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Duodenal Fistula After Kidney Surgery. Case Report
DUODENAL FISTULA AFTER KIDNEY SURGERY CASE REPORT
DAVID H. SCHNEIDER From the Charity Hospital of Louisiana, New Orleans INTRODUCTION
The purpose of this paper is to add a case of postoperative (right nephrectomy) duodenal fistula with recovery to the literature, as well as present the statistics of these cases at Charity Hospital of Louisiana at New Orleans from 1906 to 1942 inclusively. REVIEW OF THE LITERATURE
In 1935, Ockerblad and Gonzales reviewed· the literature and found 25 cases of duodenal fistulae following right nephrectomy. They had a 36 year old white female who had a right nephrectomy for pyonephrosis. Bile drainage was noticed within the first 24 hours, a jejunostomy performed on the fourth postoperative day, but the patient died on the next day. In 1936, Bouzon reported _a case occurring 6 months after a right nephrectomy for tuberculosis; patient died 2 weeks later. In 1938, Bartlett reported the case of a 28 year old female who had a nephrectomy in 1922 for tuberculosis, with the immediate appearance of biliary drainage from the wound. She was also treated conservatively, but died on the tenth postoperative day. In 1941, Cernezzi reported a case of recovery following nephrectomy for calculous pyonephrosis in a 31 year old white female, the fistula appearing on the ninth day. ETIOLOGY
The etiology of bowel fistulae may be infectious or traumatic: A. Infection 1. Perinephritis 2. Tuberculosis B. Trauma 1. Directly at operation (dissection, etc.) 2. Clamping of pedicle a. Temporary, inadvertently b. Permanent (clamps, sutures, etc.) 3. Packs (left in place which erode the bowel wall by pressure, leading to necrosis and perforation.) CLINICAL COURSE
Sometimes a patient will get well in spite of what you try to do for him; our patient may have been one of these! However, as will be shown, about half the patients with this disease die, usually of inanition due to loss of duodenal contents through the wound. These contents act (1) systemically: the chlorides 287
TABLE
SUJl.GEON
!.-Duodenal jistulae after right nephrectomy DIAGNOSIS
OPERATION
FISTULA
COURSE
I RESULT
Operative treatment sarcoma
nephrectomy
10 days
abcess
nephrectomy
3 days
3 1912 Payr
pyonephrosis
nephrectomy
8 days
4 1913 Thevenard
tuberculosis
nephrectomy
5 1915 Mayo
stones
nephrectomy
30 days
6 1920 Michon
pyonephrosis
nephrectomy
25 days
7 1920 Pousson
pyonephrosis
nephrectomy
10 days
8 1924 Pignatti 9 1926 Kearns
nephrectomy nephrectomy
7 days
nephrectomy
4 days
1 1903 Von Gecko2
vie 1911 Esau
?
10
1927 Moragna
stones hydronephrosis stones
11
1927 Ockerblad
pyonephrosis
nephrectomy
1 day
jj/1
pyonephrosis
nephrectomy
10 days
13 1930 C.H. 12
pyonephrosis
nephrectomy
1 day
14 1941 C.H. 13
neurosarcoma exploratory
12 1929 C.H.
?
4 days
jejunostomy 17 days jejunostomy 9 days closure in 2 years gastroenterostomy immediate closure suturing; 1 day suturing; 12 days suturing ?
died died cured cured cured cured cured cured died
suturing; 1 day jejunostomy 4 days suturing 11 days suturing 1 day suturing 4 days
cured
2 months
cured cured died died died died cured cured died
died died died died
Conservative therapy
1 2 3 4 5 6 7 8 9
1911 1912 1914 1914 1914 1914 1918
10
1921 1923 1920 1924 1931
11 12 13 14
Rigby Payr Mayo Mayo Mayo Miller Davis Korte ? 1920 Legueu
15 1932 16 1936 17 1938 18 1941 19 1942
Pousson Gaminara Fischer Pignatti Lepoutrer and Dupas Boyd Bouzon Bartlett Cernezzi C.H. 14
pyonephrosis ? ?
carcinoma ?
tuberculosis dead kidney ? perinephric abcess pyonephrosis tumor tuberculosis tuberculosis sarcoma ?
tuberculosis tuberculosis pyonephrosis pyonephrosis
nephrectomy 62 days nephrectomy 2 years nephrectomy 4 days nephrectomy 5 days nephrectomy ? 1 day nephrectomy nephrectomy 4 days nephrectomy ? nephrectomy 9 months nephrectomy nephrectomy nephrectomy nephrectomy nephrectomy
10 days 10 days 4 days 15 days 10 days
nephrectomy ? nephrectomy 6 months nephrectomy immediate nephrectomy 9 days nephrectomy 1 day
288
gradual 14 days 10 days 14 days 7 days 7 weeks healed 4 months
3-4 hours ? 8 weeks
4 weeks ?
