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K. Pittala et al.
bilious drainage observed which can be seen in the color of the output or determined
via laboratory analysis. Findings consistent with bile include elevated bilirubin and
amylase from the drain uid. One cohort study of DSB found a median time of
diagnosis of 13days with the longest time to diagnosis being postoperative day 75
[4]. Therefore, a high index of suspicion should be maintained with any patient who
has had a recent creation of a duodenal stump.
42.3 Diagnosis ofaBlowout
Diagnosis of DSB is most commonly accomplished with a combination of clinical signs,
laboratory studies, and cross-sectional imaging. Laboratory studies are nonspecic but
may show electrolyte abnormalities, anemia, and leukocytosis. Commonly utilized imaging modalities include X-rays or CT scan with or without IV or PO contrast. Plain lms
may show signs of small bowel obstruction, oral contrast extravasation, or presence of a
stula. Abdominal CT may show inammation around the duodenal stump and/or a uid
collection (Fig. 42.1); aspiration or drainage of the peritoneal uid will demonstrate
Fig. 42.1 Representative
CT (a, b) showing
inammation around the
duodenal stump and
peritoneal uid collection
in a case of DSB after
duodenal switch. (From
Nelson etal. 2015)
a
b
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bilious contents. Less commonly, exploratory laparotomy can be used to make the diagnosis of DSB, but the authors recommend against this in clinically stable patients.
Diagnostic surgical exploration can be performed if clinical suspicion remains high or the
patient is clinically unstable or declining. Signicant inammation around the duodenal
stump can make surgical diagnosis difcult, and multiple explorations may be necessary
if clinical status continues to decline [2–4].
42.4 General Management ofaStump Blowout
Identication and understanding of techniques to manage duodenal stump blowout
is a key factor in the effective treatment of these patients. Once the diagnosis of
DSB is made, it is imperative to promptly intervene. It is important to provide IV
uids, electrolyte replacement, and supplementary nutritional support and begin
drainage as early as possible [5]. This is important because early detection of duodenal stump blowout, through identication of presenting signs and symptoms of
the condition, can greatly improve the management outcomes of these patients [4].
Figure 42.2 provides a general algorithm in patients with post-gastrectomy
Postgastrectomy
duodenal leak
Small defect
Primary closure
with omental
buttress
Unstable
Treat sepsis with
antibiotics AND
emergency surgery
Along with drains,
feeding tube, biliary
diversion
Large defect
Control leak with
end of lateral
duodenostomy
tube
fistula/diversion, optimization
Stable
Initiate nonoperative
management with:
resuscitation, sepsis
treatment, drainage of
fluid collections, control of
of nutrition
Reassess in
three to six
months
Persistent
leak
Leak healed
Small defect:
primary
closure
Large defect: Roux en Y
duodenojejunostomy or
Thal patch
Fig. 42.2 General management owchart algorithm for patient with a post-gastrectomy duodenal leak
392
duodenal leakage, a phenomenon that can be synonymous with DSB.Aside from
conservative measures, there are a multitude of approaches to manage and treat
duodenal stump blowout, depending on the condition of the patient and severity of
the DSB.In this section, we will discuss when to utilize each approach, summarize
each technique, and present possible problems associated with each type of
management.
K. Pittala et al.
42.5 Conservative Management
Conservative management consists of starting broad-spectrum antibiotics and parenteral nutrition early in the patient’s course in addition to percutaneous drainage
using a tube duodenostomy [3]. It is generally the preferred approach in stable
patients and should be implemented immediately after a diagnosis of DSB is made
unless other serious secondary complications are present such as sepsis, bleeding,
or undrained abscesses [4]. When utilizing a percutaneous drain, the conservative
approach led to resolution of leakage in 92.3% of patients with a healing time ranging from 17 to 71days [6]. If the conservative approach fails or serious secondary
complications are present, then the surgical approach should be considered [6].
42.6 Percutaneous Approach
The percutaneous approach is typically coupled with the conservative approach, but
it can also be coupled with a surgical approach after an operation to repair a leaking
duodenal stump. Percutaneous drainage can involve drainage of abscesses or be
utilized as a duodenostomy. It is most useful if the conservative approach fails and
a re-laparotomy is impossible while also being an effective method to control postoperative infection [6]. Not only can percutaneous drains be utilized as a drainage
method but they can also be utilized to lead to stoma formation in the perforated site
of the stump which leads to spontaneous closure of the DSB [7].
