Diagnosis and management of duodenal perforations a narrative review

Diagnosis and management of duodenal perforations: a narrative review Daniel Ansari, William Toren, Sarah Lindberg, Helmi-Sisko Pyrh€onen and Roland Andersson Department of Surgery, Divi

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Scandinavian Journal of Gastroenterology

ISSN: 0036-5521 (Print) 1502-7708 (Online) Journal homepage: https://www.tandfonline.com/loi/igas20

Diagnosis and management of duodenal

perforations: a narrative review

Daniel Ansari, William Torén, Sarah Lindberg, Helmi-Sisko Pyrhönen &

Roland Andersson

To cite this article: Daniel Ansari, William Torén, Sarah Lindberg, Helmi-Sisko Pyrhönen & Roland Andersson (2019) Diagnosis and management of duodenal perforations: a narrative review, Scandinavian Journal of Gastroenterology, 54:8, 939-944, DOI: 10.1080/00365521.2019.1647456

To link to this article: https://doi.org/10.1080/00365521.2019.1647456

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Diagnosis and management of duodenal perforations: a narrative review

Daniel Ansari, William Tor
en, Sarah Lindberg, Helmi-Sisko Pyrh€onen and Roland Andersson

Department of Surgery, Division of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden

ABSTRACT

Duodenal perforation is a rare, but potentially life-threatening injury Multiple etiologies are associated

with duodenal perforations such as peptic ulcer disease, iatrogenic causes and trauma Computed

tomography with intravenous and oral contrast is the most valuable imaging technique to identify

duodenal perforation In some cases, surgical exploration may be necessary for diagnosis Specific

treatment depends upon the nature of the disease process that caused the perforation, the timing,

location and extent of the injury and the clinical condition of the patient Conservative management

seems to be feasible in stable patients with sealed perforations Immediate surgery is required for

patients presenting with peritonitis and/or intra-abdominal sepsis Minimally invasive techniques are

safe and effective alternatives to conventional open surgery in selected patients with duodenal

perfo-rations Here we review the current literature on duodenal perforations and discuss the outcomes of

different treatment strategies

ARTICLE HISTORY

Received 27 June 2019 Revised 16 July 2019 Accepted 19 July 2019

KEYWORDS

Duodenal perforation; etiology; diagnosis; management; outcome

Introduction

Duodenal perforation represents a rare but potentially

life-threatening condition The mortality rate ranges from 8% to

25% in published studies [1–3] The first description of a

per-forated duodenal ulcer was made in 1688 by Muralto and

reported by Lenepneau [4] In 1894, Dean [5] reported the

first successful surgical closure of a perforated duodenal

ulcer Surgery is still the mainstay of treatment for duodenal

perforation Many perforations are repaired using an omental

patch, a technique that was first described by Cellan-Jones in

1929 [6] and was later modified by Graham in 1937 [7] The

first laparoscopic repair for a perforated duodenal ulcer was

reported in 1990 [8

The incidence of peptic ulcer disease has decreased in

recent years [9] This can partly be explained by the use of

proton pump inhibitors (PPIs) and eradication treatment for

Helicobacter pylori However, peptic ulcer complications,

including perforation, still remain a substantial healthcare

problem This may be related to increased use of

non-ster-oidal anti-inflammatory drugs (NSAIDs) and to the aging

population [3,10] Furthermore, iatrogenic duodenal

perfora-tions are becoming more common following the widespread

use of endoscopic procedures, such as endoscopic

retro-grade cholangiopancreatography (ERCP) [11]

Optimal methods for the management of duodenal

perfo-rations remain controversial The diagnosis is often delayed

leading to decreased survival There are few randomized

controlled studies and management strategies often rely on data from observational studies, or even case reports One area of controversy includes the role of non-operative man-agement In patients that need surgery, there is still ongoing debate regarding type of repair, open or laparoscopic tech-nique and the role of gastric diversion procedures, such as pyloric exclusion

In this review, we provide an overview of duodenal perfo-rations and potential management strategies based on avail-able data

Etiology Underlying duodenal pathology

Peptic ulcer disease is a leading cause of duodenal perfor-ation Acute perforations of the duodenum are estimated to occur in 2–10% of patients with ulcers [12] The two major causes of peptic ulceration and perforation are H pylori infection and NSAIDs In patients with recurrent ulcers des-pite active treatment, hypersecretory states such as Zollinger-Ellison syndrome need to be considered

Duodenal perforations can also occur in people with con-ditions such as duodenal diverticula [13], duodenal ischemia [14,15], infectious disease [16–18] and autoimmune condi-tions, including Crohn’s disease [19], scleroderma [20] and vasculitis (e.g., abdominal polyarteritis nodosa [21]) Tumors may penetrate the duodenal wall directly or cause

CONTACT Roland Andersson roland.andersson@med.lu.se Department of Surgery, Clinical Science Lund, Lund University, Skane University Hospital,

SE-221 85 Lund, Sweden

This article has been republished with minor changes These changes do not impact the academic content of the article.

