Sequential Postoperative Bile Leak Following Laparoscopic Repair of Pre-Pyloric Perforation Revealing a Concomitant Duodenal Perforation: A Case Report

Perforated gastroduodenal disease remains a time-critical surgical emergency. A postoperative bile leak after repair of an apparently limited pre-pyloric perforation raises concern for an unrecognized biliary or duodenal injury, particularly when initial imaging demonstrates pneumobilia, biliary dilatation, and inflammatory changes around the duodeno-pancreatic junction.A 56-year-old chronic smoker presented with four days of epigastric pain, abdominal distension, tympanism, and epigastric guarding. Computed tomography showed an apparent antro-pyloric perforation, pneumobilia, air bubbles around the duodeno-pancreatic junction, biliary dilatation, and a distended sludge-filled gallbladder. Emergency laparoscopy found a 5mm pre-pyloric perforation, which was sutured with omental patching and drained. Early postoperative bile output through the subhepatic drain, persistent inflammatory markers, and repeat CT with water-soluble contrast demonstrated a suspected second perforation at D1. Emergency reoperation revealed bile in the subhepatic space, extensive fibrinous membranes, and a D1 perforation. Antegrade cholecystectomy, interrupted 3/0 polyglactin closure of the D1 defect, feeding jejunostomy, extensive peritoneal lavage, and multiple drains were performed. This case highlights the diagnostic difficulty of overlapping gastroduodenal and biliary pathology and the importance of interpreting postoperative bile drainage as a potential marker of an occult duodenal defect. Early cross-sectional reassessment and prompt source control are central to management.