Biliogastric diversion for the management of high-output duodenal fistula: report of two cases and literature review

Complex duodenal fistulae: a surgical nightmare

INTRODUCTION

A common feature of external duodenal fistulae is the devastating effect of the duodenal content rich in bile and pancreatic juice on nearby tissues with therapy-resistant local and systemic complications. This study analyzes the results of different management options with emphasis on successful fistula closure rates.

METHODS

A retrospective single academic center study of adult patients treated for complex duodenal fistulas over a 17-year period with descriptive and univariate analyses was performed.

RESULTS

Fifty patients were identified. First line treatment was surgical in 38 (76%) cases and consisted of resuture or resection with anastomosis combined with duodenal decompression and periduodenal drainage in 36 cases, rectus muscle patch, and surgical decompression with T-tube in one each. Fistula closure rate was 29/38 (76%). In 12 cases, the initial management was nonoperative with or without percutaneous drainage. The fistula was closed without surgery in 5/6 patients (1 patient died with persistent fistula). Among the remaining 6 patients eventually operated, fistula closure was achieved in 4 cases. There was no difference in successful fistula closure rates among initially operatively versus nonoperatively managed patients (29/38 vs. 9/12, p = 1.000). However, when considering eventually failed nonoperative management in 7/12 patients, there was a significant difference in the fistula closure rate (29/38 vs. 5/12, p = 0.036). The overall in-hospital mortality rate was 20/50 (40%).

CONCLUSIONS

Surgical closure combined with duodenal decompression in complex duodenal leaks offers the best chance of successful outcome. In selected cases, nonoperative management can be tried, accepting that some patients may require surgery later.

Iatrogenic Duodenal Perforation After Surgery: a Systematic Review

Duodenal perforation consequent to prior surgery is a rare but severe complication carrying serious consequences if not promptly managed. This study aims to identify the best treatment pathway available to date. This is a systematic review registered to PROSPERO. The literature research was conducted on Ovid Medline, Embase, and Cochrane up to February 2022 to identify all papers reporting surgical-related duodenal perforations. Twelve articles were included. Most of these studies were case reports or case series. The most common cause of perforation was laparoscopic cholecystectomy (72.7%). The median time to symptom appearance was 2 days. Most of these perforations were severe injuries located in the first portion of the duodenum. Only one patient was treated with a non-interventional conservative management, which failed. Five patients were managed with interventional non-surgical treatments: 4 with endoscopy (50% failure) and one with a percutaneous occluder. Different surgical treatments were reported: direct suture (100% failure), direct suture and T-tube duodenostomy (75% failure), simple abdominal drainage, and suture with pyloric exclusion. Further extensive surgeries were also reported. The overall mortality rate was 13.6%, with a median hospital stay of 38.5 days. This review shows a wide spectrum of managements for patients with duodenal perforation related to prior surgery. The decision on which treatment to adopt must consider patient’s clinical setting and duodenal defect characteristics (size, site, and time to diagnosis). A tentative treatment flowchart is provided, although larger sample size studies are needed to obtain a treatment pathway based on evidence.

Effect of postoperative utilization of somatostatin on clinical outcome after definitive surgery for duodenal fistula

PURPOSE

To evaluate the effect of postoperative utilization of somatostatin after definitive surgery for duodenal fistula (DF) in preventing a recurrence.

METHODS

Patients with definitive surgery for DF between January 2010 and December 2021 were categorized based on the utilization of somatostatin or not after the surgery. Patients in the Somatostatin group were matched to those in the Non-somatostatin group using propensity scores matching (PSM), so as to evaluate the effect of postoperative use of somatostatin by comparing the two groups.

