Multidisciplinary management of postoperative duodenal perforation using multiple drainage and stenting: A case report and review of literature

Abstract

BACKGROUND

Duodenal perforation is a severe postoperative complication with a high mortality rate of 30%-40%. Causes include ulcers, trauma, and surgical separation. Early diagnosis via computed tomography and timely intervention are crucial. Treatment varies, with conservative methods such as stenting or surgery used for critical cases. Larger perforations may require reconstructive surgery. In this case, a tailored approach including biliary diversion, stenting, placement of a duodenostomy tube, and negative pressure irrigation led to no recurrence and smooth recovery.

CASE SUMMARY

This report describes the clinical course and management of a patient who developed a duodenal perforation 9 days after resection of a retroperitoneal mass. Through timely intervention and a multidisciplinary approach, the patient experienced a favorable prognosis and recovery. Key interventions included restructuring and patching, intestinal decompression, stenting, and drainage. Crucially, stenting, drainage, and negative pressure irrigation played a pivotal role in diluting digestive secretions and providing localized protection. These measures significantly expedited the closure of the perforation and facilitated the patient's recovery.

CONCLUSION

This case highlights the need for individualized multidisciplinary treatment to attenuate duodenal leakage and ensure smooth recovery.

Key Words: Duodenal perforation; Postoperative complication; Multidisciplinary management; Stent graft; Multiple drainage; Case report

Core Tip: Few studies have reported successful stent graft implantation in duodenal perforation. In this case, we adopted the quadruple drainage method to decompress the duodenum and achieved good results. The treatment process was long and the condition was complicated. Almost all treatment methods for duodenal perforation were used in combination, and multiple critical situations were successfully resolved. This report describes a typical case of postoperative duodenal perforation treatment.

INTRODUCTION

Duodenal perforation is a serious complication following gastrointestinal surgery. Although it only has an incidence of 1.1%-2.67% after gastrectomy, this complication is associated with a high mortality rate of 30%-40%, which is substantially higher than that associated with other postoperative complications and perforation in other locations[1-3].

There are many causes of duodenal perforation, such as: Perforation or bleeding caused by gastrointestinal ulcers; duodenal injury caused by endoscopy; traumatic duodenal injury (open trauma and swallowing foreign bodies, etc.); and duodenal injury caused by separation of surgical adhesion. The poor prognosis is attributed in part to the complex anatomical positioning of the duodenum and the nature of duodenal fluids rich in functional digestive enzymes. Spillage of these intraluminal contents may erode blood vessels, leading to potentially fatal hemorrhage. Acute chemical peritonitis can be followed by systemic inflammatory response syndrome, which can progress to secondary bacterial peritonitis and sepsis.

Early diagnosis and shorter time to intervention significantly improve survival[4]. Duodenal perforation typically presents with symptoms such as abdominal pain, fever, hemodynamic instability, and alterations in effluent volume and appearance, emerging 5-10 days postoperatively[1,2,5]. The severity of these symptoms can vary widely, and their presentation can sometimes be atypical. This variability, combined with the potential for delayed onset, poses significant challenges for diagnosis. The preferred diagnostic approach is abdominopelvic computed tomography (CT), ideally with oral contrast, to accurately identify the presence of perforation. In cases where diagnosis remains uncertain, active bleeding is refractory to conservative treatment, or the patient's condition warrants immediate intervention, emergency surgical exploration should be undertaken[6].

Current guidance on managing duodenal perforation draws upon the clinical experience of high-volume professional centers[3,7-9] and guidelines on peptic ulcers[10]. The patient’s overall condition plays a pivotal role in dictating the optimal treatment approach. Conservative methods such as endoscopic clipping and stent placement have been advocated to support spontaneous recovery. Conversely, patients presenting with critical vital signs necessitate urgent surgical closure, with additional abdominal drains, diversions, and duodenostomy for damage control. For larger perforations presenting significant risk, definitive reconstructive procedures, such as duodeno-duodenostomy, Roux-en-Y duodenojejunostomy, Billroth II operation, or pancreaticoduodenectomy, are viable options. Some centers have successfully used pancreas-sparing, ampulla-preserving D1-D2 duodenectomy for emergency treatment of major duodenal perforation, with satisfactory results. This approach successfully resolved perforation and avoided the morbidity and mortality caused by pancreaticoduodenectomy[11].

