With significant advances in imaging technology and greater sophistication of image-guided per­cutaneous techniques in the current era, radiolog­ic intervention has become the mainstay of ther­apy for duodenal stump leak. The first require­ment of successful management is establishing control of abdominal sepsis. This can frequently be achieved by percutaneous drainage of intraab­dominal fluid collections with catheter placement to allow ongoing evacuation of fluid. The goal of this intervention is to completely drain intraab­dominal fluid and convert the duodenal leak into a stable duodenal fistula. This may require an aggressive approach with placement of multiple catheters and frequent trips to radiology suite for catheter repositioning and upsizing to gain opti­mal control of intraabdominal fluid.

Larger-scale operations are generally reserved for the nonhealing chronic duodenal fistula. These operations are generally best performed in the semielective setting, after patients have been medically stabilized and nutritionally opti­mized. Preoperative studies to rule out common reasons for persistence of duodenal fistula should be performed. In particular, small bowel follow­through should be performed to rule out down­stream obstruction. One approach for definitive closure is performance of a roux-en-Y duodeno­jejunostomy, in which a roux limb is connected to the duodenal stump to provide drainage. As previously stated, reoperative surgery after duo­denal stump leak can be highly challenging given the significant inflammatory changes in the field of dissection. Meticulous technique in dissec­tion and adhesiolysis is required to prevent the occurrence of inadvertent enterotomies or dam­age to the biliary system and pancreas. Another definitive procedure for chronic duodenal fistula is pancreaticoduodenectomy, in which the entire duodenum and head of the pancreas is resected with reconstruction consisting of pancreaticoje­junostomy, choledochojejunostomy, and gastro­jejunstomy.

Duodenal stump blowout, while much less com­mon than in previous decades due to a marked reduction in the number of gastrectomies per­formed, continues to be one of the most dreaded complications following gastric resection. While mortality following stump blowout has improved substantially since the dismal rates of the 1950s, taking steps to prevent this devastating complica­tion remains a contemporary concern. In situa­tions where stump blowout nonetheless occurs, rapid diagnosis and intervention are essential in minimizing associated morbidity for the patient.

Because of the weakness of the anastomosis in the early postoperative phase, many methods for reinforcement have been tried, but neither dou­ble-layer manual suturing nor stapling devices with three rows of staples reduce the leakage rate. Sealants (fibrin glue or fibrin-coated patches) are increasingly used to reinforce the anastomosis in the early healing phase. In experimental studies, however, they also do not prevent anastomotic

Using only clinical parameters and physical ex­amination, it may be difficult to differentiate between an abdominal source and a pulmonary source of infection after gastrectomy. With the widespread use of CT scanning, the site of infec­tion (above or below the diaphragm) is nowadays rarely misdiagnosed. There are, however, many intraabdominal sources for an infection. Espe­cially after total gastrectomy, with clearance of lymph nodes alongside the pancreas, there are at least three anastomoses at risk for leakage, pancreatitis may occur, and even leakage from a feeding jejunostomy site or accidental small intestinal injury may be the source of infection. In most cases, CT scan will accurately detect the cause of the infection and guide further treat­ment. Diagnostic laparoscopy is rarely needed apart for the treatment of an anastomotic leak after minimally invasive gastrectomy.