# Giant second part of duodenal perforation: Case report and management challenge

## TL;DR

A rare case of a large duodenal perforation in the second part of the duodenum is reported, highlighting the challenges in its management and the surgical interventions used.

## Contribution

This case report presents a rare instance of a giant perforation in the second part of the duodenum and discusses the lack of standardized surgical approaches for such cases.

## Key findings

- Giant perforations in the second part of the duodenum are rare and associated with high morbidity and mortality.
- There is no standard surgical recommendation for managing giant duodenal perforations in the second part.
- The case was managed with pyloric exclusion, retrocolic gastrojejunostomy, and duodenal repair.

## Abstract

Duodenal perforation poses a significant global health challenge, contributing substantially to morbidity, mortality, and hospitalizations. While most perforations occur in the first part of the duodenum, are typically small, and affect older individuals, giant perforations in the second part of the duodenum are exceedingly rare.

A 20-year-old male patient presented with a three-day history of diffuse abdominal pain, accompanied by nausea, vomiting, and anorexia of similar duration. The physical examination revealed PR = 104, BP = 110/70 mmHg and diffuse abdominal tenderness. A significant intraoperative finding was a 5 × 6 cm perforation in the second portion of the duodenum, with leakage of gastrointestinal and biliary contents consistent with biliary peritonitis. A pyloric exclusion, retrocolic gastrojejunostomy, and duodenal repair were performed.

Perforations in the second part of the duodenum are considerably rarer. However, when perforation does occur, particularly in the second part of the duodenum, management presents significant challenges, often associated with high rates of morbidity and mortality. Our patient presented with one the high-risk factors—delayed presentation—and, based on established risk stratification models, would therefore carry an estimated mortality risk of approximately 10 %. There is currently a paucity of definitive guidelines or strong expert consensus regarding the optimal surgical approach for giant duodenal perforations located in the second part. In our patient's case, we performed a repair of the perforation, pyloric exclusion, and retrocolic gastrojejunostomy.

Perforation of the second part of the duodenum is a rare occurrence and presents significant management challenges in emergency situations.

•Giant duodenal perforation in second part is rare and had sever morbidity and mortality•Giant duodenal perforation in second part management is challenging and no standard surgical recommendation•Management of giant duodenal perforation in this case was aggressive resuscitation, pyloric exclusion, retrocolic gastrojejunostomy, duodenal repair, antibiotics with support and eradication therapy and long term PPI course.

Giant duodenal perforation in second part is rare and had sever morbidity and mortality

Giant duodenal perforation in second part management is challenging and no standard surgical recommendation

Management of giant duodenal perforation in this case was aggressive resuscitation, pyloric exclusion, retrocolic gastrojejunostomy, duodenal repair, antibiotics with support and eradication therapy and long term PPI course.