RESULTS

A total of 154 patients were divided into the in the Somatostatin group (84) and the Non-somatostatin group (70). Forty-three patients (27.9%) exhibited a recurrent fistula, with which the postoperative use of somatostatin was not associated (19 [22.6%] in the Somatostatin group and 24 (34.3%) in the Non-somatostatin group; unadjusted OR 0.56; 95% CI 0.28-1.14; P = 0.11). However, the postoperative usage of somatostatin served as a protective factor for developing into high-output recurrent fistula (eight (13.3%) in the Somatostatin group and 15 (25%) in the Non-somatostatin group; adjusted OR 0.39; 95% CI 0.15-0.93; P = 0.04). After PSM, the recurrent fistula occurred in 29.2% subjects (35/120). The postoperative usage of somatostatin was not associated with recurrent fistula (13 in PSM Somatostatin group vs. 22 in PSM Non-somatostatin group; unadjusted OR 0.48; 95% CI 0.21-1.07; P = 0.07), while its postoperative usage decreased the incidence of recurrent high-output fistula (5/60 in the PSM Somatostatin group, compared with 13/60 in the PSM Non-somatostatin group; adjusted OR 0.30; 95% CI 0.09-0.95).

CONCLUSION

Postoperative use of somatostatin could effectively reduce the incidence of recurrent high-output fistula, without association with overall incidence of postoperative recurrent fistula.

Continuous irrigation and suction with a triple-cavity drainage tube in combination with sequential somatostatin-somatotropin administration for the management of postoperative high-output enterocutaneous fistulas: Three case reports and literature review

INTRODUCTION

Enterocutaneous fistula is considered one of the most serious complications in general surgery and is associated with high morbidity and mortality. Although various treatments are reported to have varying success, high-output enterocutaneous fistulas (output over 500 ml/day) continue to be associated with high mortality, and few papers on this topic exist in the literature. The aim of this study is to describe an effective multidisciplinary treatment method for postoperative high-output enterocutaneous fistula and discuss the clinical development of the therapeutic strategy.

PATIENT CONCERNS

Three patients suffered high-output enterocutaneous fistulas, in which case 1 presented with duodenal fistula, case 2 with ileal fistula, and case 3 with small bowel fistula.

DIAGNOSIS

All 3 cases were diagnosed with high-output enterocutaneous fistulas by drainage of intestinal contents.

INTERVENTIONS

With the exception of routine treatment including fluid resuscitation, correction of the electrolyte balance, control of infection, and optimal nutrition, all the cases accepted continuous irrigation and suction with triple-cavity drainage tubes in combination with sequential somatostatin-somatotropin administration were given. With regard to establishing effective drainage, the triple-cavity tube placement was performed by insertion through the initial drainage channel in case 1, percutaneous puncture with dilation by graduated dilators in case 2, and tract reconstruction in case 3. The technical details of the approach are described and clinical characteristics including fistula location, defect size, output volume, approach of triple-cavity tube placement, length of fistula tract, somatostatin and somatotropin administration time, and fistula healing time were recorded and compared. In addition, other various techniques reported in the literature are reviewed and discussed.

OUTCOMES

All the patients were cured by the multidisciplinary treatments and were followed up without fistula recurrence and other relevant complications at 1 week, 1 month, and 3 months after the treatments.

CONCLUSION

The strategy involving continuous irrigation and suction with a triple-cavity drainage tube in combination with sequential somatostatin-somatotropin administration may be a safe and effective alternative treatment for postoperative high-output enterocutaneous fistula and a more practical method that is easy to execute to manage this problem. Long-term studies, involving more patients, are still necessary to confirm this suggestion.

Prevalence and Risk Factors for Pressure Ulcers in Patients with Enterocutaneous Fistula: A Retrospective Single-Center Study in China

BACKGROUND Prevalence and associated risk factors for pressure ulcers (PU) vary in different body areas and diseases. Few studies have focused on PU in patients with enterocutaneous fistula (ECF). The aim of the present study was to investigate the prevalence and risk factors for PU in patients with ECF. MATERIAL AND METHODS From January 2016 to June 2016, medical records of 140 patients with ECF who were transferred to the Enterocutaneous Fistula Treatment Center, Jinling Hospital, were reviewed and analyzed. The prevalence of PU was investigated. To evaluate the risk factors for PU in patients with ECF, 5 patients with PU before admission were excluded, and the remaining 135 patients were divided into 2 groups: the PU group and the non-PU group. The risk factors for PU were confirmed by multivariate logistic regression analysis of characteristics on admission. RESULTS There were 42 cases with PU (5 cases with PU before admission, 37 cases with PU in the treatment after admission), and the prevalence of PU in patients with ECF was 30%. In addition, Braden risk score <19 (OR=9.33, CI: 2.80-31.08, p<0.001); underweight (BMI<18.5) (OR=5.21, CI: 1.65-16.39, p=0.005); onset of duodenal fistula (OR=4.86, CI: 1.33-17.78, p=0.017); diabetes (OR=4.95, CI: 1.03-23.85, p=0.046); and APACHE II score (OR=1.34, CI: 1.04-1.72, p=0.019) were associated with PU. CONCLUSIONS The PU prevalence was 30% in patients with ECF. Braden risk score <19, underweight, onset of duodenal fistula, diabetes, and APACHE II score were risk factors for PU in patients with ECF.