While radiology can be utilized to place drains postoperatively, another simple
method of drainage is Foley catheters. One study examined the utilization of Foley
catheters as drains after DSB and found some advantages such as allowing early
oral intake by preventing additional leakage via lling of the Foley catheter balloon
with a reduction in the duration of hospitalization [7]. To utilize a Foley catheter,
rst a pigtail catheter is inserted for initial drainage of the DSB uid; once the size
of the uid cavity is reduced and the stula tract is opacied, then a Foley catheter
is inserted to close the stula tract. Requirements necessary for successful Foley
catheter usage are sufcient length of time needed for pigtail catheter drainage
before Foley catheter insertion and Foley catheter removal only after the enterocutaneous stula tract has completely matured [7]. The optimal amount of time needed
with pigtail drainage prior to Foley catheter placement is currently unknown.
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Patients who might benet most from this approach include those with severe adhesion, frozen abdomen, carcinomatosis peritonei, or obesity [7].
A combination of the conservative and percutaneous approaches can be used for
4–6weeks prior to pursuing a surgical strategy. This should be guided by the condition of the patient as if they are not improving or worsening, surgical intervention
may need to be approached sooner [6].
42.7 Surgical Management
Surgical management of DSB can involve draining, closing, or resecting the blowout, and it is most frequently utilized in patients with more severe conditions. Some
of these include diffuse peritonitis, intra-abdominal hemorrhage, major wound disruption, bleeding duodenal ulcer, and abdominal compartment syndrome [4, 7]. The
need for reoperation is associated with higher mortality and requiring longer ICU
care, but this may be due to the patients already being in critical condition when the
operation occurs [4]. Reoperation may also be ineffective if done soon after the rst
operation because of postoperative edema, inammation, and dense adhesion [7].
The exact surgical procedure that can be implemented depends on the size of the
leak, extent of the abscess, and status of the patient [3].
The most common procedure is an exploratory laparotomy which allows for
examination of the abdomen in combination with drainage, closure, or resection of
the duodenal stump [3]. Currently, a large series comparing these interventions are
lacking, and no preferred intervention is known. Therefore, clinical judgment at the
time of operation is of utmost importance in each case.
Drainage is one of the possible avenues to explore when assessing treatment for
a DSB.One example is the usage of a Malecot catheter for control of a DSB.A 20F
Malecot catheter can be inserted into the duodenum and over-sewn with a pursestring suture, in situations where inammation is present, for drainage of a blowout
and decompression of the lumen [8]. Other types of drains may be used as well. The
key to surgical drainage procedures is examination of the entirety of the abdomen
with adequate washout and wide drainage of the blowout. Closure can be attempted
as well at the time of surgical exploration but is generally inadvisable as sutures
may not hold due to surgical inammation and edema. Some have suggested that
staples should be utilized instead of sutures for closure [5]. However, the authors
would caution that tissue aps, sutures, and staples are difcult to utilize in this
patient population due to the inability of these friable tissues to hold these repairs.
In this scenario, the goal should be source control and washout, without denitive repair.
Resection is another surgical strategy to manage a blown duodenal stump and
can be performed if there is irreversible damage to the distal resection point of the
duodenum in cases such as gastric cancer. However, the remaining tissue is at risk
for tissue breakdown and poor healing due to surrounding inammation [2]. To
perform a duodenal resection, an extended Kocher maneuver is performed with
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K. Pittala et al.
detachment of the rst and proximal second part of the duodenum from the pancreatic head through ligating small vessels and brous connections [2]. After the surgical procedure is done, it is recommended to lower the intraluminal pressures in the
duodenal stump through retrograde decompression via tube duodenostomy [2, 3].
Triple tube drainage composed of a tube gastrotomy, retrograde tube duodenostomy, and feeding jejunostomy, typically performed after duodenal perforation, can
also provide extra damage control of the affected area by providing diversion and
decompression of all enteric secretions in cases of DSB [9]. In patients who are not
fully treated at their primary laparotomy, re-exploration and washout can be performed [3]. Re-exploration may be most useful in patients with a large amount of
peritoneal contamination or who developed abdominal compartment syndrome.