2 weeks 10 days 3½ months 2 months
died cured cured died cured died died died cured cured
DUODENAL FISTULA AFTER KIDNEY SURGERY
289
first fall while the carbon dioxide combining power later decreases, and the patient develops acidosis. From the loss of fluids (as high as 4,000 cc a day) dehydration results. The blood nitrogenous waste products gradually increase, and the serum protein falls. Enzymes and other secretions of the duodenal glands, liver and pancreas are also lost. (2) Locally: the highly alkaline enzyme containing fluid acts on the skin, fat and muscle to cause severe digestion of tissue, and necrosis. TREATMENT
Treatment is directed at 2 factors. Firstly, to replace lost materials, and secondly, to prevent local tissue reaction. The first concern is body fluid balance. An output of at least 1,500 cc a day should be observed. Intake will therefore vary as the drainage. Saline should be given to keep the body chlorides within normal range. Glucose will probably have to be supplemented parenterally; the amount gauged by body caloric requirements. Proteins will have to be supplemented, for though there will be the usual body breakdown, there will be no digestion; due to loss of enzymes. This may be done with plasma, serum, blood, etc. If the CO2 combining power drops, parenteral base will also have to be given. In general, the idea being to replace loss through the fistulous tract by artificial means as well as feed the patient. Each patient will have to be treated as an individual problem. Part of this may be done in some people by collecting the drainage and refeeding it back by means of stomach tube. This stomach (or duodenal tube, if possible) may also act to decrease the positive pressure in the duodenum (Potter), if placed on suction, excepting when attempting feedings. In regards to vitamins, some will probably have to be supplemented, but it is interesting to note that it takes 2 weeks with a complete biliary fistula and a deficient diet to manifest a hemorrhagic diathesis (Snyder and Cinn). Locally, attempts should be made to prevent tissue destruction. Peptones have been advocated to react with the duodenal contents, charcoal, for absorption of ferments and acids to neutralize the alkaline secretion (0.1 N HCl, citric, 5 per cent tannic, etc.). Ointments to protect the skin (kaolin, boric, liquid latex, etc.). Suction to the wound not only acts to remove the secretion, but also collects it for measurement or refeeding. Lundquist used a balloon catheter for this purpose (unknown to the author). Donald has a unique box made from a sputum cup. Atropine and ephedrine may be tried to decrease pancreatic secretion (Mayo). All of the above measures are conservative. Radical therapy consists of suturing of the tract (immediate or late) plus gastro-enterostomy, with or without pyloric occlusion and jejunostomy (McCaughan and Purcell). Mayo recommended immediate closure. Decision of surgery, of course, rests with the individual case and condition of the patient. CASE REPORT
Mrs. I. F. (!38-74848), a 46 year old white female, was admitted November 27, 1942, discharged January 16, 1943. She complained of pain and a mass in
290
DAVID H. SCHNEIDER
the right side. On July 30, 1941 she was admitted to the urological service with a history of having had 3 to 4 attacks during the past 24 hours of 15-20 minutes' duration, cramps in the right flank with anorexia. Physical examination at that time was not remarkable except for absence of the right breast. Urinalysis showed many white blood cells and epithelial cells with occasional red blood cells and gram negative bacilli (Shigella metadysentery). Catheterization of the right kidney pelvis showed 46 cc stasis with poor function. Pyelograms disclosed right hydronephrosis and, nephroptosis. The patient was discharged August 7, 1941. She was readmitted on November 11, 1942 to the surgical service with a story of repeated attacks as above. Abdominal examination at this time showed a mass in the right hypochondrium. Under spinal analgesia, abdominal exploration was done.. A normal appendix was found and removed. The gall bladder and ducts were normal. The right kidney was found to be enlarged. Several days later, catheterization of the right ureter disclosed an obstruction at 28 cm. She had a low grade fever, and was discharged November 22, 1942. She had a right mastectomy in 1929 for "lumps". In 1938, she had an incomplete septic abortion. The patient was a pale, poorly developed 46 year old white female, chronically ill. Pertinent findings limited to the abdomen, where, in addition to the scar of previous operation, was a tender mass about the size of a football occupying the entire upper right abdomen and flank (which disappeared almost entirely on drainage of the right kidney pelvis). Laboratory Findings: Hemoglobin, 63 per cent; red blood cells, 3.lM; white blood cells, 11,000 with 52 per cent neutrophils, 44 per cent lymphocytes, 4 per cent monocytes. Urine: yellow, acid, specific gravity 1.024, no sugar, no albumin, 8-12 white blood cells per high power field, no red blood cells, occa:sional hyaline casts, gram negative rods (B. aerobicum). Blood urea nitrogen, 11.1 mg per cent; varied from 9.1 to 16.7 mg per cent throughout the postoperative course; proteins, 6.51-7 .2 gm per cent; A: G ratio, 1.8 :1; chlorides, 550-613 mg per cent. Retrograde pyelograms showed marked hydronephrosis on the right, but a normal pelvis on the left. Cystoscopy (December 3, 1942): A No. 6 whistle-tip catheter passed into the right pelvis and 280 cc pus found. Six days later, 400 cc were recovered. An intravenous injection of indigo carmine appeared in 12 minutes with poor concentration on the right side; 3 minutes with good concentration on the left. Retention catheters were placed in the right pelvis on each occasion. On December 10, a very difficult right nephrectomy was performed. The pelvis was found to be quite adherent to the gut wall, and bluntly dissected away. Blood pressure fell during the procedure, but recovered with an infusion. On the first postoperative day bile was seen to be draining from the wound. She was placed on frequent feedings of high protein diet (every 4 hours), and aluminum paste was thickly applied to the wound. An Alcock-Foley whistletip catheter was placed into the wound where a rubber drain had previously been left at operation; the catheter was found to drain best when placed in the sub-
DUODENAL FISTULA AFTER KIDNEY SURGERY
291
cutaneous tissues rather than deeper in the wound. The catheter was placed on Wangensteen suction, while a constant drip of 0.1 N HCl was started into the wound at 40 drops a minute. A few intermittent doses of parenteral vitamin K were administered. Dressings were changed frequently. Parenteral fluids, glucose, salt and transfusions were given. The pH of the drainage was 1.25-1.45. Drainage gradually slowed down. There was a slight excoriation of the skin which healed spontaneously. On the twentieth postoperative day, the fistula seemed closed, and there was no drainage from the catheter or the wound. On the twenty-second day, the water was let out of the bag; bile began to drain, so the suction was restarted. The bile drainage ceased in 2 hours (probably the bile came from around the balloon, and not a re-opening of the fistula). On the thirty-third day, the catheter was removed. On the thirty-fourth day, the wound was completely healed. The temperature never rose above 102°. The patient was discharged on the thirty-seventh postoperative day, cured. The pathological diagnosis was hydronephrosis and chronic pyelonephritis. On February 28, 1943, 2 months later, the wound had healed, the patient had gained weight, and was working on her farm. ADDITIONAL .CASES
H. R. (No. 185), a 27 year old white male, was admitted on September 25, 1929 for a right nephrectomy. Several weeks previously, at another institution, he had an operation for a fistulous tract that had been traced down from the right flank to the pelvis of the kidney, and several stones removed. His chemistry showed a blood urea nitrogen of 20.3 mg per cent, non-protein nitrogen, 44.4 mg. per cent, creatinine, 1.51 mg. per cent, and sugar, 66 mg. per cent. Serology was negative. The phthalein output was 20 per cent in 1 hour and 20 per cent in 2 hours. On October 8, 1929, an impassable stricture of the right ureter at 1 inch was found. On October 30, his right kidney was explored and found to be adherent to the surrounding structures. A rib resection was done, and the pleural cavity opened and closed. In freeing the kidney, severe bleeding was controlled by 7 large packs. The patient went into shock on removal from the table, but recovered following transfusions. On the fifth postoperative day, a fecal odor was noticed from the wound. On the eighth day, the wound was opened widely and irrigated with ST 37. On the tenth day, duodenal contents appeared on the dressing. An exploratory operation was done; the 2 remaining packs were removed, the abdomen was found full of pus, and a duodenal perforation, which was sutured. The patient died. Autopsy showed an opening in the second portion of the duodenum. Diagnosis: pyonephrosis with sinus formation, duodenal fistula, peritonitis. A. T. (No. H11332), a 31.year old white female, entered the hospital April 19, 1930, with pain in the right lower quadrant, vomiting, and nocturia of 16 days' duration. She was in the hospital 10 months ago with the same condition. Physical examination showed a tender swelling in the right lower quadrant of the abdomen. Urine contained many pus and blood cells, casts and debris. Blood counts: red blood cells, 3.275M, hemoglobin, 80 per cent, white blood cells 18,000.