Prevalence of and Risk Factors for Abdominal Bleeding in Patients with External Duodenal Fistula

Background

Abdominal bleeding is a severe complication of duodenal fistula, but few studies have focused on this problem. The purpose of the present study was to investigate the prevalence of and risk factors for intra-abdominal bleeding in patients with external duodenal fistula.

Material/Methods

From January 2014 to December 2016, medical records of 97 patients with external duodenal fistula were retrospectively reviewed and analyzed. The prevalence and risk factors for intra-abdominal bleeding were evaluated.

Results

The prevalence of abdominal bleeding in patients with external duodenal fistula was 31.9% (95%CI: 22.5–41.4%). A total of 31 patients had intra-abdominal bleeding. Results revealed that acute kidney failure (OR: 8.462, 95% CI: 1.921–37.28, p=0.005) and retroperitoneal infection (OR: 5.373, 95% CI: 1.504–19.197, p=0.010) were associated with abdominal bleeding.

Conclusions

The prevalence of abdominal bleeding in patients with external duodenal fistula was 31.9%, and acute kidney failure and retroperitoneal infection were found to be risk factors for intra-abdominal bleeding.

Surgical management of duodenal stump fistula after elective gastrectomy for malignancy: an Italian retrospective multicenter study

BACKGROUND

Duodenal stump fistula (DSF) is a severe complication of gastrectomy. Although nonsurgical therapy is preferred, surgery is still mandatory in one third of DSF patients. The aim of this article is to analyze the surgical management of DSF and factors related to its outcome.

METHODS

We performed a retrospective multicenter study using data from January 1990 to November 2011 in 16 Italian surgery centers. We collected 8,268 elective gastrectomies for malignancies, 7,987 by the laparotomic and 281 by the laparoscopic approach. Two hundred five patients developed a DSF, 75 of whom underwent surgery for DSF. We analyzed mortality and DSF healing time as well as the impact of clinical, oncological, and surgical characteristics.

RESULTS

The laparoscopic approach increased the risk of DSF development (odds ratio 5.6, 95% confidence interval 2.7-10.6, P < 0.001). The indication for first DSF surgery was intra-abdominal sepsis; the failure rate was over 30%, associated with the appearance of fistulas of neighboring organs, bleeding, and the need for reoperations. The mortality rate was 28% and was related to the presence of vascular disease (P = 0.04), more than one reoperation (P = 0.05), sepsis (P < 0.001), and renal failure (P < 0.001). Fifty-four patients recovered after a median of 39 days (interquartile range 22-68 days); the need to perform more reoperations (P < 0.01) and the presence of an abdominal abscess (P < 0.01) led to an increase in healing time.

CONCLUSIONS

Surgery for DSF has a poor prognosis. Our data will help to identify patients at risk of death, but unfortunately could not establish the best surgical procedure applicable to all cases of DSF.

Duodenal stump fistula after gastric surgery for malignancies: a retrospective analysis of risk factors in a single centre experience

BACKGROUND

Duodenal stump fistula (DSF) is the most severe surgical complication after gastrectomy. This study was designed to assess the incidence, to observe the consequences, and to identify the risk factors associated with DSF after gastrectomy.

METHODS

All procedures involving total or sub-total gastrectomy for cancer, performed between January 1987 and June 2012 in a single institution, were prospectively entered into a computerized database. Risk factors analysis was performed between DSF patients, patients with complete uneventful postoperative course and patients with other major surgical complications.

