to decompress the stomach in order to facilitate duodenal healing.

●Periduodenal (external) drains should be monitored closely; bile staining or increased output may suggest a duodenal leak. When in doubt, drain output can be sent for bilirubin or amylase measurement to help determine the presence of a leak.

●DTs should be placed to gravity drainage to allow decompression of the duodenum, which also promotes healing of the duodenal stump.

The sequence of DT and periduodenal drain removal depends on whether the stomach is in continuity with the duodenum, whether a leak is present, the type of DT used, and the nutritional and immunologic status of the patient:

●In our practice, we obtain an upper gastrointestinal (UGI) series on the fifth postoperative day in patients whose stomach is in continuity with the duodenal repair. The UGI study is delayed if the patient's gastric function has not returned by then. If there is no evidence of a duodenal leak on the UGI series, any existing DT can be clamped. If there is no evidence of a leak in one to two days after clamping of the DT, the periduodenal drains can be removed. The DTs are not removed until six to eight weeks after the surgery to ensure formation of a tract. Practices vary based on surgeon preferences and patient conditions. As an example, some surgeons leave end DTs in for a longer period of time than lateral and retrograde DTs.

●In patients whose stomach is no longer in continuity with the duodenum, UGI studies cannot assess the duodenal repair except for confirming the completeness of a pyloric exclusion (see "Surgical management of peptic ulcer disease", section on 'Perforated duodenal ulcer'). In such patients, contrast study via an existing lateral or retrograde DT and/or computed tomography is required to confirm healing of the duodenal leak before any periduodenal drain or DT can be safely removed, utilizing a similar sequence and timeline described above.

MORBIDITIES AND MORTALITY

Mortality — Historically, a duodenal stump leak following surgery performed for peptic ulcer disease used to cause a perioperative mortality rate of 50 percent [3].

Most contemporary series (after 2000) of duodenal leaks following gastrectomies performed for gastric cancer [4,5,45] or ulcer disease [35] reported a postoperative mortality rate of approximately 10 percent (range 9 to 16 percent). In one exception, the mortality rate in patients who required reoperation for duodenal leaks was 30 percent [1]. Most death was caused by overwhelming sepsis, multiorgan failure, or bleeding.

In a single-center series of 52 leaks, the mortality rate was 21.2 and 2.4 percent, respectively, after emergency or elective surgery, respectively [7].

Morbidities — Most patients who develop a duodenal leak have additional complications, with the overall morbidity rate being as high as 75 percent [5]. Common complications associated with a duodenal leak (and their prevalences) include abdominal abscess (38 percent), wound infection (28 percent), sepsis (26 percent), central line infection (15 percent), pneumonia (13 percent), and acute renal failure (10 percent) [5].

The risk of developing a recurrent leak following a primary duodenal stump leak repair is high [2]. Goals at reoperation should primarily be directed at controlling the source of ongoing sepsis. Beyond that, we employ all primary and adjunct techniques available to reduce the risk of a recurrent leak. As an example, if the initial surgery was a standard Graham patch repair of a perforated duodenal ulcer, at reoperation we might exclude the duodenum, place a retrograde duodenostomy tube, or even add biliary diversion. At reoperation, it is not sufficient to merely repeat the previous repair, which would not only be more technically difficult but also virtually certain to fail again.

Although most patients who survive a duodenal leak do recover, the healing process can be quite protracted. In one review, patients who are managed nonoperatively healed their leak in 17 to 71 days; those who underwent reoperation had a median healing time of 43 days [8].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastric surgery for cancer".)

SUMMARY AND RECOMMENDATIONS

●Etiologies and incidences – A duodenal leak can originate from perforated peptic ulcer disease (PUD), traumatic injury, or postsurgical suture or staple line dehiscence. Of these, postgastrectomy leaks are most common in contemporary practice and occur after 1 to 2 percent of gastrectomies. (See 'Introduction' above and 'Epidemiology' above.)

●Risk factors and prevention – Postgastrectomy duodenal leaks primarily result from a disruption of the duodenal stump closure. For patients who undergoing elective open or laparoscopic gastrectomy, we suggest reinforcing the duodenal stump staple line with sutures (Grade 2C). A lack of stump reinforcement is an independent risk factor for duodenal stump leak in multiple studies. (See 'Etiology and risk factors' above and 'Prevention' above.)

●Clinical manifestations and diagnosis – Patients with a duodenal leak typically present with severe abdominal pain, fever, and/or hemodynamic instability (tachycardia or hypotension). In those who still have an indwelling surgical drain near the duodenal stump, the effluent may increase in volume and/or become bilious or bloody. Stable patients suspected of having a duodenal leak should undergo abdominopelvic CT, which can usually diagnose the leak. Unstable patients require immediate surgical exploration, where diagnosis is made intraoperatively. (See 'Clinical manifestation' above and 'Diagnosis' above.)

●Management

•Unstable patients – Patients with a duodenal leak who present with diffuse peritonitis, intra-abdominal hemorrhage, major wound dehiscence, uncontrolled sepsis, clinical deterioration, or multiorgan failure/shock should undergo immediate emergency surgical exploration. The leak may be primarily closed, or an end or lateral duodenostomy tube (DT) may be used to control the leak in unstable patients who cannot tolerate more extensive procedures (algorithm 1). (See 'Unstable patients' above.)

•Stable patients – Initial treatment of a postoperative duodenal leak in stable patient is nonoperative, which heals the leak in 25 to 75 percent of patients. Nonoperative management of a duodenal leak includes (see 'Initial management of stable patients' above):

-Resuscitation of the patient and management of sepsis.

-Drainage of fluid collections.

-Control of fistula with diversion of intestinal, biliary, and pancreatic fluid.

-Optimization of nutrition and wound care.

Stable patients with a duodenal leak that has not closed after three to six months of nonoperative treatment likely require elective operative or endoscopic intervention. Primary closure should be attempted with buttressing of the repair with viable tissue (eg, omentum or serosal patch) for a small defect. Patients with larger defects may require more complex techniques such as closure with a Thal patch or creation of Roux-en-Y duodenojejunostomy. (See 'Subsequent management of stable patients with persistent leak' above.)

-Paraduodenal (external) drainage should be used in all cases. In selected situations, the use of lateral or retrograde (decompressive) DTs and/or biliary diversion may be beneficial.

-Enteral feeding access, such as with a jejunostomy tube, should also be secured at the index operation. (See 'Adjunctive measures' above.)

●Postoperative care – Duodenal healing may be prolonged. Once source control has been established, supportive care with appropriate antibiotics, nutritional supplementation, and drain management should continue until the patient is physiologically normalized. We confirm duodenal healing with imaging studies before removing drains and tubes. DTs should not be removed before six to eight weeks to allow a tract to mature. (See 'Postoperative care' above.)

●Morbidities and mortality – With improved care, the mortality rate associated with a duodenal leak has decreased from 50 percent in 1960s to 10 percent after 2000. The morbidity rate remains high. (See 'Morbidities and mortality' above.)