292
DAVID H. SCHNEIDER
Urine cultures showed B. coli. Blood chemistry: non-protein nitrogen, 50 mg. per cent, chlorides, 335 mg. per cent, CO2 combining power, 62 volumes per cent, but dropped to 40 volumes per cent on the fourteenth postoperative day. Cystoscopy showed a blocked right ureter with pus exuding from the orifice. She had a septic temperature and began fecal vomiting May I. A right nephrectomy was performed the next day. Pyonephrosis with many adhesions were found. The duodenum was torn and sutured. The cavity drained. Patient supported parenterally. Beef juice and 0.lN HCl applied to the wound. She died on the fourteenth day in acidosis. Autopsy showed bilateral edema of the lungs, acute toxic hepatitis, splenitis, glomerular and interstitial nephritis, postoperative right nephrectomy and duodenorrhaphy. A. R. (No. T41-35195), a 39 year old white female was admitted July 27, 1941 with a story of left paralysis and a mass in the right side. She had known that she has had hypertension for 11 years. In 1934, her blood pressure was 195/140. In March 1941, when her systolic pressure was 280, she had a left spastic paraplegia. In January 1938, she began having inconstant right sided dull pain with a mass. On March 3, 1939, the right kidney region was explored and an inoperable neurosarcoma found. She was given several courses of deep x-ray therapy with marked reduction in the size of the mass. Her past history is significant in the fact that in 1934 she had an appendectomy for chronic appendicitis, and her blood pressure then was 195/135. On admission, her temperature, pulse and respiratory rates were normal. The blood pressure was 195/85. A complete spastic paralysis of the left side of the face, arms and legs was found. The heart and lungs were normal. Abdominal examination showed scars of a previous operation and a mass in the right iliac region from the pelvic brim to the kidney region. Urinalysis was not remarkable on admission. Blood counts were within normal range. On July 27, 1941, the blood urea nitrogen was 32.1 mg. per cent. One month later the non-protein nitrogen was 52 mg. per cent, chlorides, 397.8 mg. per cent. On August 22, blood urea nitrogen was 45 mg. per cent, chlorides, 600 mg. per cent, CO2 combining power, 30 volumes per cent, proteins, 5.11 gm. per cent, icteric index, 23.1. Serology was negative An electrocardiogram showed evidences of myocardial disease. Retrograde pyelo~ grams showed dilatation of the right kidney pelvis with rotation on its axis. Right lateral pyelogram in normal position. Cystoscopy (July 31, 1941) showed poor kidney function on the right side. On August 13, the right kidney was explored. Dense scar tissue was found, the bowel and peritoneum being adherent. The bowel was nicked and immediately repaired. The kidney and adrenal found to be grossly normal. Kidney accidentally punctured, and bled profusely. The wound was packed with iodoform gauze, and closed. On the third postoperative day, fecal drainage was noted from the wound. Wangensteen suction was started to the stomach, and the patient supported parenterally. Bile appeared on the wound on the fifth day; and methylene blue, fed orally, appeared on the dressing in 15 minutes. Her temperature spiked constantly while the patient went steadily downhill. Suction was placed into the wound on the seventh day. The patient died on the twenty-first day. No autopsy was performed.
DUODENAL FISTULA AFTER KIDNEY SURGERY
293
Diagnosis: hypertension, old cerebral accident, neurosarcoma of right kidney (healed?), duodenal fistula, terminal pneumonia, inanition, uremia and acidosis. QUESTIONABLE CASES
A. R. (No. 18), a 40 year old colored female, entered the hospital September 17, 1914, with a painful mass in the abdomen and sudden severe exacerbations of recurrent spells of pain and vomiting. Urine showed 2 plus albumin and many pus cells; culture yielded gram negative organisms of the colon-typhoid group. Her leucocytosis was 19,444, with 90 per cent neutrophils. Culture of the pus from the right flank showed B. coli. Right ureteral catheterization showed pus in the pelvis. On September 19, the right flank was incised and drained; pyonephrosis was found. On October 4, a large tumor was found in the right side of the abdomen. The next day, the previous incision was enlarged, and multiple abscesses of the kidney found. Nephrectomy was performed, and clamps left on the pedicle. The wound was packed with iodoform gauzes. On the fourth postoperative day, clamps were removed. On the sixth day, a fecal fistula was discovered. She died 2 days later. Diagnosis: fecal fistula, multiple abscesses of the right kidney with perinephric abscess. M. M. (No. 15053), 47 year old white female, was admitted April 13, 1934 with a draining wound from the right side. Since the age of 15, she had been having right lumbar pains radiating to the hypogastrium. Hematuria on only one occasion. In 1933, an appendectomy was performed; 1 week later, a right pyelolithotomy (?) for stones. Since then, has had a persistent draining sinus from the kidney wound. The significant findings on admission, outside of a blood pressure of 165/108, were limited to the abdomen, where there was a draining sinus, tender, in the middle of a flank scar, and a firm mass beneath. Pressure over the mass caused fluid to exude from the sinus. Urinalysis showed albumin and much pus, but no organisms, and a sterile culture. Blood studies showed a leucocytosis of 14,000 with 90 per cent neutrophils. Chemistry (May 3): non-protein nitrogen 171 mg. per cent, blood urea nitrogen 114 mg. per cent, creatinine 2.2 mg. per cent, sugar 93 mg. per cent, and CO2 combining power of 58 volumes per cent. After drainage of the right pelvis by means of ureteral catheterization of 150 cc pus st;,i,sis, the mass markedly decreased in size. On April 19, a right nephrectomy was performed. The peritoneum was twice opened and sutured. An intra- and extra-capsular nephrectomy was performed. The pyonephrotic kidney was ruptured in removal. The patient went into temporary shock. On the si.,::th postoperative day a fecal fistula developed. The wound sloughed markedly. She became progressively worse, and died on the twentyfifth day. Diagnosis: right pyonephrosis with draining sinus, fecal fistula, and terminal uremia. Though there is a possibility that these latter 2 cases may very well be duodenal rather that fecal fistulae, there is no record on the charts of any bile coming from the wound. Their clinical courses are quite suggestive of the former condition rather than the latter. However, I am merely presenting them as fecal and not duodenal.