ß 2019 The Author(s) Published by Informa UK Limited, trading as Taylor & Francis Group.

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or

2019, VOL 54, NO 8, 939 –944

https://doi.org/10.1080/00365521.2019.1647456

obstruction [22] Perforations can also be related to

chemo-therapy [23,24] Impacted gallstones in the duodenum have

also been associated with perforations [25]

Iatrogenic perforations

Endoscopic perforations

Upper endoscopy may lead to iatrogenic perforations to the

duodenum The incidence of endoscopic perforations is higher

for therapeutic procedures The rate of duodenal perforations

after ERCP ranges from 0.09 to 1.67% [26,27] The Stapfer

clas-sification has been developed to categorize ERCP-related

per-forations [28] Type I perforations are large lateral or medial

duodenal wall perforations usually caused by the endoscope

itself Type II perforations, also known as peri-Vaterian injuries,

are related to the sphincterotomy Type III perforations

repre-sent distal bile duct injuries caused by wire or basket

instru-mentation, while type IV perforations represent retroperitoneal

air alone on imaging and are often asymptomatic Risk factors

for ERCP-related perforations have been reported to include

old age, sphincter of Oddi dysfunction, precut, intramural

injection of contrast medium and anatomical abnormalities,

such as Billroth II gastrectomy [29,30]

Operative injury

Duodenal injuries may be caused by surgical

instrumenta-tion They may go unnoticed during the initial operation and

manifest themselves several days later as a delayed

perfor-ation a consequence of coagulperfor-ation necrosis of the duodenal

wall Laparoscopic cholecystectomy is one of the most

com-mon surgical procedures in general surgery In a series of

77,604 patients undergoing laparoscopic cholecystectomy, a

total of 12 duodenal injuries (0.015%) were reported [31] In

the world literature, 74 cases of duodenal injury after

laparo-scopic cholecystectomy have been identified [32] The

mech-anisms of injury were mainly related to thermal burns by

electrocautery or by sharp or blunt dissection

Trauma

Traumatic injuries to the duodenum are uncommon,

repre-senting less than 2% of all abdominal injuries [33] The

majority of these traumatic lesions are due to penetrating

mechanisms Isolated duodenal injuries are rare Duodenal

injuries often occur together with other organ injuries and

damages to large vessels [34]

Foreign bodies

Ingested foreign bodies generally pass through the

gastro-intestinal tract without complications Less than 1% cause

perforations [35–38] Sharp and thin foreign bodies have

been associated with a higher perforation risk Implanted

for-eign bodies such as endoprosthesis [39] or artificial vascular

grafts [40,41] can cause erosion into the duodenum leading

to fistula and abscess formation or vasculo-enteric fistulas

Spontaneous perforations

This type of perforation occurs in neonates The underlying cause remains unknown [42]

Diagnosis

Perforation of the duodenum is defined as a transmural injury to the duodenal wall A partial thickness laceration may over time develop into a transmural injury Duodenal perforation can cause acute pain associated with free perfor-ation, or less acute symptoms associated with abscess or fis-tula formation

Perforation of the duodenum with spillage of intraluminal contents into the peritoneal cavity causes acute chemical peritonitis This is followed by a systemic inflammatory response syndrome (SIRS), which can progress to secondary bacterial peritonitis and sepsis Patients with retroperitoneal perforation may lack peritoneal signs and present more indolently

Double-contrast computed tomography (CT) scan is the most valuable method for diagnosing duodenal perforation

It should be performed whenever there is a clinical suspicion and the patient does not need immediate surgery CT fea-tures of perforation include discontinuity of the duodenal wall and the presence of extraluminal air or extravasated oral contrast Other CT findings include duodenal wall thickening, fat stranding and periduodenal fluid collection [43]

Treatment

Management of duodenal perforations includes conserva-tive, endoscopic and surgical strategies (Figure 1) The main goals of treatment are resuscitation, control of infection, nutritional support and restoration of gastrointestinal tract continuity

Conservative treatment

Initial conservative management consists of nil per os, intra-venous fluid therapy, broad-spectrum antibiotics, intraintra-venous PPIs, nasogastric tube insertion andH pylori eradication The added value of somatostatin remains controversial However, there are some data to support the benefit of somatostatin for enterocutaneous fistula closure [44]

Non-operative management of perforated duodenal ulcers

is feasible in selected patients Perforated ulcers may seal spontaneously with fibrin, omentum or by fusion of the duo-denum to the underside of the liver between the gallbladder and the falciform ligament [45] Approximately, 50–70% of patients with perforated peptic ulcers respond to conserva-tive treatment without surgery [46,47] For patients under-going conservative treatment, a gastroduodenogram may be performed soon after admission to investigate if there is any contrast extravasation Conservative management seems to

be safe if the gastroduodenogram shows self-sealing [48] Operative management is usually recommended if there

is free leakage of contrast medium into the peritoneal cavity

Progressive abdominal signs or intra-abdominal sepsis should

warrant surgery

In high-risk patients, who cannot tolerate surgical

treat-ment, conservative management may also include

percutan-eous drainage of fluid collections [49]

