Current status in the multidisciplinary management of duodenal fistula

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The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net

Review

Current status in the multidisciplinary management of duodenal fistula Benoy I. Babu, Jonathan G. Finch* Department of General Surgery, Northampton General Hospital, Northampton, UK

article info

abstract

Article history:

Introduction: Paradigms in the management of duodenal fistula have evolved over the last

Received 27 August 2012

half a century. Despite advances, morbidity and mortality still remain high. This paper

Received in revised form

provides a comprehensive, up to date, systematic review in the management of duodenal

19 November 2012

fistula, classifying the various strategies in the management of duodenal fistula

Accepted 18 December 2012

Materials and methods: A review was performed on Medline, Embase and Cochrane library

Available online 1 February 2013

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

Keywords:

two (1e68). The manuscripts were broadly divided in to “non-interventional” and “inter-

Duodenal fistula

ventional”. The interventional group was subdivided in to “minimally invasive” and the

TPN

“open surgical approach”. Results: A total of 147 patients were treated conservatively (non-interventional group), with a median duration of 28 days (range 13e42days) 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. ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Introduction Duodenal fistula represents 3e14% of all enterocutaneous fistulas.1 In contrast to other intestinal fistula, duodenal fistulae present with problems peculiar to a high enzyme rich output, anatomical location and skin care.2

Most duodenal fistulae arise as a surgical complication either due to inadequate closure or devascularisation of duodenum usually developing within a week of the insult.3e6 Other causative factors implicated in the formation of duodenal fistulae are Crohn’s,7,8 trauma,3,6,9 peptic ulcer disease,10 pancreatitis11 and cancer.7,12

* Corresponding author. Tel.: þ44 1604634700. E-mail address: [email protected] (J.G. Finch). 1479-666X/$ e see front matter ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.surge.2012.12.006

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Despite advances in managing duodenal fistula for over half a century, morbidity and mortality figures still range from 38% to 75% and 7e40%, respectively.1 The solution to this problem requires thorough comprehension of the cause and associated complications, taking into consideration the patient’s co-morbid factors. Successful management usually entail (1) control of sepsis, (2) good nutritional support, (3) skin protection and (4) ensuring ultimate closure of fistula and maintaining intestinal continuity.13 This paper provides a comprehensive and up to date overview on the management of duodenal fistula classifying, for the first time, various strategies employed in its management.

159

Boolean operators to broaden the search result. The Cochrane systematic reviews methodology program was utilized to cross-reference the three databases leaving a final study population of 42 manuscripts. The search strategy and reasons for excluding manuscripts are provided in Fig. 1. The output data was processed using EndNote X.02ª1988e2006 Thomson.

Inclusion criteria Published peer-reviewed clinical studies in humans were sought with data on duodenal fistula. Reference lists of primary research and review articles involving duodenal fistula were examined.

Methods

Exclusion criteria

Literature search

Reviews without original data, non-English language papers, pediatric population (children <18years), animal studies, articles with incomplete data were excluded. When multiple publications from an institution reporting the same cohort of patients were encountered, the most recent and complete article was included.

Information source A computerized search was performed of the MEDLINE, EMBASE and Cochrane library databases using the OVID search engine (Version 10.5.1, Source ID 1.13281.2.21; Ovid Technologies, Inc., New York, NY, USA).

Data extraction Search criteria The review was performed from inception of the databases, the earliest being 1948 to Feb 2011. The keywords "duodenal fistula"; "gastrointestinal fistula" and “enterocutaneous fistula"; were used. The keywords were combined with the aid of

Study endpoints consisted of number of patients, mean age, aetiology of fistula, type and position of fistula, supportive management, management options, post management confirmation (if mentioned) and mortality.

Fig. 1 e Consort diagram for search strategy.

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Categorization of repair Due to lack of randomised controlled trials in the management of duodenal fistula, a narrative summary of evidence was undertaken. The authors broadly divided the selected manuscripts based on their management into “non-interventional” and “interventional”. Any form of treatment involving invasive techniques was classified as “interventional”. Based on the type of approach the interventional category was divided into “minimally invasive” and “open surgical”. The minimally invasive category was defined as a procedure with minimal damage to tissue at point of entrance. The two main techniques used in the “minimally invasive” group were “Diversion” and “Repair”. The various techniques used in the open surgical approach were “Decompression and diversion”, “Simple closure  patch”, “Resection anastomosis”, and “Bypass surgery”.

