Duodenojejunostomy leaks after pancreaticoduodenectomy

Background A duodenojejunostomy (DJ) or gastrojejunostomy (GJ) leak is a potentially fatal complication after pancreaticoduodenectomy (PD). However, due to its rarity, this complication has not been fully characterized. Methods We reviewed 3029 PDs performed at our institution over a 26-year period and identified patients who suffered a leak at the DJ or GJ anastomosis. Perioperative data from patients with such a leak were examined in detail and were compared to patients who did not experience such a leak after PD. Results A total of 13 patients experienced a DJ or GJ leak after PD, amounting to a 0.4% leak rate. Common clinical signs of a leak included an acute abdomen, enterocutaneous fistula, and a fever. Twelve of thirteen patients also had a leukocytosis, with five patients having a peak white blood cell count exceeding 30,000 cells/mm(3). The median time interval between surgery and diagnosis of the DJ or GJ leak was 10 days; three patients were diagnosed after being discharged from the hospital and one patient was diagnosed on the day of their planned discharge. In a multivariate model, perioperative risk factors for a DJ or GJ leak included a preoperative BUN-to-creatinine ratio > 20 (odds ratio=6, p=0.01), intraoperative blood loss >= 11 (odds ratio=6, p=0.03), and a total pancreatectomy (odds ratio=7, p=0.005). In the DJ or GJ leak group, 12 of 13 patients were managed operatively. The median postoperative length of stay was 35 days after PD, and four patients died within 4 months of surgery as a result of their complicated postoperative course. Conclusion DJ or GJ leaks occur infrequently after PD, but are associated with substantial morbidity. The clinical presentation is usually delayed, and surgical management is the preferred approach. Early diagnosis, attention to preoperative volume status, and continued efforts to control blood loss may minimize the impact of DJ or GJ leaks in some instances.