Postoperative Findings Mimicking Duodenal Leak After Graham Patch Repair: Intact Repair With Retroperitoneal Abscess

Perforated duodenal ulcers represent a surgical emergency requiring prompt operative intervention. The Graham omental patch is the most commonly performed procedure for emergent repair; however, postoperative findings suggestive of leakage remain a serious concern and are associated with significant morbidity and mortality. Traditionally, suspected postoperative leaks have prompted early surgical re-exploration due to the risk of peritonitis and sepsis. However, select patients with concerning postoperative findings may be managed successfully with appropriate drainage, decompression, and nutritional support. We present the case of a 79-year-old male patient who was brought to the emergency department with progressive altered mental status and generalized abdominal pain. Imaging revealed findings consistent with a perforated duodenal ulcer, and the patient underwent emergent exploratory laparotomy with Graham patch repair and placement of a Jackson-Pratt drain. During the postoperative period, bilious output from the drain raised concern for a possible duodenal leak. A contrast-enhanced CT scan with enteric (oral) contrast demonstrated contrast entering the drain, prompting surgical re-exploration. Intraoperatively, the previous repair was found to be intact without evidence of active leakage; instead, a retroperitoneal abscess extending along the duodenal sweep was identified and drained. With continued supportive management, including nasogastric decompression, antibiotics, proton-pump inhibitor therapy, and nutritional support via gastrostomy tube, the patient demonstrated progressive clinical improvement. Drain output gradually diminished and ceased, consistent with resolution of the postoperative process. This case highlights that postoperative findings suggestive of duodenal leak may not represent true failure of the primary repair and underscores the importance of correlating radiologic, intraoperative, and clinical findings. Careful assessment and appropriate supportive management may allow for favorable outcomes in selected hemodynamically stable patients following Graham patch repair.