Ani Operative Technic for the Managemenit of Acuteanid Chroniic Lateral Duodenal Fistulas *

EARL F. WOLFMIAN, JR., M.D., GUILLERMO TREVINO, M.D.,DAVID K. HEAPS, M.D., GEORGE D. ZUIDEMNA, M.D.

Fronm the Department of Surgery, The Utniversity of MWichigan .M1edical School,Anin Arbor, Michigan

DEFINITIVE surgical management of majoracute injuries to the second and third por-tions of the duodenum has been enigmatic.Furthermore, should the patient survive theinitial injury, and a chronic duodenal fistuladevelop, the morbidity and mortality ratesfrom surgical intervention have been high.1-4.9 11,18,13190,2'O,2,4,27 The experience of

most observers indicates that lateral duo-denal fistulas demonstrate little tendency toheal spontaneously. 20 While distal ob-struction is often cited as a cause for thedevelopment and persistence of fistulas inother viscera, this seldom contributes tothe chronicity of lateral duodenal fistulas.Probable factors responsible for their chron-icity are: 1) increased intraduodenal pres-sure during peristalsis;6, 14 and 2) the pro-pensity of the duodenal mucosa to extrude,once a defect has been made, completelythrough the bowel wall, and to grow out-side of the bowel lumen. It has been notedthat fistulas occurring due to a dehiscenceof a duodenal stump,712.l) or those occur-ring following an end or lateral cath-eter duodenostomy usually close spontane-ouslv.lf The likely reason is that in theselatter instances the mucosa is preventedfrom extruding either by the sutures usedto hold the catheter in place, or by thechronic inflammatory reaction about thesite of an end duodenal fistula.The present experiments were under-

taken to determine whether the duodenal

mucosa would extrude and spread over acontiguous surface once a defect was madethrough the muscularis propria of the bowelwall. We postulated that if such spread didoccur, perhaps the mucosa would cover aserosal patch abutted against a defect inthe duodenum and result in the restorationof duodenal continuity. Such an operationfor duodenal fistulas and injuries wouldhave the obvious advantages of technicalsimplicity and broader application thanpreviously recommended procedures suchas primary closure, sleeve excision withend-to-end anastomosis, subtotal gastric re-section, and pancreatricoduodenectomy. Inthe present study, the use of a serosal patchwas investigated in covering acute andchronic lateral duodenal openings and gas-tric defects. The purpose of this latter in-vestigation w7as to determine whether ornot acid chvme in contact with the serosaof the bowel might lead to digestion.Finally, as an alternative procedure, for usein instances where large areas of the du-odenal wall are destroyed or excised, aRoux-Y duodenojejunostomy to the side ofa lateral duodenal defect was studied todetermine if peptic digestion of the Rouxlimb might occur from acid chb7me passingover it.

Method

Twenty-two healthy mongrel dogs weigh-ing between 15 and 17 Kg. were anesthe-tized intravenously with thiopental (25mg./Kg.). The abdomen w\as scrubbed

563

* Stibmitted for piiblication Mlay 22, 1963.

564 WOLFMAN, TREVINO, HEAPS AND ZUIDEMA

_ - mtr @ -_B _o-F-.g g .

FIG. 1. Excisional defect in duodenum ofNote tendency of duodenal mucosa to extrudonto the serosal surface.

with pHisoHex®, sprayed with Betadiand sterile drapes applied. A midlineotomy incision was then made andduodenum exposed.