294
DAVID H. SCHNEIDER RESULTS
Summary of Charity Hospital Cases (1906-1942) : Procedures-right only: N ephrectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . Nephropexy............................................................... Pyelolithotomy............................................................ N ephrolithotomy... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploratory............................................................... Incision and Drainage.................................................... . N ephrostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
236 166 67 30 22 14 12
Total....................................................................
546
Fistulae following right renal operation: per cent
Duodenal..................................................... Fecal.........................................................
4 2
0.7 0.4
Total.......................................................
6
1.1
Cases in literature plus Charity Hospital Cases are shown in table 1. Results of treatment: treatment
per cent
cases
died
Conservative....................................... Operative..........................................
19 14
10
55
7
50
Total.............................................
33
17
54
SUMMARY
A case of post-nephrectomy duodenal fistula with recovery is presented along with 3 additional cases with fatal outcome. Two cases of fecal fistula following right nephrectomy are presented to show that they may also occur (one-third fistulae found here). Statistics are given to show the frequency of this disease here and the mortality rates. Treatment: (a) Conservative, which is systemic and local. (b) Radical; surgical, either, immediate or late, depending on patient and surgeon. CONCLUSIONS
Postoperative duodenal (and fecal) fistulae resulting from operations on the right kidney are not as rare as the literature would lead one to believe. Treatment depends 6n the individual patient, but in general, should follow along the above lines. If the meager figures above are any indication at all, there is practically no difference between conservative and radical treatment, the mortality being about the same in both. These complications may sometimes be avoided by a subcapsular, rather than an extracapsular nephrectomy. I wish to herewith extend my deepest gratitude to Dr. Monroe Wolf, chief of the Department of Urology, independent service, for his help and encouragement ' in preparing this paper, and to Dr. Roger Maihles, senior visiting surgeon, for permission for the use of the case presented.
DUODENAL FISTULA AFTER KIDNEY SURGERY
295
REFERENCES BARTLETT, M. K., AND LOWELL, W. H.: Acute post-operative duodenal fistulae. New Eng. J. Med., 218: 587, 1938. BouzoN: Late duodenal fistulae after nephrectomy. Bourdeaux Chirurgicale Jan. 1936· reviewed in Urol. and Cutan. Rev., 40: 277, 1936. ' ' ' BoYD, M.: Personal communication to Ockerblad. CERNEZZI, A., Medical therapy of postoperative duodenal fistula with report of a case following right nephrectomy. Gazzetta degli ospedali e delle cliniche, 62: 163, 1941. DAVIS, E. G.: Duodenal-ureteral fistula of spontaneous origin. J. A. M. A., 70: 376, 1918. DoNALD, JR., C. J.: A simple method for the treatment of upper intestinal fistula. Proc. Staff meet. Mayo Clinic, 17: 156, 1942. EsA u: Subcutane Zerreissung der rechten N eire mit Abcedierung und Duodenalfistelbildung. Med. Klin., 40: 1538, 1941. . FISCHER: Ueber Duodenalfisteln nach Nephrectomie. Zentralbl. f. d. Chir. u. Grenzeb., 1921. GAMINARA, A.: Un Caso de fistula duodeno-cutanea post-operatoria tratada con el sifonaje; curazion. An. Fae. de Med. Montevido, 8: 954, 1923. HICKEN, N. F., WHITE, L.B., AND CORAY, Q. B.: External biliary fistula. Surg., Gynec. & Obst., 74: 828, 1942. KEARNS, W. M.: Urologists' Correspondence Club Letter, July 30, 1934, and personal communication to Ockerblad. KORTE: Quoted by Kolpe, 1904. Quoted by Melchoir, Die Chirurgie des Duodenum, 1914. LEGUEU, F.: Fistule duodenale survenant un mois apres les nephrectomie. Surles fistules duodenales apres la nephrectomie. Reported at Societe Fr. d'urologie, J. d'urol. Med. et Chir., 9: 203, 1920. LE POUTRE, C., AND DUPAS, L.: Les fistules duodenales consecutives ala nephrectomie droite. Arch. des Mal. des Reins, 5: 712, 1931. LUNDQUIST, D. L.: Occlusion of biliary sinus by balloon catheters. California and West. Med., 52: 230, 1940. MAROGNA, P.: Sulle fistole duodenal consecutive a nephrectomia. Ann. ital. di chir., 6: 657 1927. MAYO, W. J.: Accidental injuries to the descending portion of the duodenum. J. A. M.A., 62: 343, 1914. MAYO, W. J.: Procedures following Nephrectomy. Collected Papers of the Mayo Clinic, 7: 349, 1915. McCAUGHAN, J.M., AND PURCELL, H.K.: Pancreatic fistulae. Arch. Surg., 43: 269, 1941. MICHou, E.: Nephrectomie droit suivie de fistule duodenale. Societe Fr. d'Urologie, January, 1920. Reviewed in Arch. des mal. des reins, 5: 712, 1930 (by Lepoutre et Dupas. MILLER, C. J.: Personal communication to Ockerblad. OcKERBLAD, N. F., AND GONZALES, N. G.: Duodenal fistulae due to perinephric abscess and following right nephrectomy. A. J. Surg., 28: 105, 1935. PAYR: Duod11malfistel nach Nephrectomie. Munchen Wochenschr., 59: 2259, 1912. PERL, J. J.: Treatment of external fistulae. Am. J. Surg., 30: 176, 1935. PIGNATTI, A.: Sulle fistole duodenali consecutive a nephrectomie. Bull. d'sc. Med. di Bologna, s.10, 2: 402, 1924. POTTER, C.: Treatment of duodenal, high intestinal and pancreatic fistulae. J. Missouri Med. As., 29: 374, 1932. PoussoN: Suite de la discussion sur les fistules intestinales consecutives a la nephrectomie. J. d'urol. et Med. et Chir., 9: 267, 1920. RIGBY, H. M.: A note of external duodenal fistula; with a record of some unpublished cases. Brit. J. Surg., 12: 43, 1924. SNYDER, W. H., AND CrnN R.: Pancreatic fistulae. Surg., Gynec. & Obst., 62: 57, 1932. THEVENARD: Fistule duodeno-cutanee d'une cicatrice de nephrectomie lombaire vielle de 10 ans; gastro-enterostomie, exclusion du pylorie, guerison. Paris Chir., 5: 870, 1913. THOMPSON, L. R.: A new suprapubic drain. J. Urol., 37: 721, 1937. THOMPSON, L. R.: A new technique for treatment of duodenal fistulae. Am. J. Surg., 43: 783, 1939. VoN GECKOVIC, M.: Ueber fisteln des duodenum. Arch. f. klin. Chir., 69: 843, 1903. ZUCKERMAN, I. C., KoGuT, B., JACOBI, M. AND COHEN, J.: Studies in human biliary physiology, 111. Am. J. Digest. Dis., 6: 332, 1939.