Results Description and quality of included studies One thousand and twenty six citations were identified from initial screening of the three electronic databases (MEDLINE, COCHRANE and EMBASE). Computerised deletion of the citations based on the exclusion criteria resulted in 262 manuscripts which warranted a full review. One article was excluded due to double publication. Three articles were not accessible through the British Library online catalogue resourcing. Two hundred and one articles were rejected, as they were not related to duodenal fistula. A final total of 42 studies met the inclusion criteria (Fig. 1).

There was a lack of randomised controlled trials and all the available studies that met the inclusion criteria were of level four evidence, based on the Oxford Centre for Evidence-based Medicine- Levels of Evidence.14

Characteristics of study population From a total of 42 manuscripts, 349 patients were identified with data on the management of duodenal fistula. The median (range) number of patients per manuscript was 2 (1e68). None of the reports provide information on why a particular mode of management was selected in preference to other alternatives. The mean age was 46 years (SD e 16.7yrs). The most common cause noted in the development of a duodenal fistula was previous surgery in 48% (177) of patients. Duodenal ulcer and its perforation were implicated in 13% (47) patients. The majority of the fistulae were noted to have an output of over 1000 ml/day. All the manuscripts focused on the control of sepsis in the initial management of duodenal fistula. The overall mortality rate was 19% (63) patients. No obvious criterion for selection of technique was followed in the implementation of a particular interventional management.

Non-interventional management Seventeen manuscripts mention of initiating a noninterventional method of managing their patients (Table 1). A combined total of 147 patients were treated conservatively in this group over a median duration of 28 days (range 13e42days). The nutritional status was managed with total parenteral nutrition or the appropriate hyperalimentation as decided by the managing team. Five reports confirm the use of

Table 1 e Non-interventional approach in the management of duodenal fistula. (EN e enteral nutrition, AB e antibiotics, PPI e proton pump inhibitors, TPN e total parenteral nutrition, iv-intravenous, NGS enasogastric suction, NJ enasojejunal). First author

No of pts

Mean age

Cause of fistula

Cogbill TH6 Cozzaglio L4 Ahmad RR39 Verma GR10

3 19 16 8

30.1 66 36.1 Median 45

Trauma Surgery Trauma DU, NSAID

Sivalingam P43 Rossi JA3 Chiang F12

1 9 21

50 53.3 63

Villar R40 Gilmartin D5 Williams NMA27 NA36 Lu Y41 Reddy AN

1 2 8 22 1 1

64 23e75 51 NA 46 51

DU Perforation Surgery, trauma Iagtrogenic, cancer Surgery Surgery Surgery

Reber HA7 Feliciano DV26 Garden OJ13 Talving P14

7 5 22 1

Surgery Spontaneous Cancer, Crohn’s

29 54.4 26

Surgery Surgery Trauma

Conservative management

TPN, somatostatin, gabexate TPN, OCT, AB, EN, AB, PPI, TPN, feeding jejunostomy AB, iv fluids AB, cimetidine, TPN, TPN TPN, somatostatin TPN, NGS, cimetidine TPN Parenteral hyperalimentation TPN, somatostatin, Hyperalimentation, cimetidine, NGS Parentral nutrition, cimetidine NA Parenteral, NJ feed, AB, Octreatide, jejunostomy feeds, TPN

Days to healing

Mortality

NA 19 14.3 28

0 3 4 0

35 29

0 2 0

35 42 29

0 0 1 2

13 28

0

30

0

NA 28 14

0 1 0

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somatostatin or its analogue. There were 13 (9%) deaths recorded in this group.

Various authors have attempted at diverting the duodenal contents with the help of a duodenostomy.3,5,9,23,24

Interventional management

Simple closurepatch. Seven reports have described a simple closure of the duodenal fistula.4,6,8,10,11,25,26 Mainly three types of patches have been reported, the omental patch,14,25 the serosal patch27,28 and the rectus abdominis flap29,30 with variable results. Two manuscripts describing the use of rectus abdominis flap in 14 patients had previous corrective surgery with a mortality of 14%.