Here, we report a comprehensive treatment strategy for duodenal perforation with some innovative modifications. We standardized and summarized the combined regimen as an intraduodenal stenting and quadruple drainage strategy, consisting of: Routine intra-abdominal drainage, paraduodenal negative-pressure irrigation drainage; duodenostomy tube drainage; and nutritional decompression drainage via jejunostomy. This approach maximized biliary/stomach diversion and local irrigation. This multifaceted and tailored strategy resulted in no recurrence of the leak, facilitating a smooth and uneventful recovery for the patient.

CASE PRESENTATION

Chief complaints

A 61-year-old man presented with a mass-like occupying lesion in the right lower abdomen detected during a physical examination > 3 months previously.

History of present illness

The patient was found to have large, multifocal right-sided abdominal masses (Figure 1A). Histopathological examination of biopsy specimens revealed spindle-shaped cells, suggesting a malignant neoplasm of soft tissue origin (pathology result: Dedifferentiated liposarcoma).

Figure 1 Preoperative imaging and resected specimen of the abdominal masses. A: Preoperative enhanced computed tomography showing mesenteric tumor of the right hemicolon (image from the arterial phase); B: Resected specimen of the mesentery with multiple tumor nodules and the right hemicolon.

History of past illness

The patient had no history of chronic illnesses (e.g., hypertension, diabetes, asthma, etc.), no previous surgery, and no known drug, food, or environmental allergies.

Personal and family history

The patient denied any significant personal or family medical history.

Physical examination

Examination of the right lower-to-middle abdomen revealed a firm, palpable mass ~5 cm in size, which was nontender with limited mobility. There was no rebound tenderness or guarding. Bowel sounds were normal.

Laboratory examinations

Routine blood tests, liver and kidney functions, and the coagulation profile showed no significant abnormalities. Tumor marker analysis revealed cancer antigen (CA) 72-4 > 500 U/mL, while CA19-9, CA242, CA125, carcinoembryonic antigen, and α-fetoprotein (AFP) were within normal ranges.

Imaging examinations

A mass-like soft tissue shadow was observed inferior to the pancreas. Multiple soft tissue lesions were noted in the mesentery of the right lower abdomen, with malignancy not ruled out (Figure 1A).

FINAL DIAGNOSIS

The patient was diagnosed with dedifferentiated liposarcoma, duodenal perforation, complicated intra-abdominal infection, and intra-abdominal hemorrhage.

TREATMENT

Following exclusion of surgical contraindications, the patient underwent laparoscopic right hemicolectomy and excision of the retroperitoneal masses (Figure 1B). During surgery, a tight adhesion was observed between a mesocolonic mass and the descending and horizontal segments of the duodenum. Before the end of the operation, the operator carefully checked that the serosal surface of the duodenum was intact. Multiple soft tissue masses were observed in the mesocolon and retroperitoneum; the larger of which was located on the right side of the duodenum (lobed and connected to the retroperitoneal mass). The surgical procedure, while complex, was executed successfully, and a drainage tube was placed posterior to the anastomosis site (Figure 2). Initial postoperative recovery was unremarkable except for a sudden increase in drainage effluent volume on postoperative day (POD) 5 (Figure 3). Although the intervention did not cause any immediate change in condition, the patient reported a progressive, albeit tolerable, increase in back pain on POD6-9. Concurrently, elevated body temperature and laboratory indicators suggested infection, which was unresponsive to antibiotics. On POD9, the patient produced 200 mL of blood-like effluent, accompanied by a rapid drop in hemoglobin levels from 97 g/L to 78 g/L within a 5 hours window. These signs of acute abdominal hemorrhage and the patient’s deteriorating condition necessitated emergency surgical intervention. Upon evacuation of the hematoma and dissection of the adhesions within the abdominal cavity, thorough examination revealed a 1 cm perforation located on the anterior aspect of the horizontal portion of the duodenum, accompanied by adjacent hemorrhage. With the help of intraoperative endoscopy, the defect was further confirmed with methylene blue, or the blue dye test, before the surgical team undertook several critical measures to address this complex presentation. Localized suture of the duodenal perforation was attempted, with additional strengthening through a ligamentum teres hepatis patch. To reduce damage from duodenal digestive fluids and lower intestinal intraluminal pressure, gastric and biliary diversions were created, along with retrograde insertion of a decompression tube via distal jejunostomy. A feeding jejunostomy tube ensured nutritional support while bypassing the duodenal repair site. Additionally, new drainage tubes were positioned inferiorly to the liver and within the pelvis (Figure 2).