Again, the authors recommend washout, drainage, and time over a resection or an
attempted repair of the injury.
42.8 Special Considerations inDuodenal Switch
Bariatric patients present specific difficulties in both the diagnosis and management of DSB.Due to their size, cross-sectional imaging with CT or MRI
can be difficult to obtain, and the quality of the exam is lower due to the
patient’s fat content [10]. Not only that, patients with morbid obesity, while
overweight, may also be nutritionally depleted leading to issues with wound
healing [11]. It’s also well known that morbidly obese tend to present with a
less concerning physical exam with tachycardia at times being the main sign of
intra-abdominal leak.
Management of bariatric patients presents a variety of difculties. First of all,
conservative treatment has been shown to be very successful in duodenal stump
leaks (intravenous antibiotics, drainage, and parenteral nutrition) [4], but this
approach may be inadequate for patients with morbid obesity or complete stump
blowout. The bariatric population is also more susceptible to infectious and noninfectious complications which can be triggered by a stump blowout and lead to
extensive peritonitis requiring invasive management [12].
Drainage of the duodenal stump early may be the most important factor in treating duodenal stump blowout to limit the spread of inammatory factors into the
peritoneal space, and this is usually done using a pigtail catheter into the periduodenal space or a Foley catheter inserted into a duodenostomy [5]; however, this can
prove to be a challenge with morbidly obese patients due to the level of central
adiposity present. This can lead to difculty placing drainage tubes due to the thickness and composition of the abdominal wall as well as difculty placing trocars for
laparoscopic intervention [10].
As mentioned previously, reoperation should only be considered in cases of
widespread peritonitis or hemoperitoneum when it is essential to stabilize patients
in critical condition, as there are much higher mortality rates (up to 56% mortality
rate with patients undergoing one or more reoperations) associated with surgical
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intervention than conservative treatment [4]. Given the difculty of performing
open operations on the bariatric population, this high mortality rate for invasive
intervention may be even higher in bariatric patients. When surgical intervention
is indicated, it is important to be able to quickly locate and access the duodenal
stump to repair the blowout. This can be challenging if the duodenum has retracted
into the retroperitoneal space or in the setting of bariatric patients who have high
levels of visceral adipose tissue. A Kocher maneuver may be required to better
mobilize the duodenum for easier access. The Kocher maneuver involves dissecting the peritoneal attachments on the right of the duodenum so that it is free to be
reected to the left or, in the case of duodenal stump blowout, mobilization for
ease of repair.
Not only is the mechanical exploration of bariatric patients more difcult due to
their size, there is also a component of ischemia that obesity brings with it. With
bariatric patients, increased visceral adiposity can also lead to ischemia around the
duodenal stump because fat tissue is hypo-perfused relative to other tissues and
prone to poor oxygenation [10]. This can lead to increased risk for infection in
obese patients as the oxidative mechanism of killing bacteria is impaired in and
around large collections of fat tissue.
Another extremely important note for the duodenal switch population is that they
usually have comorbidities that require medications that increase susceptibility to
bleeding such as heparin derivatives for DVT prophylaxis [10]. Obese patients are
prone to DVT after surgery due to decreased circulating antithrombin III and
decreased thrombolytic activity [13] and therefore need more DVT prophylaxis,
putting them at risk for increased bleeding after surgery. This can be especially
dangerous if there is a rupture of a blood vessel near the duodenal stump because in
a patient with impaired hemostasis, it could impair the surgeon’s ability to visualize
the stump for repair during reoperation, and it remains a danger in the postoperative phase.
In addition to the traditional two-anastomosis duodenal switch, another type of
duodenal switch that is gaining popularity is the single anastomosis duodeno-ileal
bypass (SADI). In this procedure, a sleeve gastrectomy is performed similarly to
BPD-DS; however, instead of the Roux-en-Y conguration of the small intestine
with a 100cm common channel after the duodeno-ileal anastomosis, a loop of distal
ileum is brought up to connect directly to the transected duodenum to create a single
anastomosis with a 300cm common channel. The creation of one less anastomosis
in the SADI means there is statistically less likelihood of downstream obstruction or
leakage leading to peritonitis or duodenal stump blowout; however, studies to date
show that there are comparable levels of complications between the two procedures
as well as comparable levels of weight loss [14].