In 12 of these animals (Group I)acute duodenal fistula was created andered with a serosal patch in the folloNmanner: The duodenum was exposeda defect 2.0 x 3.0 cm. created by excithe complete thickness of the lateral7.5 cm. from the pylorus. This positionapproximately opposite the level ofpancreatic duct. The duodenal mucosaallowed to extrude (Fig. 1) and the d(was then closed by anastomosing an irsegment of jejunum six inches fromligament of Treitz about the openinga two layer anastomosis of an outer ro'interrupted 4-0 silk and an inner layecontinuous 3-0 chromic catgut (Fig. 2Care was taken not to constrict the dunal lumen at the site of anastomosis.abdomen was then closed without diage. Five hundred milliliters of lactRinger's solution was given intraven(during the operative procedure and stard kennel rations resumed on thepostoperative day. The animals were sficed at varying periods ranging frornto 159 days and the site of the repafistulas studied, both grossly and histo

Annals of SurgeryApril 1964

cally, for evidence of mucosal regenerationover the serosal patch.

In three other animals a lateral duode-nostomy was created 7.5 cm. from thepylorus by suturing a No. 18 Robinson cath-eter into the duodenum (Group II). On thefourth postoperative day the catheter wasremoved, and the resultant defect closedin a manner identical to that describedabove. These animals were sacrificed at 100to 110 days following the second operation.

In another four animals a Roux-Y duode-nojejunostomy was employed to cover theduodenal defect created (Group III). In

dogt these, following excision of a portion ofthe duodenal wall, a Roux-Y limb was cre-ated by dividing the jejunum 15 cm. distal

ine®, to the ligament of Treitz. The distal endceli- of the transected bowel was anastomosedthe to the lateral duodenal defect using a two-

layer technic of an outer row of interruptedan 4-0 silk and an inner row of continuous 3-0

cov-

wingand CZcxmdme)isingwallwasthe Awasefect,itactthe

withw of3r of, 3).iode-Therain--ated)uslyand-firstacri-a 28tiredlogi-

FIG. 2. Technic of anastomosing jejunum aboutduodenal defect

MANAGEMENT OF FISTULAS

chromic catgut. Fifteen cm. distal to theduodenojejtinostomy an end-to-side jejuno-jejunostomy was made. These animals were

sacrificed at periods ranging from 111 to134 days. One dog died on the third post-operative day from an anastomotic leak.

In three dogs a gastric defect was madeby excising 2.0 x 3.0 cm. of the anteriorwall of the distal stomach (Group IV).This opening was closed in a manner iden-tical to that employed in Group I utilizinga serosal patch. These animals were sacri-ficed between 118 and 150 days.

Results

Those animals treated with a serosalpatch immediately sutured over the defectin the duodenal wall all survived withoutsequelae until sacrificed. At postmortemexamination there was no sign of anasto-motic leakage, intestinal obstruction, or di-gestion of the serosal patch. Upper gastro-intestinal x-rays revealed no evidence ofconstriction of the duodenal lumen and thiswas confirmed at autopsy. Gross and micro-scopic examination of the repaired defectdemonstrated partial mucosal spread over

the jejunal surface by 28 days (Fig. 4).

FIG. 3. Completed anastomoses showing serosalpatch occluding duodenal opening.

FIG. 4. Histologic section of duodenal defectcovered with a serosal patch obtained 28 dayspostoperatively. There is a thin band of granula-tion tissue over the jejunal serosa and beginningepithelialization at the edges.

At this time the serosa of the jejunum was

covered by a thin band of granulation tis-sue. There was regeneration of a singlelayer of duodenal mucosa at the edges ofthe defect, but the center was not yet epi-thelialized. Numerous goblet cells were

present and the mucosa of the duodenumheavily infiltrated with plasma cells. Atseven weeks the defect was covered byduodenal mucosa which although lower inheight than normal, had formed villi andsmall glands (Fig. 5). Numerous gobletcells were present. In an animal sacrificedat 130 days, the defect was completely cov-

FIG. 5. Repaired defect seven weeks post-operatively. Jejunal serosa is entirely covered byduodenal mucosa which although low in heightshows beginning villous and gland formation.