Minimally invasive approach Eight reports provide data on various non-surgical techniques used in the management of duodenal fistula. The fistula output in all the 8 reports was denoted as high (Table 2). Surgery was implicated as the main cause in the formation of the fistula. None of the reports provide information as to the reason for choosing the particular technique. There were no deaths noted in this group.

Resection anastomosis. Although considerable variations exist, eleven manuscripts describe this surgical technique in the management of duodenal fistula.3,7,10,12,13,31e36

Diversion technique. Three reports on five patients had successful healing of their fistula using stents in the diversion of high output duodenal fistula.15e17 Various radiological15 and endoscopic techniques16,17 have been used in the deployment of these stents. Twenty-eight patients had percutaneous duodenal diversion of their high output fistula.4,18 The various percutaneous diversion techniques used were transhepatic, transbiliary and percutaneous duodenostomy.4,18

Repair technique. Three reports on different tissue adhesive agents have been reported with success, deployed with the aid of interventional radiological techniques.19e21

Open surgical approach A combined total of 166 patients had open surgery for the correction of their duodenal fistula. The median days to surgical intervention were 30 days (2e150 days). There was a mortality of 30% (50 patients) in this group. There are considerable variations in the surgical techniques used (Table 3).

Decompression and diversion. Six reports describe this technique. Tanski et al have managed to decompress the duodenum with the double lumen, Puestow-olander tube.22

Bypass. Five reports provide data on various forms of Roux-en-Y operations.1,4,27,37,38 Some of the authors have resorted to this method for larger duodenal defects.4

Discussion Duodenal fistulae have historically been difficult to manage. Over the last half a century various strategies have been adopted in treating this condition. To the best of our knowledge, the data presented here constitute the most up to date comprehensive overview of the management of duodenal fistula. Interpretation of results must take into consideration probable positive publication bias inherent in reporting heterogeneous data, a varied clinical picture, and the limited scientific value of studies with small cohorts (the median number of patients per series was 2 (range 1e68)). Although various interventional techniques have been attempted each being successful in their own right, their success rates should be analysed with caution due to variability in their patient cohort, technique and type of fistula. Due to the complexity of managing this condition, a multidisciplinary team approach providing 24-h care would seem

Table 2 e Minimally invasive approach in the management of duodenal fistula. First author

No. of pts

Mean age

Cause of fistula

Khairy GEA19 Brady AP20 Sabharwal T21 Boulougouri K15

1 1 1 1

21 65 68 57

Trauma Surgery Surgery Surgery

Bloch P16

2

52.5

Surgery

Zarzour JG18

6

50

Surgery

Cozzaglio L4

22

Median 66

2

46

Eisendrath P17

Post-surgery

Surgery

Type of surgical procedure

Mode of application

Gelfoam Fibrin sealent Tissue adhesive Self-expanding occlusion device (amplatzer septal occluder) Transparietal abdominal endoscopic intubation Percutaneous transhepatic duodenal drainage Percutaneous abdominal drainage, percutaneous transhepatic biliary drainage, percutaneous duodenostomy Self-expanding plastic stent

Percutaneous Glue Radiological Endoscopic and percutaneous

0 0 0

Endoscopy

0

Radiological

0

Percutaneous

Endoscopy

Mortality

na

0

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Table 3 e Open surgical approach in the management of duodenal fistula. First author 31

No.

Mean age

Cause

Drapkin LR Milias K1

1 2

64 n.a

Cogbill TH6

3

30.1

Ulcer Pancreatitis, trauma Trauma

83 Median 66 Median 45

Post-surgery Post-surgery Ulcer, NSAIDS

53.3

Post-surgery, trauma Post-surgery, malignancy Crohn’s Post-surgery Post-surgery Trauma e then surgery Duodenal diverticulitis Duodenal perforation Perforation Trauma, roux-en-y, Bilroth 1 Surgery

Van Houten32 Cozzaglio L4 Verma GR10 Rossi JA3

1 27 21 9

Chiang F12

20

63

Yamamoto.T33 Gilmartin D5 Tanski EV22 Cruz RJ9

2 11 2 3

36 23e75 43

Lee VTW37

1

74

Banchuin T34

2

33

Agarwal P29 Paluszkiewicz P44

8 6

Williams NMA27

5

51

Nakagoe T25 Cukingnan RA38 Vakili C35 Wilk PJ8 NA36 de Alves JB24 Kittrick E 1965 Chander J30

