What is the management for a patient with a history of gastric carcinoma, who underwent resection with Roux-en-Y (Roux-en-Y) reconstruction, started oral intake on the 4th day, then developed abdominal pain, and an upper gastrointestinal (GI) series showed leakage from the duodenal stump?

Management of Duodenal Stump Leakage After Gastric Resection

Percutaneous drainage is the first-line treatment for duodenal stump leaks after Roux-en-Y reconstruction, as recommended by the World Journal of Emergency Surgery guidelines. 1

Initial Management Approach

• Immediate actions:

  • NPO (nil per os) status
  • Broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic bacteria
  • Aggressive fluid resuscitation to maintain hemodynamic stability
  • Nutritional support via parenteral nutrition

• Diagnostic confirmation:

  • The upper GI series has already confirmed the duodenal stump leak
  • CT scan may be useful to assess the extent of the leak and any collections

Treatment Algorithm

1. Percutaneous Drainage (First-line)

• Image-guided percutaneous drainage of any collections is the primary treatment 1
• The drain should be placed to effectively evacuate the leaked contents
• Drain management:
  • Intermittent lavage every 4-6 hours rather than continuous free drainage
  • Clamping between lavages to promote internal drainage 2
  • Daily assessment of drain output and characteristics

2. Supportive Care

• Continue broad-spectrum antibiotics
• Maintain NPO status
• Establish distal feeding access or continue parenteral nutrition
• Monitor inflammatory markers daily (WBC, CRP)
• Monitor vital signs for signs of sepsis or deterioration

3. When to Consider Surgical Intervention

Surgical re-exploration is indicated if:

• Patient develops hemodynamic instability
• Signs of sepsis persist despite adequate drainage
• The leak becomes uncontained
• Clinical deterioration despite conservative management 2

Surgical Options When Needed

If surgical intervention becomes necessary:

• Repair of the duodenal stump with omental patch for small perforations (<1cm)
• For larger defects, consider tube duodenostomy through the open end of the duodenum 3
• In hemodynamically unstable patients, damage control surgery with open abdomen may be considered 2

Monitoring and Follow-up

• Daily assessment of clinical status, inflammatory markers, and drain output
• Repeat imaging to confirm improvement before considering drain removal
• The drain should remain until output decreases significantly and imaging confirms improvement 1
• Consider water-soluble upper GI series before initiating oral intake 2

Common Pitfalls and Caveats

• Premature drain removal can lead to inadequate management of the leak
• Failure to recognize downstream obstruction can perpetuate the leak
• Continuous free drainage via percutaneous drains may prevent internal drainage of material into the gastric lumen 2
• Duodenal stump leaks are associated with significant morbidity and mortality if not managed appropriately 4
• Risk factors for duodenal stump leaks include duodenal ulcer, intraoperative contamination, and lower pre-operative hemoglobin 5

Conclusion

For this patient with a duodenal stump leak after gastric carcinoma resection with Roux-en-Y reconstruction, percutaneous drainage is the recommended first-line treatment. Surgical re-exploration should be reserved for cases where conservative management fails or the patient's condition deteriorates.