DAVID H. SCHNEIDER From the Charity Hospital of Louisiana, New Orleans INTRODUCTION
The purpose of this paper is to add a case of postoperative (right nephrectomy) duodenal fistula with recovery to the literature, as well as present the statistics of these cases at Charity Hospital of Louisiana at New Orleans from 1906 to 1942 inclusively. REVIEW OF THE LITERATURE
In 1935, Ockerblad and Gonzales reviewed· the literature and found 25 cases of duodenal fistulae following right nephrectomy. They had a 36 year old white female who had a right nephrectomy for pyonephrosis. Bile drainage was noticed within the first 24 hours, a jejunostomy performed on the fourth postoperative day, but the patient died on the next day. In 1936, Bouzon reported _a case occurring 6 months after a right nephrectomy for tuberculosis; patient died 2 weeks later. In 1938, Bartlett reported the case of a 28 year old female who had a nephrectomy in 1922 for tuberculosis, with the immediate appearance of biliary drainage from the wound. She was also treated conservatively, but died on the tenth postoperative day. In 1941, Cernezzi reported a case of recovery following nephrectomy for calculous pyonephrosis in a 31 year old white female, the fistula appearing on the ninth day. ETIOLOGY
The etiology of bowel fistulae may be infectious or traumatic: A. Infection 1. Perinephritis 2. Tuberculosis B. Trauma 1. Directly at operation (dissection, etc.) 2. Clamping of pedicle a. Temporary, inadvertently b. Permanent (clamps, sutures, etc.) 3. Packs (left in place which erode the bowel wall by pressure, leading to necrosis and perforation.) CLINICAL COURSE
Sometimes a patient will get well in spite of what you try to do for him; our patient may have been one of these! However, as will be shown, about half the patients with this disease die, usually of inanition due to loss of duodenal contents through the wound. These contents act (1) systemically: the chlorides 287
TABLE
SUJl.GEON
!.-Duodenal jistulae after right nephrectomy DIAGNOSIS
OPERATION
FISTULA
COURSE
I RESULT
Operative treatment sarcoma
nephrectomy
10 days
abcess
nephrectomy
3 days
3 1912 Payr
pyonephrosis
nephrectomy
8 days
4 1913 Thevenard
tuberculosis
nephrectomy
5 1915 Mayo
stones
nephrectomy
30 days
6 1920 Michon
pyonephrosis
nephrectomy
25 days
7 1920 Pousson
pyonephrosis
nephrectomy
10 days
8 1924 Pignatti 9 1926 Kearns
nephrectomy nephrectomy
7 days
nephrectomy
4 days
1 1903 Von Gecko2
vie 1911 Esau
?
10
1927 Moragna
stones hydronephrosis stones
11
1927 Ockerblad
pyonephrosis
nephrectomy
1 day
jj/1
pyonephrosis
nephrectomy
10 days
13 1930 C.H. 12
pyonephrosis
nephrectomy
1 day
14 1941 C.H. 13
neurosarcoma exploratory
12 1929 C.H.
?
4 days
jejunostomy 17 days jejunostomy 9 days closure in 2 years gastroenterostomy immediate closure suturing; 1 day suturing; 12 days suturing ?
died died cured cured cured cured cured cured died
suturing; 1 day jejunostomy 4 days suturing 11 days suturing 1 day suturing 4 days
cured
2 months
cured cured died died died died cured cured died
died died died died
Conservative therapy
1 2 3 4 5 6 7 8 9
1911 1912 1914 1914 1914 1914 1918
10
1921 1923 1920 1924 1931
11 12 13 14
Rigby Payr Mayo Mayo Mayo Miller Davis Korte ? 1920 Legueu
15 1932 16 1936 17 1938 18 1941 19 1942
Pousson Gaminara Fischer Pignatti Lepoutrer and Dupas Boyd Bouzon Bartlett Cernezzi C.H. 14
pyonephrosis ? ?
carcinoma ?
tuberculosis dead kidney ? perinephric abcess pyonephrosis tumor tuberculosis tuberculosis sarcoma ?
tuberculosis tuberculosis pyonephrosis pyonephrosis
nephrectomy 62 days nephrectomy 2 years nephrectomy 4 days nephrectomy 5 days nephrectomy ? 1 day nephrectomy nephrectomy 4 days nephrectomy ? nephrectomy 9 months nephrectomy nephrectomy nephrectomy nephrectomy nephrectomy
10 days 10 days 4 days 15 days 10 days
nephrectomy ? nephrectomy 6 months nephrectomy immediate nephrectomy 9 days nephrectomy 1 day
288
gradual 14 days 10 days 14 days 7 days 7 weeks healed 4 months
3-4 hours ? 8 weeks
4 weeks ?
