What is the management of duodenal perforation?

Management of Duodenal Perforation

Surgery is the treatment of choice for duodenal perforation, with the specific approach determined by perforation size, hemodynamic stability, and timing of presentation. 1

Initial Assessment and Stabilization

Immediate surgical exploration is mandatory for unstable patients presenting with peritonitis without delay. 1

For stable patients, computed tomography with intravenous and oral contrast is the most valuable imaging technique to identify duodenal perforation and assess its extent. 2 However, in some cases, surgical exploration may be necessary for definitive diagnosis. 2

Surgical Management Based on Perforation Size

Small Perforations (<1-2 cm)

Primary repair with simple closure and omental patch (Graham patch) is the recommended approach for small duodenal perforations. 1

• For perforations <1 cm in hemodynamically stable patients, laparoscopic primary suture with omental patch is recommended whenever technically possible. 1
• Simple closure with or without an omental patch is safe and effective for perforations <2 cm. 1
• Triple-loop suturing is critical when the gastroduodenal artery is involved due to collateral blood supply to the transverse pancreatic arteries. 1
• Laparoscopic repair can be safe and effective for experienced surgeons in selected stable patients. 1, 3

Large Perforations (>2 cm)

For large duodenal perforations, there is no consensus on optimal surgical treatment, but pancreas-sparing duodenectomy is suggested for ulcers in D1/D2 segments. 1

The selection of appropriate technique depends on: 1

• Presence of an experienced surgeon
• Significant duodenal tissue loss
• Hemodynamic stability of the patient
• Location of perforation

Eight surgical techniques have been identified for managing large perforated duodenal ulcers: omental plug, triple tube technique, gastric body partition, duodenojejunostomy, serial patch, pedicled patch, pancreas-sparing duodenal resection, and gastric resection. 1

For perforations involving the ampulla, definitive resectional approach is not recommended in the emergency setting due to reconstruction complexity. 1

Damage Control Surgery

Damage control surgery with open abdomen should be considered in hemodynamically unstable patients with severe peritonitis and septic shock. 1

Damage control options include: 1

• Pyloric exclusion
• Gastric decompression
• External biliary drainage
• These should be performed contemporary to primary repair of the perforated duodenal ulcer

The open abdomen is indicated for: 1

• Severe physiological derangement
• Need for deferred intestinal anastomosis
• Planned second look for intestinal ischemia
• Persistent source of peritonitis (failure of source control)
• Extensive visceral edema with concerns for abdominal compartment syndrome

Surgical Approach: Open vs Laparoscopic

Laparoscopic repair is safe and effective in stable patients with early presentation (<12 hours) and small perforations. 3

• Laparoscopic management compares favorably with open procedures regarding surgical time and complications. 3
• Intraoperative endoscopy may be helpful to facilitate localization of the bleeding or perforation site. 1, 3
• Endoscopic guidance can identify the perforation site in approximately 83% of cases (35 of 42 patients). 3
• If the perforation cannot be localized laparoscopically, the surgeon should proceed with laparotomy. 1

Conservative Management

Conservative management may be feasible only in stable patients with sealed perforations confirmed by water-soluble contrast study. 2, 4

• Patients should undergo gastroduodenogram with water-soluble contrast medium. 4
• If the perforation is sealed, nonsurgical treatment can be attempted. 4
• If the perforation is leaking, secure surgical closure is necessary. 4

This approach should be reserved for highly selected patients, as medical treatment failures have a death rate approaching 50%. 5

Adjunctive Measures

Biopsies of the perforated ulceration should be performed to exclude malignancy. 1

• An immediate or delayed biopsy is recommended for all perforated ulcers. 1
• Gastric ulcers should be resected or at least biopsied due to possibility of neoplasm. 1

Place a nasogastric tube for proximal gastric decompression to reduce pressure on the repair site. 6

External drainage should be placed near the duodenal repair site to control any potential leak. 6

Postoperative Management

Monitor for complications including: 6

• Increased drain output
• Fever and leukocytosis
• Abdominal pain (signs of duodenal fistula)
• Gastric outlet obstruction or leak from repair site

Following recovery, all patients should be evaluated for Helicobacter pylori and treated appropriately if infected. 4, 3

Avoid NSAIDs, smoking, and other ulcerogenic factors to prevent recurrent ulceration. 6

Common Pitfalls

• Delaying surgical exploration in unstable patients can significantly increase mortality. 1
• Inadequate suturing of gastroduodenal artery bleeding—triple-loop suturing is essential. 1
• Attempting laparoscopic repair in hemodynamically unstable patients or with extensive peritoneal contamination. 1
• Failing to place external drainage near the repair site increases risk of uncontrolled leak. 6
• Not testing for H. pylori postoperatively leads to high recurrence rates. 4, 3