Duodenal perforation following right nephrectomy in a paraplegic patient with pyonephrosis: a case report and clinical insights

Duodenal perforation is a life-threatening acute complication with high morbidity and mortality, particularly among patients with multiple comorbidities. We present the case of a 46-year-old Asian male with a history of paraplegia and type 2 diabetes mellitus who developed duodenal perforation following right nephrectomy for non-functional kidney complicated by perirenal abscess and lumbar sinus tract infection. The patient sustained a thoracolumbar fracture and spinal cord injury due to blunt trauma 6 years prior, resulting in permanent lower limb paraplegia. Preoperative imaging confirmed right renal non-function, and sequential interventions including perirenal abscess aspiration, ureteral stenting, and nephrectomy were performed. Duodenal perforation (4 mm in diameter) was identified via gastroscopy on postoperative day 6, initially managed with endoscopic clipping, and subsequent radical surgery (subtotal gastrectomy + Roux-en-Y gastrojejunostomy + cholecystolithotomy + cholecystostomy) was required due to persistent leakage. Multidisciplinary team (MDT) collaboration, targeted antibiotic therapy based on pharmacokinetic/pharmacodynamic (PK/PD) principles, and staged nutritional support were implemented. The patient achieved clinical cure after 3 months of comprehensive management. This case highlights the importance of early diagnosis using computed tomography (CT) and endoscopy, individualized surgical strategies, and MDT collaboration in managing postoperative duodenal perforation in high-risk patients with paraplegia and diabetes.