Refractory duodenal stump blowout after PPU repair requiring four laparotomies: Pitfalls of early complex reconstruction and need for staged damage control strategies in high-risk patients

A 63-year-old man with diabetes and hypertension presented to emergency department with three days of abdominal pain, septic shock, and diabetic ketoacidosis, with imaging showing pneumoperitoneum and laboratory tests revealing severe metabolic acidosis and markedly elevated lactate. Emergency laparotomy identified a 2-cm duodenal perforation that was treated with primary repair using a Graham patch and peritoneal drainage, after which his initial hemodynamic status improved. On postoperative day six he developed bilious drainage, leading to re-exploration and Billroth II Roux-en-Y gastrojejunostomy; this was followed by recurrent duodenal stump leak, a third operation with tube duodenostomy, and ultimately a fourth laparotomy with stump re-closure and duodenostomy relocation. Despite these repeated interventions and intensive care, the patient’s course was complicated by persistent sepsis, jaundice with deranged liver enzymes, bilateral pleural effusions, ventilator-associated pneumonia, suspected ischemic colitis, and progressive multiorgan failure, culminating in death two months after the index operation. This case is unique because duodenal stump blow-out refractory to Billroth II reconstruction, tube duodenostomy, and re-closure has been reported almost exclusively after surgery for advanced gastric cancer rather than benign perforated peptic ulcer disease, and sequential failure of all three strategies in the same patient appears to be extremely uncommon. It underscores that in hemodynamically fragile, septic PPU patients, early complex reconstruction may exacerbate stump failure and morbidity, and that staged external diversion, wide drainage, and early feeding jejunostomy may represent safer alternatives. Key learning points from this case are the need to recognize high-risk features (shock, diabetes, high lactate, large perforation, inotrope requirement), to favor simplified damage-control strategies with aggressive nutritional support, and to pursue early re-exploration when persistent high-output bilious drainage is accompanied by clinical deterioration, even in the absence of clear radiologic evidence of leakage.