1 1 1 9 3 1 1 6

22 24 22 30 NA 51 54 38e56

Reber HA7 Feliciano DV26 Garden OJ13 Storm FK11 Talving P14

12 2 2 2 1

29 54.4 23.5 26

Surgery Trauma Trauma Crohn’s Surgery Surgery Peptic ulcer perforation Cancer, Crohn’s Surgery Surgery Surgery Trauma

sensible. Various major centres usually have an “intestinal failure team” with inputs from clinicians (physicians and surgeons), pharmacist, dieticians, biochemists, specialist nursing staff and social workers. Emphasis on sepsis control has been a general first step in the management of duodenal fistula. A broader spectrum antibiotic and seldom surgery has been resorted to in recent years in the control of infection. Radiology has played a major role in the management of duodenal fistula for over half a century, ranging from it being used as a guide to diagnose septic foci to key interventional strategy in the management of a collection. Definitive surgery for the fistula in the presence of sepsis is likely to fail and should be avoided where possible. A trend was noted towards low duodenal output fistulae being treated conservatively and interventional management used for higher output fistulae, though no uniformity existed in classifying the volume of output.

Surgical technique

Mortality

Bypass Resection anastomosis, bypass

0 0

Simple repair, duodenal resection and primary repair Excision Duodenal suture, tube duodenostomy, roux-en-y Antrectomy, vagotomy þ pyoloroplasty, resuturing duodenum and jejunum Tube duodenostomy, truncal vagotomy gastrojejunostomy, billroth II, pyloric exlcusion gastrojejunostomy tube duodenostomy Wedge resection, diverting duodenostomy

0 0 8 11 4

17

Resection of segment and primary closure Diversion of GIT secretions, decompression of BT Puestow-olander tube Modified duodenal diverticulization

0 2 0

Roux loop duodenojejunostomy

0

Gastrojejunostomy

0

Rectus abdominis musculo-peritoneal flap Duodenostomy and T-tube cholangisostomy

1 0

Roux-en-Y reconstruction, serosal patch technique, gastroenterostomy Simple closure of defect, omental pedicle graft Retrocolic roux-en-y anastomosis Side to side anastomosis, duodenal decompression Closure of fistula Resection and anastomosis Gastrostomy and three piece tubing Serosal patch technique Rectus abdominis muscle flap

2

Excision and end to end, direct suture closure Simple duodenorrhaphy Duodeno-jejunal anastomosis. Closure of fistula Omental patch

2 0 0 0 0

0 0 0 0 2 0 0 1

Somatostatin and its analogues have been used in conservatively managed high output duodenal fistula, with anecdotal evidence of a decrease in fistula output.4,39e41 Effective nutritional support is the cornerstone in managing duodenal fistulae. Strategies range from nil by mouth and total parenteral nutrition to nasogastric hyperalimentation. Although most authors have suggested nil per os, Cozzaglio and colleagues have demonstrated a significant decrease in mortality in patients maintained on oral feeding.4 Despite total parenteral nutrition has been around for over four decades,42 the impact of its advantages in duodenal fistula management is obscured to some extent by the lack of controlled clinical studies. Based on the data collected, the authors conclude that it would be advisable to adopt a conservative policy of “wait and watch” for 4e6 weeks.4 The success rate of closure with noninterventional management is between 25 and 75%.18 Further interventional approach is appropriate after this period or once the patient has nutritionally recovered to

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withstand a major intervention. This may not be possible in conditions when sepsis control is essential especially within the first 48 h. Various interventions are described, with variable successes. In the absence of randomised controlled trials no interventional modality can be said to be superior to the other. It would seem reasonable, after a period of sepsis control and nutritional augmentation, in those fistulae that fail to close spontaneously, to attempt a low risk “minimally invasive” intervention, where necessary expertise is available. The initial conservative period should be up to 6 weeks. More risky open surgical approaches should clearly be reserved for those that fail and are probably best performed in specialist centres.

16.

17.

18.

19.

20.

Financial support 21.

None declared.

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22. 23.

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