Figure 2 Surgical illustrations. A and B: First operation: Multiple soft tissue tumors of the colonic mesentery and the right hemicolon were resected. The larger tumor was tightly adherent to the lateral wall of the duodenum; B and C: Second operation and intervention: Intraoperative exploration revealed a perforation on the anterior wall of the horizontal portion of the duodenum. The perforation was repaired with sutures and reinforced using a ligamentum teres hepatis patch. Gastroenteric and biliary diversions were created, and a feeding jejunostomy tube was placed. Postoperative examination indicated persistent unhealed duodenal perforation, and a covered duodenal stent was placed over the perforation site; C and D: Third operation: A duodenostomy tube was directly placed at the perforation site and secured with a wrap of the ligamentum teres hepatis. Additionally, a paraduodenal drain with irrigation and suction capabilities was placed. CT: Cholecystostomy tube; NT: Nasogastric tube; CDS: Ccovered duodenal stent; RDT: Retrograde duodenal decompression tube; PJ: Percutaneous jejunostomy tube; DT: Duodenostomy tube; IDT: Irrigable drainage tube.

Figure 3 Postoperative drainage volume and inflammatory markers. A: Daily drainage volume from the operation day through postoperative day 8; B: Serial serum C-reactive protein, white blood cell count, and procalcitonin measurements from postoperative day 1 to postoperative day 8. POD: Postoperative day; CRP: C-reactive protein; WBC: White blood cell; PCT: Procalcitonin.

Despite the initial control of active hemorrhage and shock following the second operation, the patient’s condition was still complicated by persistent sepsis refractory to high-end antibiotics. Additionally, intermittent reddening of effluent was observed along with an increase in effluent amylase levels, suggesting ongoing intra-abdominal issues. On POD4, the drain positioned inferior to the liver yielded 500 mL of bloody effluent, and the patient presented with symptoms of hemorrhagic shock. Enhanced CT scan and angiography revealed extravasation of the contrast agent from abdominal blood vessels (Figure 4A and B), leading to the decision to perform embolization of a distal branch of the superior mesenteric artery (Figure 4C). However, the patient’s shock state persisted despite these aggressive interventions, and a second emergency operation was needed.

Figure 4 Imaging and interventional management of postoperative intra-abdominal hemorrhage and duodenal perforation. A and B: Enhanced computed tomography and angiography showed contrast extravasation from abdominal vessels, suggesting active bleeding; C: Consequently, embolization of the superior mesenteric artery branches was performed; D: A covered stent was placed at the site of the duodenal perforation under interventional guidance.

A long nasogastric tube was advanced into the duodenum for further decompression. Through this nasogastric tube, a contrast agent was administered to ascertain the presence of ongoing duodenal leakage. Unfortunately, contrast agent extravasation from the duodenal lumen into the abdominal cavity was definitive, indicating a breach at the site of the previously attempted repair of the duodenal perforation. To address this complication, a covered duodenal stent was placed over the perforation site (Figure 4D).

