Surgical Treatment of Duodenal Perforation
Immediate Management Decision
For hemodynamically stable patients with small duodenal perforations (<1 cm), perform laparoscopic primary suture repair with omental patch (Graham patch); for unstable patients or large perforations (>2 cm), proceed immediately to open surgical exploration with damage control surgery principles. 1, 2
Algorithmic Approach Based on Clinical Presentation
Step 1: Assess Hemodynamic Stability
Unstable Patients (Peritonitis, Septic Shock):
- Immediate surgical exploration without delay is mandatory 1, 2
- Do not delay with imaging or conservative measures 1
- Consider damage control surgery with open abdomen for severe peritonitis and septic shock 1, 2
- Use laparotomy rather than laparoscopy in unstable patients 1
Stable Patients:
Step 2: Determine Perforation Size and Location
Small Perforations (<1 cm):
- Laparoscopic primary suture with omental patch is the preferred approach 1, 2
- This technique is safe, feasible, and associated with decreased operative time, blood loss, and length of stay 1
- Simple closure with or without omental patch is effective for perforations <2 cm 2
Large Perforations (>2 cm):
- No consensus exists on optimal surgical treatment 1
- Selection depends on: surgeon experience, extent of duodenal tissue loss, hemodynamic stability, and operative factors 1
- Multiple techniques available: omental plug, triple tube technique, gastric body partition, duodenojejunostomy, serial patch, pedicled patch, pancreas-sparing duodenal resection 1
- For ulcers in D1/D2, consider pancreas-sparing duodenectomy 1
- Avoid definitive resectional approaches involving the ampulla in emergency settings due to reconstruction complexity 1
Step 3: Special Considerations During Surgery
When Gastroduodenal Artery is Involved:
- Triple-loop suturing is critical due to collateral blood supply to transverse pancreatic arteries 2
- Inadequate suturing of this vessel is a common pitfall that increases mortality 2
Damage Control Options for Large Perforations:
- Pyloric exclusion with gastric decompression 1
- External biliary drainage 1
- These should be performed contemporary to primary repair 1
Mandatory Intraoperative Actions:
- Perform biopsies of the perforated ulceration to exclude malignancy 1, 2
- This is particularly important for gastric ulcers due to neoplasm possibility 2
Essential Adjunctive Measures
Immediate Postoperative Setup:
- Place nasogastric tube for proximal gastric decompression to reduce pressure on repair site 2, 3
- Place external drainage near the duodenal repair site to control potential leaks 2, 3
Postoperative Monitoring:
- Monitor for increased drain output, fever, leukocytosis, and abdominal pain indicating duodenal fistula 2, 3
- Watch for gastric outlet obstruction or leak from repair site 2, 3
- If fistula develops: maintain nil per os status, provide total parenteral nutrition, and continue external drainage 3
Context-Specific Scenarios
Post-Bariatric Surgery Duodenal Perforation:
- Assess the jejuno-jejunostomy for stricture or anomalies (kinking, twisting) that may have caused back pressure 1
- If stricture found, resect to avoid vascular compromise and re-perforation 1
Iatrogenic Perforation (ERCP-related):
- Conservative management may be feasible in stable patients with sealed perforations 4
- Endoscopic closure with metallic clips is an alternative for early-identified perforations in highly selected stable patients 5, 6, 7
- However, surgical intervention remains standard for free wall perforations with peritoneal contamination 8, 7
Critical Pitfalls to Avoid
Timing Errors:
- Delaying surgical exploration beyond 6 hours in unstable patients significantly increases mortality 2, 9
- Do not attempt conservative management in patients with peritonitis or intra-abdominal sepsis 4
Technical Errors:
- Attempting laparoscopic repair in hemodynamically unstable patients or with extensive peritoneal contamination increases mortality 2
- Inadequate triple-loop suturing when gastroduodenal artery is involved 2
- Failing to place external drainage near repair site increases uncontrolled leak risk 2
Diagnostic Errors:
- Not exploring for underlying causes (jejuno-jejunostomy obstruction in post-bariatric patients) 1
- Failing to biopsy perforated ulcers to exclude malignancy 1, 2
Evidence Quality Considerations
The recommendations are based primarily on 2022 World Journal of Emergency Surgery guidelines 1 and 2025 Praxis Medical Insights summaries 2, 3, which synthesize expert consensus. The quality of evidence is acknowledged as low to very low 1, reflecting the rarity of duodenal perforation and lack of randomized trials. However, the consistency across guidelines and the life-threatening nature of this condition support these strong recommendations despite limited evidence quality.