As it can be challenging to make the diagnosis for the litany of reasons mentioned above, the authors recommend placing a drain over the biliary stump at the
time of surgery. The drain is both diagnostic of the duodenal stump leak while at the
same time providing source control and can be therapeutic. Outside of pancreatic
surgery, this is one of the few times the authors recommend leaving an abdominal
drain in place on a primary gastrointestinal surgery.
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42.9 Conclusion
Duodenal stump blowout is a dreaded complication of duodenal switch, and it is
important for physicians to understand how to manage and treat patients effectively
when it happens. Early identication and intervention are essential for the prevention and mitigation of severe secondary complications. Diagnosis with clinical
signs, laboratory studies, and cross-sectional imaging gives a window into the
severity of the patient’s condition and leads to the decision for conservative or invasive management. As diagnosis is challenging, the authors recommend leaving a
surgical drain over the stump at the primary surgery. Conservative treatment is the
best option for stable patients; however, if the patient becomes unstable, then a surgical approach may be required. In the conservative approach, percutaneous drain
placement is usually paired with antibiotics and parenteral nutrition. Invasive management is most useful in critically ill patients with intra-abdominal hemorrhage,
major wound disruption, bleeding duodenal ulcer, and abdominal compartment syndrome. Duodenal switch is a powerful tool for excess weight loss in bariatric
patients, but this comes at an increased risk for complications such as duodenal
stump blowout. It is imperative for bariatric surgeons to be familiar with the presentation and management of DSB in order to ensure patient safety and successful
outcomes.
References
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morbid obesity: systematic review and meta-analysis of weight results, diabetes resolution and
early complications in single-centre comparisons. Obes Rev. 2014;15(7):555–63.
2. Vasiliadis K, Fortounis K, Kokarhidas A, Papavasiliou C, Nimer AA, Stratilati S, etal. Delayed
duodenal stump blow-out following total gastrectomy for cancer: heightened awareness for the
continued presence of the surgical past in the present is the key to a successful duodenal stump
disruption management. A case report. Int J Surg Case Rep. 2014;5(12):1229–33.
3. Nelson L, Moon RC, Teixeira AF, Jawad MA. Duodenal stump leak following a duodenal
switch: a case report. Int J Surg Case Rep. 2015;14:30–2.
4. Patricia YPC, Kevin WKF, Yee LF, Jing FK, Kylie S, Kee LS.Duodenal stump leakage.
Lessons to learn from a large-scale 15-year cohort study. Am J Surg. 2020;220(4):976–81.
5. Ali BI, Park CH, Song KY.Outcomes of non-operative treatment for duodenal stump leakage
after gastrectomy in patients with gastric cancer. J Gastric Cancer. 2016;16(1):28–33.
6. Aurello P, Sirimarco D, Magistri P, Petrucciani N, Berardi G, Amato S, etal. Management
of duodenal stump stula after gastrectomy for gastric cancer: systematic review. World J
Gastroenterol. 2015;21(24):7571–6.
7. Oh JS, Lee HG, Chun HJ, Choi BG, Lee SH, Hahn ST, etal. Percutaneous management
of postoperative duodenal stump leakage with Foley catheter. Cardiovasc Intervent Radiol.
2013;36(5):1344–9.
8. Kutlu OC, Garcia S, Dissanaike S.The successful use of simple tube duodenostomy in large
duodenal perforations from varied etiologies. Int J Surg Case Rep. 2013;4(3):279–82.
9. Agarwal N, Malviya NK, Gupta N, Singh I, Gupta S.Triple tube drainage for “difcult” gastroduodenal perforations: a prospective study. World J Gastrointest Surg. 2017;9(1):19–24.
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10. Lascano CA, Kaidar-Person O, Szomstein S, Rosenthal R, Wexner SD.Challenges of laparoscopic colectomy in the obese patient: a review. Am J Surg. 2006;192(3):357–65.
11. Parrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L.American Society for
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12. Shuster A, Patlas M, Pinthus JH, Mourtzakis M.The clinical importance of visceral adiposity: a critical review of methods for visceral adipose tissue analysis. Br J Radiol.