As the previous surgery seemed insufficient for local control of the duodenal perforation, a revised surgical strategy was implemented to better address the duodenal perforation. A duodenostomy tube was directly positioned at the perforation site and secured with a wrap of the ligamentum teres hepatis. Additionally, a paraduodenal drain equipped with irrigation and suction capabilities was installed (Figure 2).

OUTCOME AND FOLLOW-UP

Despite the resolution of local hemorrhage, the patient’s condition remained challenging, with severe infection that escalated to acute kidney injury. In the intensive care unit, the patient received anti-infective treatment and continuous renal replacement therapy. Serial ultrasonography and CT scans revealed significant abdominal fluid accumulation beyond the capacity of the existing drainage systems. Interventional radiology was used to guide targeted puncture drainage at two major sites of fluid collection, adjacent to the stomach and within the abdominal cavity, resulting in substantial control of infection and symptomatic relief (Figure 5).

Figure 5 Targeted puncture drainage under interventional radiology guidance at two major sites of fluid collections adjacent to the stomach and within the abdominal cavity. Beyond the direct manifestations of duodenal perforation, notably hemorrhage and infection, the patient’s recovery was complicated by a series of challenges secondary to extensive surgical interventions and the critical nature of his overall condition. The patient presented with extensive deep venous thrombosis, coagulopathy, urinary system dysfunction, malnutrition, and the need for rehabilitation and physical therapy. Under multidisciplinary management, a significant milestone was achieved by 10 weeks following the third operation: All tubes were successfully removed, and the patient resumed oral intake without significant symptoms.

DISCUSSION

The most commonly used surgical technique to address duodenal perforation involves a two-step process: Through-and-through (abutment) or interrupted Lembert (plication) sutures to seal the perforation, followed by a local patch to strengthen the closure. Despite the variety of patch options, including Graham patch[7,8], Cellan-Jones repair, serosal patching from the jejunal outer wall and fibrin sealant[12-16], the risk of failure, characterized by early postoperative reperforation and/or hemorrhage, remains considerable even with definitive surgical closure[17]. In this patient, we used a Graham patch during the first repair of duodenal perforation, but reperforation and bleeding still occurred postoperatively. The failure was attributable to exposure to persistent chemical erosion from bile, pancreatic juice, and high-activity digestive enzymes, while local inflammatory edema and fragile perifocal tissues further compromised wound healing. Conventional single repair or ordinary drainage strategies lack targeted intervention for the above pathological links, which explains the poor outcome of traditional repair in our high-risk patient.

To overcome the limitations of conventional repair, we proposed and implemented a quadruple drainage strategy tailored to this patient’s condition. This combined regimen integrated biliary and gastric diversion, duodenostomy tube decompression, and paraduodenal negative-pressure irrigation.

Two distinct sets of drains were utilized in our case: Routine abdominal and paraduodenal drains[18]. The first set included drains placed posterior to the anastomosis during the first operation, inferior to the liver, and in the pelvic region during the second operation. The second set included paraduodenal irrigation (a levy drain[19]) and duodenostomy drainage. Apart from preventative roles, these drains were valuable as diagnostic indicators of overall abdominal conditions, as the volume and appearance of effluents reflect the presence of bleeding and infection.

Paraduodenal irrigation (a saline wash and drain with negative pressure), also known as a levy drain[19], has been demonstrated in several single-center studies to significantly improve surgical outcomes. This strategy dilutes duodenal fluids and protects surrounding tissues from digestive enzymes and bacterial infection[20]. duodenostomy tube placement is recommended when the surrounding tissues are too fragile to support primary closure[21,22]. It serves dual purposes of local clearance and intraluminal decompression, thereby reducing the spillage of duodenal contents and mitigating potential sequelae[23].