2 weeks 10 days 3½ months 2 months
died cured cured died cured died died died cured cured
DUODENAL FISTULA AFTER KIDNEY SURGERY
289
first fall while the carbon dioxide combining power later decreases, and the patient develops acidosis. From the loss of fluids (as high as 4,000 cc a day) dehydration results. The blood nitrogenous waste products gradually increase, and the serum protein falls. Enzymes and other secretions of the duodenal glands, liver and pancreas are also lost. (2) Locally: the highly alkaline enzyme containing fluid acts on the skin, fat and muscle to cause severe digestion of tissue, and necrosis. TREATMENT
Treatment is directed at 2 factors. Firstly, to replace lost materials, and secondly, to prevent local tissue reaction. The first concern is body fluid balance. An output of at least 1,500 cc a day should be observed. Intake will therefore vary as the drainage. Saline should be given to keep the body chlorides within normal range. Glucose will probably have to be supplemented parenterally; the amount gauged by body caloric requirements. Proteins will have to be supplemented, for though there will be the usual body breakdown, there will be no digestion; due to loss of enzymes. This may be done with plasma, serum, blood, etc. If the CO2 combining power drops, parenteral base will also have to be given. In general, the idea being to replace loss through the fistulous tract by artificial means as well as feed the patient. Each patient will have to be treated as an individual problem. Part of this may be done in some people by collecting the drainage and refeeding it back by means of stomach tube. This stomach (or duodenal tube, if possible) may also act to decrease the positive pressure in the duodenum (Potter), if placed on suction, excepting when attempting feedings. In regards to vitamins, some will probably have to be supplemented, but it is interesting to note that it takes 2 weeks with a complete biliary fistula and a deficient diet to manifest a hemorrhagic diathesis (Snyder and Cinn). Locally, attempts should be made to prevent tissue destruction. Peptones have been advocated to react with the duodenal contents, charcoal, for absorption of ferments and acids to neutralize the alkaline secretion (0.1 N HCl, citric, 5 per cent tannic, etc.). Ointments to protect the skin (kaolin, boric, liquid latex, etc.). Suction to the wound not only acts to remove the secretion, but also collects it for measurement or refeeding. Lundquist used a balloon catheter for this purpose (unknown to the author). Donald has a unique box made from a sputum cup. Atropine and ephedrine may be tried to decrease pancreatic secretion (Mayo). All of the above measures are conservative. Radical therapy consists of suturing of the tract (immediate or late) plus gastro-enterostomy, with or without pyloric occlusion and jejunostomy (McCaughan and Purcell). Mayo recommended immediate closure. Decision of surgery, of course, rests with the individual case and condition of the patient. CASE REPORT
Mrs. I. F. (!38-74848), a 46 year old white female, was admitted November 27, 1942, discharged January 16, 1943. She complained of pain and a mass in
290
DAVID H. SCHNEIDER
the right side. On July 30, 1941 she was admitted to the urological service with a history of having had 3 to 4 attacks during the past 24 hours of 15-20 minutes' duration, cramps in the right flank with anorexia. Physical examination at that time was not remarkable except for absence of the right breast. Urinalysis showed many white blood cells and epithelial cells with occasional red blood cells and gram negative bacilli (Shigella metadysentery). Catheterization of the right kidney pelvis showed 46 cc stasis with poor function. Pyelograms disclosed right hydronephrosis and, nephroptosis. The patient was discharged August 7, 1941. She was readmitted on November 11, 1942 to the surgical service with a story of repeated attacks as above. Abdominal examination at this time showed a mass in the right hypochondrium. Under spinal analgesia, abdominal exploration was done.. A normal appendix was found and removed. The gall bladder and ducts were normal. The right kidney was found to be enlarged. Several days later, catheterization of the right ureter disclosed an obstruction at 28 cm. She had a low grade fever, and was discharged November 22, 1942. She had a right mastectomy in 1929 for "lumps". In 1938, she had an incomplete septic abortion. The patient was a pale, poorly developed 46 year old white female, chronically ill. Pertinent findings limited to the abdomen, where, in addition to the scar of previous operation, was a tender mass about the size of a football occupying the entire upper right abdomen and flank (which disappeared almost entirely on drainage of the right kidney pelvis). Laboratory Findings: Hemoglobin, 63 per cent; red blood cells, 3.lM; white blood cells, 11,000 with 52 per cent neutrophils, 44 per cent lymphocytes, 4 per cent monocytes. Urine: yellow, acid, specific gravity 1.024, no sugar, no albumin, 8-12 white blood cells per high power field, no red blood cells, occa:sional hyaline casts, gram negative rods (B. aerobicum). Blood urea nitrogen, 11.1 mg per cent; varied from 9.1 to 16.7 mg per cent throughout the postoperative course; proteins, 6.51-7 .2 gm per cent; A: G ratio, 1.8 :1; chlorides, 550-613 mg per cent. Retrograde pyelograms showed marked hydronephrosis on the right, but a normal pelvis on the left. Cystoscopy (December 3, 1942): A No. 6 whistle-tip catheter passed into the right pelvis and 280 cc pus found. Six days later, 400 cc were recovered. An intravenous injection of indigo carmine appeared in 12 minutes with poor concentration on the right side; 3 minutes with good concentration on the left. Retention catheters were placed in the right pelvis on each occasion. On December 10, a very difficult right nephrectomy was performed. The pelvis was found to be quite adherent to the gut wall, and bluntly dissected away. Blood pressure fell during the procedure, but recovered with an infusion. On the first postoperative day bile was seen to be draining from the wound. She was placed on frequent feedings of high protein diet (every 4 hours), and aluminum paste was thickly applied to the wound. An Alcock-Foley whistletip catheter was placed into the wound where a rubber drain had previously been left at operation; the catheter was found to drain best when placed in the sub-
DUODENAL FISTULA AFTER KIDNEY SURGERY
291
cutaneous tissues rather than deeper in the wound. The catheter was placed on Wangensteen suction, while a constant drip of 0.1 N HCl was started into the wound at 40 drops a minute. A few intermittent doses of parenteral vitamin K were administered. Dressings were changed frequently. Parenteral fluids, glucose, salt and transfusions were given. The pH of the drainage was 1.25-1.45. Drainage gradually slowed down. There was a slight excoriation of the skin which healed spontaneously. On the twentieth postoperative day, the fistula seemed closed, and there was no drainage from the catheter or the wound. On the twenty-second day, the water was let out of the bag; bile began to drain, so the suction was restarted. The bile drainage ceased in 2 hours (probably the bile came from around the balloon, and not a re-opening of the fistula). On the thirty-third day, the catheter was removed. On the thirty-fourth day, the wound was completely healed. The temperature never rose above 102°. The patient was discharged on the thirty-seventh postoperative day, cured. The pathological diagnosis was hydronephrosis and chronic pyelonephritis. On February 28, 1943, 2 months later, the wound had healed, the patient had gained weight, and was working on her farm. ADDITIONAL .CASES
H. R. (No. 185), a 27 year old white male, was admitted on September 25, 1929 for a right nephrectomy. Several weeks previously, at another institution, he had an operation for a fistulous tract that had been traced down from the right flank to the pelvis of the kidney, and several stones removed. His chemistry showed a blood urea nitrogen of 20.3 mg per cent, non-protein nitrogen, 44.4 mg. per cent, creatinine, 1.51 mg. per cent, and sugar, 66 mg. per cent. Serology was negative. The phthalein output was 20 per cent in 1 hour and 20 per cent in 2 hours. On October 8, 1929, an impassable stricture of the right ureter at 1 inch was found. On October 30, his right kidney was explored and found to be adherent to the surrounding structures. A rib resection was done, and the pleural cavity opened and closed. In freeing the kidney, severe bleeding was controlled by 7 large packs. The patient went into shock on removal from the table, but recovered following transfusions. On the fifth postoperative day, a fecal odor was noticed from the wound. On the eighth day, the wound was opened widely and irrigated with ST 37. On the tenth day, duodenal contents appeared on the dressing. An exploratory operation was done; the 2 remaining packs were removed, the abdomen was found full of pus, and a duodenal perforation, which was sutured. The patient died. Autopsy showed an opening in the second portion of the duodenum. Diagnosis: pyonephrosis with sinus formation, duodenal fistula, peritonitis. A. T. (No. H11332), a 31.year old white female, entered the hospital April 19, 1930, with pain in the right lower quadrant, vomiting, and nocturia of 16 days' duration. She was in the hospital 10 months ago with the same condition. Physical examination showed a tender swelling in the right lower quadrant of the abdomen. Urine contained many pus and blood cells, casts and debris. Blood counts: red blood cells, 3.275M, hemoglobin, 80 per cent, white blood cells 18,000.
