A Case of Delayed Duodenal Perforation Due to Afferent Loop Obstruction Associated with an Internal Hernia That Developed 9 Years After Total Gastrectomy, Roux-en-Y Reconstruction

Abstract

The patient was a 74-year-old man who had undergone total gastrectomy for early gastric cancer with retrocolic Roux-en-Y reconstruction 9 years ago. He presented to our hospital complaining of upper abdominal pain, abdominal fullness, and fever. We made a diagnosis of acute afferent loop obstruction and performed emergency open surgery. Intraoperatively, the jejunum was found to be strangulated through the mesenteric defect of the Roux-en-Y anastomosis, and we released the ileus and closed the hernia orifice. On the sixth postoperative day, the patient developed abdominal pain and fullness, and high fever (39℃). Abdominal CT revealed a retroperitoneal abscess, and we performed emergency surgery again under the diagnosis of peritonitis. Intraoperative exploration revealed a late-onset perforation of the third portion of duodenum with intestinal necrosis involving a 4-cm segment, and we performed debridement of the necrotic area and external drainage using a T-tube because of external fistula formation. The postoperative course was satisfactory, and the patient was discharged on the 38th postoperative day. We report this case with a review of the literature, as it was a case of delayed duodenal perforation due to a rare afferent loop obstruction that was difficult to treat.