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Chapter 43
Duodenoileal Anastomosis Testing
RamonVilallonga, SergiSanchez-Cordero, andMarcBeisani
43.1 Introduction
Gastrointestinal leak is one of the most serious complications following bariatric
surgery. The rates of leaks after bariatric surgery vary from 0 to 7% after sleeve
gastrectomy (SG), 0 to 5.6% after Roux-en-Y gastric bypass (RYGB), and 0.7 to
8% after biliopancreatic diversion with duodenal switch (BPD-DS) [1]. Despite the
decreasing worldwide incidence over time, gastrointestinal leak remains a signicant cause of morbidity and mortality after bariatric surgeries [2]. The etiology of
leaks is multiple but generally falls into mechanical/tissue causes or ischemic
causes, both of which involve intraluminal pressure that exceeds the strength of the
tissue and/or staple line.
The diagnosis of a gastrointestinal leak after bariatric surgery can be challenging. The patient’s presentation varies according to the type and timing of the leak
and also the patient’s systemic inammatory response. The clinical presentation,
signs, and symptoms are highly variable, ranging from asymptomatic to septic
shock [3, 4]. An early detection is associated with a better outcome, and a high
index of suspicion is the cornerstone in the diagnosis [2]. However, patients with
morbid obesity may show equivocal presentations, leading to late diagnosis and
R. Vilallonga (*)
Endocrine, Metabolic and Bariatric Unit, Center of Excellence for the EAC-BC, Department
of General and Digestive Surgery, Vall d’Hebron University Hospital, Universitat Autònoma
de Barcelona, Barcelona, Spain
ELSAN, Clinique Saint Michel, Centre Chirurgical de l’Obesite, Toulon, France
S. Sanchez-Cordero · M. Beisani
Bariatric and Metabolic Surgery Unit, General Surgery Department, Moises Broggi
Hospital—Consorci Sanitari Integral, Carrer d’Oriol Martorell, Barcelona, Spain
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and
Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_43
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R. Vilallonga et al.
potentially catastrophic consequences [3, 4]. As a major complication following
bariatric surgery, routine intraoperative leak tests should be always considered and
could be an especially relevant aspect considering the legal environment in some
countries.
Traditionally, leak tests have been a way to rule out intraoperative technical mistakes or other issues leading to leaks. Different techniques have been developed
with the aim of identifying a suture line leak. The most common are air insufation
or methylene blue dye injection through a naso- or orogastric tube and an intraoperative upper gastrointestinal endoscopy. More recently, a green indocyanine (ICG)
leak test has also been introduced, and some other authors have described a double
transoral test, including methylene blue and ICG [5]. Regardless of the type of test
used, intraoperative identication of a leak should warrant an appropriate repair and
retesting before completion of the operation and can help to easily prevent severe
postoperative complications.
However, we do not have an ideal intraoperative leak test, and its utility during
bariatric surgery is controversial. Some studies have shown that the use of a routine
intraoperative leak test was not associated with a decrease in the incidence of postoperative leaks [6, 7]. The reality is that there is no high-quality clinical evidence,
not to mention prospective randomized studies, to suggest that any such interventions signicantly decrease leak incidence after bariatric surgery. In fact, some
authors have pointed out that the use of routine leak tests that increase the intraluminal pressure may damage the fresh suture line. However, both hand-sewn and
stapled suture lines have a burst strength well in excess of any intragastric pressure
likely to be created by a brief intraoperative leak check, be it air, liquid, or an intraoperative endoscopy [8]. Moreover, a study including multiple data showed no evidence of either benet but also no harm of intraoperative leak test in patients who
underwent SG, RYGB, or BPD-DS [1].
Although it may not be 100% reliable, leak testing is not likely to create iatrogenic damage to properly constructed fresh suture lines [1, 8]. So, given the potential benet of detecting and correcting immediately a suture leak, and the small
effort that the test implies when the team is used to do it, we strongly recommend to
introduce one in the routine performance of the duodenal switch and its variants.
Besides, the medico-legal aspects should also be taken into consideration [9].
43.2 Methylene Blue Test (Fig.43.3)
The methylene blue test consists of injecting the dye through a previously placed
orogastric tube located at the antrum of the gastric sleeve, in order to inate the cavity and see if any blue leaks out of the lumen. It is a very straightforward test that,
when performed by a trained surgical and anesthetic team, may take less than 2min
to complete. It does not have a high sensibility, but, when positive, it allows to identify and immediately repair inadvertent technical mistakes.
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