What we did and why

In this patient, immediate operative intervention was undertaken. After extensive adhesiolysis, a small amount of purulence was visualized in the RUQ around the duodenum. A perforation in the proximal duodenal stump secondary to direct erosion from a 3 cm gallstone was encountered. The duodenum was kocherized demonstrating no cholecystoduodenal fistula. The proximal duodenum in the area of perforation was friable and necrotic; however, the second and third portions of the duodenum were normal in course and caliber. The gallbladder was secondarily inflamed but felt normal without evidence of stones. The proximal duodenal stump was debrided to healthy bleeding tissue with immediate return of bile and a large stone was removed (figure 2). Through the duodenotomy, a normal appearing ampulla could be visualized/palpated 2–3 cm from the perforation with free extrusion of bile; therefore, we repaired the duodenum primarily without further evaluation of the biliary tree. Had the ampulla not been easily visualized, a cholecystectomy would have been performed with pediatric feeding tube placement through the cystic duct and exiting the ampulla to allow for direct visualization and palpation of the extrahepatic biliary tree to avoid iatrogenic injury with duodenal closure. Given the patient’s age and absence of preceding symptoms of colic, it was felt that the gallbladder was likely not the source, but rather stasis in the proximal afferent limb, now repaired flush to the ampulla, therefore we elected not to perform cholecystectomy. The duodenal wall was closed in layers. The repair was drained with two closed suction drains. Postoperatively, nasogastric decompression and antibiotics were maintained for 72 hours followed by slow resumption of enteral nutrition. The patient recovered without incident, discharging to home on the 7th postoperative day after removal of surgical drains and has been seen in follow-up with no further symptoms and doing well.

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Figure 2

Duodenal stump perforation with enterolith.

A rare late complication after gastrectomy with reconstruction is duodenal stump blowout or afferent loop syndrome. Typically, afferent loop syndrome or duodenal stump blowout occur in the first 7 days from operation and are rare complications, occurring in 0.3%–5% of cases.1–3 However, recent case reports have highlighted unusual cases of afferent loop syndrome occurring decades after initial operation due to the formation of enteroliths, some of which have been managed with less invasive modalities.1 2 4–9 Enteroliths in the afferent loop can lead to obstruction and duodenal stump perforation and pose complex surgical decision-making to the acute care general surgeon.1 10

Historically, PUD was treated surgically. Advances in medical therapy and our understanding of PUD including H elicobacter pylori eradication and acid suppression have more than halved the incidence of operations for the treatment of PUD.11 With the ageing North American population, the acute care surgeon will be confronted with delayed complications of remote ulcer surgery such as the case described above.12