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DAVID H. SCHNEIDER
Urine cultures showed B. coli. Blood chemistry: non-protein nitrogen, 50 mg. per cent, chlorides, 335 mg. per cent, CO2 combining power, 62 volumes per cent, but dropped to 40 volumes per cent on the fourteenth postoperative day. Cystoscopy showed a blocked right ureter with pus exuding from the orifice. She had a septic temperature and began fecal vomiting May I. A right nephrectomy was performed the next day. Pyonephrosis with many adhesions were found. The duodenum was torn and sutured. The cavity drained. Patient supported parenterally. Beef juice and 0.lN HCl applied to the wound. She died on the fourteenth day in acidosis. Autopsy showed bilateral edema of the lungs, acute toxic hepatitis, splenitis, glomerular and interstitial nephritis, postoperative right nephrectomy and duodenorrhaphy. A. R. (No. T41-35195), a 39 year old white female was admitted July 27, 1941 with a story of left paralysis and a mass in the right side. She had known that she has had hypertension for 11 years. In 1934, her blood pressure was 195/140. In March 1941, when her systolic pressure was 280, she had a left spastic paraplegia. In January 1938, she began having inconstant right sided dull pain with a mass. On March 3, 1939, the right kidney region was explored and an inoperable neurosarcoma found. She was given several courses of deep x-ray therapy with marked reduction in the size of the mass. Her past history is significant in the fact that in 1934 she had an appendectomy for chronic appendicitis, and her blood pressure then was 195/135. On admission, her temperature, pulse and respiratory rates were normal. The blood pressure was 195/85. A complete spastic paralysis of the left side of the face, arms and legs was found. The heart and lungs were normal. Abdominal examination showed scars of a previous operation and a mass in the right iliac region from the pelvic brim to the kidney region. Urinalysis was not remarkable on admission. Blood counts were within normal range. On July 27, 1941, the blood urea nitrogen was 32.1 mg. per cent. One month later the non-protein nitrogen was 52 mg. per cent, chlorides, 397.8 mg. per cent. On August 22, blood urea nitrogen was 45 mg. per cent, chlorides, 600 mg. per cent, CO2 combining power, 30 volumes per cent, proteins, 5.11 gm. per cent, icteric index, 23.1. Serology was negative An electrocardiogram showed evidences of myocardial disease. Retrograde pyelo~ grams showed dilatation of the right kidney pelvis with rotation on its axis. Right lateral pyelogram in normal position. Cystoscopy (July 31, 1941) showed poor kidney function on the right side. On August 13, the right kidney was explored. Dense scar tissue was found, the bowel and peritoneum being adherent. The bowel was nicked and immediately repaired. The kidney and adrenal found to be grossly normal. Kidney accidentally punctured, and bled profusely. The wound was packed with iodoform gauze, and closed. On the third postoperative day, fecal drainage was noted from the wound. Wangensteen suction was started to the stomach, and the patient supported parenterally. Bile appeared on the wound on the fifth day; and methylene blue, fed orally, appeared on the dressing in 15 minutes. Her temperature spiked constantly while the patient went steadily downhill. Suction was placed into the wound on the seventh day. The patient died on the twenty-first day. No autopsy was performed.
DUODENAL FISTULA AFTER KIDNEY SURGERY
293
Diagnosis: hypertension, old cerebral accident, neurosarcoma of right kidney (healed?), duodenal fistula, terminal pneumonia, inanition, uremia and acidosis. QUESTIONABLE CASES
A. R. (No. 18), a 40 year old colored female, entered the hospital September 17, 1914, with a painful mass in the abdomen and sudden severe exacerbations of recurrent spells of pain and vomiting. Urine showed 2 plus albumin and many pus cells; culture yielded gram negative organisms of the colon-typhoid group. Her leucocytosis was 19,444, with 90 per cent neutrophils. Culture of the pus from the right flank showed B. coli. Right ureteral catheterization showed pus in the pelvis. On September 19, the right flank was incised and drained; pyonephrosis was found. On October 4, a large tumor was found in the right side of the abdomen. The next day, the previous incision was enlarged, and multiple abscesses of the kidney found. Nephrectomy was performed, and clamps left on the pedicle. The wound was packed with iodoform gauzes. On the fourth postoperative day, clamps were removed. On the sixth day, a fecal fistula was discovered. She died 2 days later. Diagnosis: fecal fistula, multiple abscesses of the right kidney with perinephric abscess. M. M. (No. 15053), 47 year old white female, was admitted April 13, 1934 with a draining wound from the right side. Since the age of 15, she had been having right lumbar pains radiating to the hypogastrium. Hematuria on only one occasion. In 1933, an appendectomy was performed; 1 week later, a right pyelolithotomy (?) for stones. Since then, has had a persistent draining sinus from the kidney wound. The significant findings on admission, outside of a blood pressure of 165/108, were limited to the abdomen, where there was a draining sinus, tender, in the middle of a flank scar, and a firm mass beneath. Pressure over the mass caused fluid to exude from the sinus. Urinalysis showed albumin and much pus, but no organisms, and a sterile culture. Blood studies showed a leucocytosis of 14,000 with 90 per cent neutrophils. Chemistry (May 3): non-protein nitrogen 171 mg. per cent, blood urea nitrogen 114 mg. per cent, creatinine 2.2 mg. per cent, sugar 93 mg. per cent, and CO2 combining power of 58 volumes per cent. After drainage of the right pelvis by means of ureteral catheterization of 150 cc pus st;,i,sis, the mass markedly decreased in size. On April 19, a right nephrectomy was performed. The peritoneum was twice opened and sutured. An intra- and extra-capsular nephrectomy was performed. The pyonephrotic kidney was ruptured in removal. The patient went into temporary shock. On the si.,::th postoperative day a fecal fistula developed. The wound sloughed markedly. She became progressively worse, and died on the twentyfifth day. Diagnosis: right pyonephrosis with draining sinus, fecal fistula, and terminal uremia. Though there is a possibility that these latter 2 cases may very well be duodenal rather that fecal fistulae, there is no record on the charts of any bile coming from the wound. Their clinical courses are quite suggestive of the former condition rather than the latter. However, I am merely presenting them as fecal and not duodenal.