We attempted intraluminal decompression first with retrograde jejunal intubation, and later with a long nasogastric tube, with the latter proving more efficacious. Given that duodenal contents originate from the gastric and biliary systems, diversion of these fluids substantially reduces the burden on the perforation site. We observed minimal output from the gastric diversion, raising questions on its clinical necessity when balanced against additional surgical trauma. Biliary diversion, however, is a definitive approach with well-documented efficacy.

Traditional tripletube drainage includes gastric decompression, retrograde duodenostomy, and feeding jejunostomy, focusing on intraluminal diversion and enteral nutrition[24]. In comparison, our quadruple drainage strategy incorporated biliary diversion and paraduodenal negativepressure irrigation, together with duodenostomy tube placement and intestinal stent graft sealing. The quadruple system achieved comprehensive digestive fluid diversion, precise local decompression, continuous lavage of enzymerich exudates, and physical leakage sealing simultaneously. It more effectively interrupted the cycle of leakage, tissue corrosion, bleeding, and sepsis, providing a more favorable microenvironment for perforation healing, which makes it more suitable for complex postoperative duodenal perforation with failed primary repair.

Due to the well-reported role of recombinant basic fibroblast growth factor (rbFGF) in promoting the recovery of skin and mucosal damages, we augmented the saline solution with rbFGF to enhance healing of the duodenal perforation. Specifically, 1 mL of basic fibroblast growth factor solution was added to 500 mL of normal saline, administered via continuous paraduodenal negative-pressure irrigation, once daily for 2 weeks. Regarding the safety and efficacy of local mucosal and intracavitary application of rbFGF, the available evidence is supportive. In an open pilot study, Hull et al[25] reported that oral administration of an acid-stable form of bFGF to patients with non-steroidal anti-inflammatory drug-associated gastric ulcers was safe and well tolerated, with no evidence of systemic absorption; after four weeks, 4 of 9 ulcers had healed completely and the remainder showed a mean 89% reduction in area, supporting the safety and efficacy of topically applied basic fibroblast growth factor on gastrointestinal mucosa. Consistent with these clinical observations, Fedakar-Senyucel et al[26], using a rat esophageal anastomosis model, demonstrated that local and sustained release of fibroblast growth factor from a gelatin film markedly enhanced anastomotic healing relative to controls, as evidenced by significantly higher bursting pressures (63.2 mmHg vs 22.5 mmHg), tissue hydroxyproline concentrations (6.0 μg/mg vs 2.4 μg/mg), and submucosal and muscular collagen deposition scores, supporting the efficacy of locally applied fibroblast growth factor in strengthening internal anastomotic repair.

The covered duodenal stent utilized in this case was produced by Sewoon Medical, South Korea (model 221218, size 18PC), with a diameter of 18 mm and length of 120 mm. It was braided from nitinol shape-memory alloy, and designed to have fully covered self-expandable cylindrical stent features, with flared cup-shaped ends to minimize migration tendency. The off-label use of covered stents delivered endoscopically to seal perforations has been highlighted in some case reports and a prospective trial of 28 patients, demonstrating the safety of this technique, especially for iatrogenic damage resulting from endoscopic procedures[13,27-32]. In this case, the stent sealed the leak and reduced the risk of further intraperitoneal contamination, and helped locate the perforation during subsequent surgical interventions, as selecting a stent of appropriate shape and diameter ensured that it stay in place without further securing.

Surgical interventions for duodenal perforation are associated with a high mortality rate, estimated at 30%, leading to the recommendation of minimally invasive or conservative approaches[3,33,34]. This case demonstrates that for complex postoperative duodenal perforation with reperforation and hemorrhage after conventional repair, individualized quadruple drainage combined with stent implantation and multidisciplinary intervention is a reliable salvage strategy. It provides a practical reference for managing similar complicated clinical scenarios when standard surgical repair fails.

CONCLUSION

This case underscores the importance of individualized treatment plans in achieving optimal outcomes in a field where standard protocols are yet to be established. These interventions collectively proved pivotal in halting duodenal leakage, as demonstrated by the cessation of postoperative bleeding and smooth recovery of the patient.