Endoscopic management

Endoscopic treatment is an attractive treatment modality

due to its minimally invasive nature Early endoscopic closure

(<24 h) is considered to be technically easier because the

inflammatory changes are less pronounced [50]

TTSC

Through-the-scope clips (TTSC) can be used for endoscopic

closure of small duodenal perforations Linear perforations

<1 cm are most suitable for the use of TTSC [50,51]

OTSC

In contrast to common endoscopic clips, the over-the-scope

clips (OTSC) are able to compress larger quantities of tissue

The OTSC system is shaped like a bear trap to enable a

full-thickness closure of the tissue The OTSC technique can be

used for perforations ranging from 1 to 3 cm OTSC

treat-ment has been shown to be effective for peptic ulcer

perfo-rations, with few complications [52]

Endoloop with clips

A combined technique using TTSC and an endoloop can be used if the OTSC technique is unavailable [53]

SEMS

Self-expandable metal stents (SEMS) are alternative endoscopic treatment options for duodenal perforations [50,51,54]

Surgical treatment

The choice of surgical treatment depends on the size and localization of the perforation, the viability of the duodenal walls, the degree of local contamination and underly-ing etiology

Simple surgical repair

The main surgical treatment is simple repair of the perfor-ation site This can be performed as a primary closure with

or without the addition of an omental patch Alternatively, a pedicled omental flap (Cellan–Jones repair) [6] or free omen-tal plug (Graham patch) [7] can be sutured into the perfor-ation Sutureless techniques have also been developed using

a gelatin sponge and fibrin glue to seal off the perforation [55] There seem to be no significant differences in terms of postoperative morbidity and mortality rates when comparing primary closure, omentopexy or tegmentation (without clos-ure) [55–57] Surgical repair can be performed either with conventional open surgery or with laparoscopy The results

Figure 1 A general management algorithm for duodenal perforations Abbreviations: NG: nasogastric; NPO: nil per os; OTSC: over-the-scope clip; PPI: proton pump inhibitor; SEMS: self-expandable metal stent; TTSC: through-the-scope clip.

of a recent meta-analysis including seven randomized

con-trolled trials showed a significant benefit for the laparoscopic

approach for the treatment of perforated peptic ulcer disease

with a significant reduction in postoperative complications

and hospital stay [58]

Abdominal drains

The routine placement of abdominal drains after surgical

repair is controversial The literature suggests no benefit in

preventing postoperative fluid collections or abscesses [59]

Furthermore, drains may be associated with increased

mor-bidity such as drain wound site infection

Pyloric exclusion

Pyloric exclusion involves surgical repair of the duodenum,

gastrotomy and closure of the pylorus from within and

finally the formation of a gastrojejunostomy The rationale

behind this procedure is to divert all gastric and biliary

secre-tions from the duodenum The added benefit of using a

gas-tric diversion procedure such as pyloric exclusion for

duodenal perforations has been questioned in recent years

Importantly, the procedure has been associated with more

postoperative complications and longer hospital stay

com-pared to simple repair without pyloric exclusion [60–62]

Reconstructive surgery

For large duodenal perforations, a duodeno-duodenostomy

may be necessary [33] If this is not possible, a Roux-en-Y

duodenojejunostomy may be performed over the

ation A Billroth II operation may be necessary if the

perfor-ation is to the first or proximal second portion of the

duodenum If the duodeno-pancreatic head complex is

destroyed, a pancreaticoduodenectomy may be

neces-sary [63]

Tube duodenostomy

Tube duodenostomy is a damage control procedure for large

duodenal perforations when other repair techniques are not

possible due to the magnitude of duodenal damage,

hemo-dynamic instability of the patient or the lack of surgical

expertise for complex reconstruction [64] The perforation is

sutured around a catheter inserted into the perforation to

enhance directed fistulation of the perforation The catheter

is removed after a minimum of 6 weeks A feeding

jejunos-tomy may be placed for enteral nutritional support

Prognostic factors

The main prognostic factor remains the time interval

between the perforation and treatment Mortality increases

when the delay is greater than 24 h [3,11,65] Other

prognos-tic factors have been reported but are mainly related to

clin-ical signs of sepsis, such as increased Acute Physiology and

Chronic Health Evaluation II (APACHE II) score [65,66] Old

age and co-morbidity are also strong adverse prognostic fac-tors [65]

Conclusion

Duodenal perforation is caused by a variety of different mechanisms Some duodenal perforations can be managed conservatively, while others require prompt surgical treat-ment The type of treatment should be individualized and depends on the mechanism of injury, the timing, location and extent of the injury and the clinical state of the patient Open surgery is still the gold standard for patients that need surgical intervention and most duodenal perforations can be managed with a simple repair of the defect Gastric diversion procedures such as pyloric exclusion have been used for many years to treat duodenal perforations, but there is little evidence to support any benefit Minimally invasive treat-ments are slowly emerging as alternative methods to open surgery in the treatment of duodenal perforation

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Roland Andersson http://orcid.org/0000-0003-0778-8630

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