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 © 2019 The Author(s) Published by Informa UK Limited, trading as Taylor & Francis Group Published online: 27 Jul 2019 Submit your article to this journal Article views: 5598 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=igas20 SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY 2019, VOL 54, NO 8, 939–944 https://doi.org/10.1080/00365521.2019.1647456 REVIEW Diagnosis and management of duodenal perforations: a narrative review €nen and Roland Andersson Daniel Ansari, William Toren, Sarah Lindberg, Helmi-Sisko Pyrho Department of Surgery, Division of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden ABSTRACT ARTICLE HISTORY 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 perforations Here we review the current literature on duodenal perforations and discuss the outcomes of different treatment strategies Received 27 June 2019 Revised 16 July 2019 Accepted 19 July 2019 Introduction Duodenal perforation represents a rare but potentially lifethreatening condition The mortality rate ranges from 8% to 25% in published studies [1–3] The first description of a perforated 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-steroidal anti-inflammatory drugs (NSAIDs) and to the aging population [3,10] Furthermore, iatrogenic duodenal perforations are becoming more common following the widespread use of endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP) [11] Optimal methods for the management of duodenal perforations remain controversial The diagnosis is often delayed leading to decreased survival There are few randomized KEYWORDS Duodenal perforation; etiology; diagnosis; management; outcome 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 management In patients that need surgery, there is still ongoing debate regarding type of repair, open or laparoscopic technique and the role of gastric diversion procedures, such as pyloric exclusion In this review, we provide an overview of duodenal perforations and potential management strategies based on available data Etiology Underlying duodenal pathology Peptic ulcer disease is a leading cause of duodenal perforation 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 despite active treatment, hypersecretory states such as Zollinger-Ellison syndrome need to be considered Duodenal perforations can also occur in people with conditions such as duodenal diverticula [13], duodenal ischemia [14,15], infectious disease [16–18] and autoimmune conditions, 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, SE221 85 Lund, Sweden This article has been republished with minor changes These changes 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-ncnd/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 built upon in any way 940 D ANSARI ET AL obstruction [22] Perforations can also be related to chemotherapy [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 classification has been developed to categorize ERCP-related perforations [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 represent distal bile duct injuries caused by wire or basket instrumentation, 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 instrumentation They may go unnoticed during the initial operation and manifest themselves several days later as a delayed perforation a consequence of coagulation necrosis of the duodenal wall Laparoscopic cholecystectomy is one of the most common 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 laparoscopic cholecystectomy have been identified [32] The mechanisms of injury were mainly related to thermal burns by electrocautery or by sharp or blunt dissection Trauma Traumatic injuries to the duodenum are uncommon, representing 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 gastrointestinal tract without complications Less than 1% cause perforations [35–38] Sharp and thin foreign bodies have been associated with a higher perforation risk Implanted foreign 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 perforation, or less acute symptoms associated with abscess or fistula 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 features 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 conservative, 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, intravenous fluid therapy, broad-spectrum antibiotics, intravenous PPIs, nasogastric tube insertion and H 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 duodenum 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 conservative treatment without surgery [46,47] For patients undergoing 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 SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY 941 Figure 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 Progressive abdominal signs or intra-abdominal sepsis should warrant surgery In high-risk patients, who cannot tolerate surgical treatment, conservative management may also include percutaneous drainage of fluid collections [49] Endoscopic management Endoscopic treatment is an attractive treatment modality due to its minimally invasive nature Early endoscopic closure (