An Effective Surgical Treatment for Repeatedly Leaking Duodenal Stumps

In spite of the overpowering advancements of surgery, that have occurred in the last decades, the optimal treatment of duodenal stump leakage remains uncertain. Between 1997 and 2015, 14 procedures were performed in 11 patients due to duodenal stump leakage, following subtotal gastric resection with Billroth II reconstruction for either ulcer perforation or bleeding. Seven patients underwent conventional surgery aimed at sealing the fistulas: five patients had resuture, one implantation of a Petzer catheter through a purse-string suture, and one percutaneous drainage. Seven patients underwent the so-called “double Roux-en-Y conversion” operation—four of whom underwent the procedure primarily and three following leakage after the first procedure—which consisted of a mucosal roof on duodenal stump seromuscular anastomosis formed between the duodenal stump and the side of an isolated jejunal loop, antegrade jejuno-duodenal drainage, and two end-to-side jejuno-jejunal anastomoses. The clinical course proved fatal in two cases (2/11 = 18%). One patient died following the insertion of a Petzer catheter and omental wrapping, and the other died after percutaneous drainage. Three of the five patients who underwent resuturing for a continued leak had the double Roux-en-Y reconstruction technique. Although this procedure is more extensive, it has proved superior in terms of major complications (2/7 vs 5/7), the number of hospital days (18 vs 23), and postoperative mortality rate (0/7 vs 2/7). The use of the double Roux-en-Y conversion, consisting of an anastomosis of the tension-free small bowel mucosa with appropriate blood supply to the duodenal stump, and jejuno-duodenal antegrade drainage is a useful alternative for the treatment of the challenging duodenal stump blow out and the more complex repeatedly leaking duodenal stumps.