Reconstruction procedures for gastric cancer include the Billroth-I, Billroth-II, and R-Y reconstruction, with Billroth-II and R-Y reconstruction having an afferent loop and duodenal stump. Postoperative complications of R-Y reconstruction include Roux stasis syndrome, Petersen’s hernia, and duodenal stump leakage [11], with the latter considered to be caused by increased pressure at the edge of the stump due to intestinal peristalsis [12, 13]. To our knowledge, there have been only two reports of perforation of DD after gastric cancer surgery, one case with Billroth-II reconstruction [14] and two cases with R-Y reconstruction [15], both of which were considered to be caused by increased pressure in the afferent loop of the duodenum. Our patient was receiving postoperative care following repair of a femoral neck fracture, and there was food residue in the DD. In addition to weakening of the diverticular wall due to chronic inflammation caused by food residue remaining in the DD for many years, the temporary decrease in intestinal peristalsis caused by the physical stress of femoral bone surgery, especially the decrease in duodenal peristalsis, was considered to have increased pressure in the duodenum and caused the perforation of the DD.

Treatment options for perforation of DD can be conservative or surgical. Conservative treatment may be chosen for patients with micro-perforation, localized inflammation or abscess, and stable general condition with few symptoms [3, 16], but surgical treatment should be chosen for patients with panperitonitis or sepsis or those with significant leakage of intestinal contents due to perforation who are not expected to improve with conservative treatment. The first surgical treatment for perforation of DD is diverticulectomy and two-tiered duodenal closure [17,18,19]. However, in cases of severe inflammation of the duodenum and insecure closure or weakness of the duodenal wall, a duodenojejunostomy may be needed to reduce the risk of duodenal leakage or fistula. Although variations from R-Y duodenojejunostomy with gastro-jejunal exclusion to truncal vagotomy/antrectomy with Billroth II gastrojejunostomy or even pancreaticoduodenectomy have been reported [15, 20,21,22], an increase in surgical complications due to the high invasiveness of the procedure is a concern. Intra-abdominal drainage and feeding jejunostomy have also been reported to improve symptoms [23], and surgery such as surgical drainage or tube-duodenostomy is an option for older patients who are not expected to improve with conservative treatment and cannot tolerate highly invasive surgery or whose general condition is unstable. Fortunately, although our patient was 97 years old, she was still able to tolerate the surgery, which was completed with only a diverticulectomy and two-tiered duodenal closure. Because she had previously undergone total gastrectomy and R-Y reconstruction, gastrojejunostomy was not feasible. In addition, due to her age, it was difficult to perform highly invasive surgery such as pancreatoduodenectomy. If simple closure is not feasible because of excessive inflammation and a large DD fistula, palliative surgery such as surgical drainage or duodenojejunostomy, or biliary drainage through the biliary duct with cholecystectomy, may be considered.

In conclusion, in patients with total gastrectomy and R-Y reconstruction who develop a DD, the possibility of perforation due to increased intraduodenal pressure should be considered.