Volume 159Number 4 565

566 WOLFTMAN, TREVINO, HEAPS AND ZUII)EMA

FIG. 6. Repaired defect 130 daystively shows comnplete coverage of t:serosa by mature duodenal epithelium ctwo-thirds normal height.

ered by mature duodenal epitheliuwas one-half to two-thirds norms(Fig. 6). A final section examinedmately six months postoperativelythe site of the duodenal opening t4healed and covered by mucosa othickness (Fig. 7).Those animals with chronic duo

tulas (Group II), treated in aidentical to that in Group I, dema similar healing process. Repaireexamined grossly and histologicalriods ranging from 100 to 120 day7sthe defects to be covered by maodenal mucosa somewhat less thaiheight. It was noted that in allthere was an infiltration of plasmcthe duodenal and jejunal mucosa.Animals treated by anastom

Roux-Y limb of jejunum about the (

opening (Group III) were sacriitween 111 and 134 days and simiof healing to the above two grotnoted. Of interest, was the absencdence of peptic digestion in theadjacent to the suture line.The gastric wall openings cove

a serosal patch were examined gr(histologically between 118 and I

Annals of SurgeryApril 1964

Grossly the repaired defects were welllhealed as evidenced by gastric epitlhelillm1bridging the defect. This epithelializationiwvas confirmedchistologicallv. Fturthermore,there was n1o evidence of digestion of thejejunal serosa, but a moderate infiltration ofchronic inflammatory cells in the underly-ing muscularis propria of the jejunum wasnoted.

DiscussionA defect in the duodenal wall too large to

be closed by primary suture is often en-countered associated with blunt abdominaltrauma, or may be unintentionally produced

postopera- during resection of a tumor of the righthe jejunal)ne-half to kidney or right colon. Such tissue losses

may also follow the excision of chroniclateral duodenal fistulas as a result of the

im which foreshortening and scarring occasioned byal height chronic inflammatory reaction. A myriad ofapproxi- operative procedures have been advocatedshowed for the repair of such lesions, ' 4 10 11 13 l5

o be well 1,21,23-25 but despite these, morbidity andf normal mortality rates from such repairs remain

high. Since many of the patients with acutedenal fis- traumatic lesions of the duodenum alsomanner have severe associated injuries, the de-

onstrated finitive treatment of the duodenal injuryd fistulas should be simple and complicated resec-lv at pe-, showediture du-n normalinstancesa cells in

losing aduodenalficed be-ilar signsaps were.e of evi-jejunum

red withossly andL50 days.

SITE OFORIGINAL DEFECT

FIc. 7. Repaired defect six months postopera-tively. There is complete epithelialization over thejejunal serosa by mature villous producing, glandforming dIio(lenal mucosa of normal height.

MANAGEMENT OF FISTULAS

tions and anastomosis avoided if possible.Fturtlhermore, many of those operated upon

for closure of chronic duodenal fistula, or

in whom a portion of the duodenum is re-

sected becauise of malignant invasion, are

poor operative risks from a nutritional andmetabolic viewpoint. Here, too, the sim-plest operative procedure should be pro-

ductive of the best results.Recent reports by Kobold and Thal 18

and Jones and Joergensen,1 have empha-sized the need for the simple technic forthe closure of acute duodenal defects. Thestudy here reported supports these authors'observations. From our studies it appears

that the serosal patch is the operation ofchoice when one-half to two-thirds of theduodenal wall remains intact and is viable.Experimentally, under these circumstances,the duodenal mucosa will spread over theabutted jejunal serosa and restore the mu-

cosal continuity of the duodenum. Such an

operation could also be employed for largeduodenal wall defects proximal to the am-

pulla of Vater, for the passage of acidchyme over the serosal patch has not causedeither digestion of the jejunal wall, or pre-

vented the ingrowth of normal duodenalmucosa. In those instances where one-halfor less of the duodenal wall remains, usu-

ally as a result of intentional resection, a

Roux-Y anastomosis, either side-to-side, or

end-to-side, would be preferable in orderto avoid producing duodenal stenosis. Ifthis operation is utilized the anastomosedlimb of jejunum should be either at thelevel of or below the ampulla of Vater.Experimentally, animals with such anasto-moses did not develop anastomotic ulcera-tion of the jejunal limb.