RESULTS

Over this 25 years period, 1287 gastrectomies were performed. DSF was present in 32 cases (2.5 %). Mean post-operative onset was 6.6 days. 19 patients were treated conservatively and 13 surgically. Mean DSF healing time was 31.2 and 45.2 days in the two groups, respectively. Mortality was registered in 3 cases (9.37 %), due to septic shock (2 cases) and bleeding (1 case). In monovariate analysis, heart disease (p < 0.001), pre-operative lymphocytes number (p = 0.003) and absence of manual reinforcement over duodenal stump (p < 0.001) were found to be DSF-specific risk factors, whereas liver cirrhosis (p = 0.002), pre-operative albumin levels (p < 0.001) and blood losses (p = 0.002) were found to be non-DSF-specific risk factors. In multivariate analysis heart disease (OR 5.18; p < 0.001), liver cirrhosis (OR 13.2; p < 0.001), bio-humoral nutritional status impairment (OR 2.29; p = 0.05), blood losses >300 mL (OR 4.47; p = 0.001) and absence of manual reinforcement over duodenal stump (OR 30.47; p < 0.001) were found to be independent risk factors for DSF development.

CONCLUSIONS

Duodenal stump fistula still remains a life-threatening complication after gastric surgery. Co-morbidity factors, nutritional status impairment and surgical technical difficulties should be considered as important risk factors in developing this awful complication.

Current status in the multidisciplinary management of duodenal fistula

INTRODUCTION

Paradigms in the management of duodenal fistula have evolved over the last half a century. Despite advances, morbidity and mortality still remain high. This paper provides a comprehensive, up to date, systematic review in the management of duodenal fistula, classifying the various strategies in the management of duodenal fistula

MATERIALS AND METHODS

A review was performed on Medline, Embase and Cochrane library databases using the Cochrane systematic reviews methodology. A final population of 42 studies reported on 349 patients, with a median (range) number of patients per study of two (1-68). The manuscripts were broadly divided in to "non-interventional" and "interventional". The interventional group was subdivided in to "minimally invasive" and the "open surgical approach".

RESULTS

A total of 147 patients were treated conservatively (non-interventional group), with a median duration of 28 days (range 13-42 days) with 13 (9%) deaths recorded in this group. No deaths were reported in the 8 reports on minimally invasive approach.166 patients had open surgical approach with a mortality rate of 30% (50 patients).

DISCUSSION AND CONCLUSION

In the absence of randomised controlled trials, no one interventional modality can be considered superior. Initial multidisciplinary conservative approach with sepsis control and nutritional augmentation should be for 6 weeks. It would seem reasonable, in those fistulae that fail to close spontaneously, to attempt a low risk "minimally invasive" intervention where necessary expertise is available. More risky open surgical approaches should clearly be reserved for those that fail and are best performed in specialist centres.

Gastroduodeno-plasty performed by distal gastric transection.- A new technique for large duodenal defect closure

Introduction

Duodenal ulcer lesions can represent a surgical challenge, especially if the duodenal wall is chronically inflamed, the defect exceeds a diameter of 3 cm and the ulceration is located in the second part of the duodenum.

Patient and method

We present the case of a 70-year-old male, who suffered from a 3 x 4 cm duodenal defect caused by duodenal pressure necrosis due to a 12.5 x 5.5 x 5 cm gallstone. Additionally, this stone caused intestinal obstruction (Bouveret’s syndrome) and bleeding with signs of shock. Besides the gallstone extraction, the common bile duct was drained by a T-tube and the duodenal defect closure was performed by a gastroduodeno-plasty and Bilroth II gastroenterostomy. The postoperative phase was uneventful. The reconstructed duodenum was endoscopically accessible and showed no pathological findings on follow-up.

Conclusion

The reconstruction of a large defect (> 3 cm) of the second part of the duodenum is safely feasible by a gastroduodeno-plasty. The critical gastroduodenal anastomosis can be protected by duodenal decompression, achieved by placing a T-tube in the common bile duct.