Finally, the serosal patch principle seems

applicable in those cases where excision ofa chronic duodenal fistula results in a de-fect too large to close primarily, or to re-

inforce a primary closure. Those animalsin whom such fistulas were patched demon-strated mucosal coverage similar to thatobserved in acutely repaired defects. We

T-tube in common bile duct

FIG. 8. Chronic duodenal fistula treated by ex-cision and primary closure reinforced with a sero-sal patch.

recently had occasion to employ this serosalpatch technic clinically in association withprimary closure in the management of a

chronic, lateral duodenal fistula.

Case ReportA 62-year-old man was admitted in extremis

on 12-27-61, with a lateral duodenal fistula occur-

ring after cholecystectomy, transduodenal sphinc-terotomy and common bile duct exploration 10days previously. Initial treatment was supportiveconsisting of fluid and electrolyte maintenance,antibiotics, and sump drainage to the abdominalwound. Because of the inability to maintain fluid,electrolyte and metabolic hemoestasis by paren-

teral routes, a gastrostomy, and feeding jejunos-tomy were done under local anesthesia on 1-2-62.Postoperatively he showed gradual, but progressiveimprovement. At the time of discharge on 3-8-62,the abdominal wound had healed, the fistula hadceased draining and he was able to maintain hisnutrition orally. Five days later the fistula re-

opened and drainage of bile through an openingin the right upper quadrant operative incision was

Volume 159Number 4 567

568 WOLFMAN, TREVINO, HEAPS AND ZUIDEMA Annals of SurgeryApril 1964

noted. Radio-opaque contrast medium injected intothe fistulous opening on the skin demonstrated theinternal opening to extend into the second portionof the duodenum. Supportive treatment was re-instituted and operation advised, but the patientpreferred waiting uintil a later date. Duiring thenext four months he maintained his nutrition with-out difficulty, but continued to have intermittentexternal biliary drainage from the abdominal in-cision. He was re-admitted to the hospital on7-15-62 and after a two-week period of skin prepa-ration the fistula was excised on 7-31-62. At thetime of operation the fistula extended into thesecond portion of the duodenum. An additionalfinding was a 2.0 cm. stone impacted in the distalportion of the common bile duct. A choledochos-tomy was done, the stone removed, and the com-mon bile duct closed about a T-tube. The fistulawas then excised producing a 3 cm. defect in theduodenal wall. Although it was possible to obtaina two-layer primary closure in a transverse direc-tion without compromising the lumen of the du-odenum, a loop of jejunum was sutured to theduodenum about the site of closure (Fig. 8). Thepatient's postoperative course was entirely un-eventful.

In the case reported, the jejnum wassutured about the site of primary closureto act as a deterrent against recurrence ofthe fistula. Cleveland and Waddell8 havereported duodenal fistula as being the mostcommon postoperative complication intheir series of patients operated upon forretroperitoneal rupture of the duodenumoccurring in 33 per cent, and found anover-all incidence of 14 per cent in a col-lected series of 28 similar cases reportedbetween 1951 and 1961.

SummaryLaboratory data are presented in support

of the serosal patch technic for repairingacute defects of the duodenal wall toolarge to be closed primarily. Experimentallysuch closures were resistant to acid diges-tion of the jejunal wall and were also satis-factory for the repair of chronic duodenalfistulas. Roux-Y repairs were also efficaciousin repairing lateral duodenal defects pro-viding the duodenejejunostomy was at thelevel of, or below, the entrance of the bileand pancreatic ducts.

The operative management of a patientwith a chronic duodenal fistula treated byprimary closure reinforced with a serosalpatch is presented.

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Volume 159 MANAGEMENT OF FISTULAS 569Number 4

18. Kobold, E. E. and A. P. Thal: A SimpleMethod for the Management of ExperimentalWounds of the Duodenum. Surg., Gynec. &Obst.,116:340, 1963.

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