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DAVID H. SCHNEIDER RESULTS
Summary of Charity Hospital Cases (1906-1942) : Procedures-right only: N ephrectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . Nephropexy............................................................... Pyelolithotomy............................................................ N ephrolithotomy... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploratory............................................................... Incision and Drainage.................................................... . N ephrostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
236 166 67 30 22 14 12
Total....................................................................
546
Fistulae following right renal operation: per cent
Duodenal..................................................... Fecal.........................................................
4 2
0.7 0.4
Total.......................................................
6
1.1
Cases in literature plus Charity Hospital Cases are shown in table 1. Results of treatment: treatment
per cent
cases
died
Conservative....................................... Operative..........................................
19 14
10
55
7
50
Total.............................................
33
17
54
SUMMARY
A case of post-nephrectomy duodenal fistula with recovery is presented along with 3 additional cases with fatal outcome. Two cases of fecal fistula following right nephrectomy are presented to show that they may also occur (one-third fistulae found here). Statistics are given to show the frequency of this disease here and the mortality rates. Treatment: (a) Conservative, which is systemic and local. (b) Radical; surgical, either, immediate or late, depending on patient and surgeon. CONCLUSIONS
Postoperative duodenal (and fecal) fistulae resulting from operations on the right kidney are not as rare as the literature would lead one to believe. Treatment depends 6n the individual patient, but in general, should follow along the above lines. If the meager figures above are any indication at all, there is practically no difference between conservative and radical treatment, the mortality being about the same in both. These complications may sometimes be avoided by a subcapsular, rather than an extracapsular nephrectomy. I wish to herewith extend my deepest gratitude to Dr. Monroe Wolf, chief of the Department of Urology, independent service, for his help and encouragement ' in preparing this paper, and to Dr. Roger Maihles, senior visiting surgeon, for permission for the use of the case presented.
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REFERENCES BARTLETT, M. K., AND LOWELL, W. H.: Acute post-operative duodenal fistulae. New Eng. J. Med., 218: 587, 1938. BouzoN: Late duodenal fistulae after nephrectomy. Bourdeaux Chirurgicale Jan. 1936· reviewed in Urol. and Cutan. Rev., 40: 277, 1936. ' ' ' BoYD, M.: Personal communication to Ockerblad. CERNEZZI, A., Medical therapy of postoperative duodenal fistula with report of a case following right nephrectomy. Gazzetta degli ospedali e delle cliniche, 62: 163, 1941. DAVIS, E. G.: Duodenal-ureteral fistula of spontaneous origin. J. A. M. A., 70: 376, 1918. DoNALD, JR., C. J.: A simple method for the treatment of upper intestinal fistula. Proc. Staff meet. Mayo Clinic, 17: 156, 1942. EsA u: Subcutane Zerreissung der rechten N eire mit Abcedierung und Duodenalfistelbildung. Med. Klin., 40: 1538, 1941. . FISCHER: Ueber Duodenalfisteln nach Nephrectomie. Zentralbl. f. d. Chir. u. Grenzeb., 1921. GAMINARA, A.: Un Caso de fistula duodeno-cutanea post-operatoria tratada con el sifonaje; curazion. An. Fae. de Med. Montevido, 8: 954, 1923. HICKEN, N. F., WHITE, L.B., AND CORAY, Q. B.: External biliary fistula. Surg., Gynec. & Obst., 74: 828, 1942. KEARNS, W. M.: Urologists' Correspondence Club Letter, July 30, 1934, and personal communication to Ockerblad. KORTE: Quoted by Kolpe, 1904. Quoted by Melchoir, Die Chirurgie des Duodenum, 1914. LEGUEU, F.: Fistule duodenale survenant un mois apres les nephrectomie. Surles fistules duodenales apres la nephrectomie. Reported at Societe Fr. d'urologie, J. d'urol. Med. et Chir., 9: 203, 1920. LE POUTRE, C., AND DUPAS, L.: Les fistules duodenales consecutives ala nephrectomie droite. Arch. des Mal. des Reins, 5: 712, 1931. LUNDQUIST, D. L.: Occlusion of biliary sinus by balloon catheters. California and West. Med., 52: 230, 1940. MAROGNA, P.: Sulle fistole duodenal consecutive a nephrectomia. Ann. ital. di chir., 6: 657 1927. MAYO, W. J.: Accidental injuries to the descending portion of the duodenum. J. A. M.A., 62: 343, 1914. MAYO, W. J.: Procedures following Nephrectomy. Collected Papers of the Mayo Clinic, 7: 349, 1915. McCAUGHAN, J.M., AND PURCELL, H.K.: Pancreatic fistulae. Arch. Surg., 43: 269, 1941. MICHou, E.: Nephrectomie droit suivie de fistule duodenale. Societe Fr. d'Urologie, January, 1920. Reviewed in Arch. des mal. des reins, 5: 712, 1930 (by Lepoutre et Dupas. MILLER, C. J.: Personal communication to Ockerblad. OcKERBLAD, N. F., AND GONZALES, N. G.: Duodenal fistulae due to perinephric abscess and following right nephrectomy. A. J. Surg., 28: 105, 1935. PAYR: Duod11malfistel nach Nephrectomie. Munchen Wochenschr., 59: 2259, 1912. PERL, J. J.: Treatment of external fistulae. Am. J. Surg., 30: 176, 1935. PIGNATTI, A.: Sulle fistole duodenali consecutive a nephrectomie. Bull. d'sc. Med. di Bologna, s.10, 2: 402, 1924. POTTER, C.: Treatment of duodenal, high intestinal and pancreatic fistulae. J. Missouri Med. As., 29: 374, 1932. PoussoN: Suite de la discussion sur les fistules intestinales consecutives a la nephrectomie. J. d'urol. et Med. et Chir., 9: 267, 1920. RIGBY, H. M.: A note of external duodenal fistula; with a record of some unpublished cases. Brit. J. Surg., 12: 43, 1924. SNYDER, W. H., AND CrnN R.: Pancreatic fistulae. Surg., Gynec. & Obst., 62: 57, 1932. THEVENARD: Fistule duodeno-cutanee d'une cicatrice de nephrectomie lombaire vielle de 10 ans; gastro-enterostomie, exclusion du pylorie, guerison. Paris Chir., 5: 870, 1913. THOMPSON, L. R.: A new suprapubic drain. J. Urol., 37: 721, 1937. THOMPSON, L. R.: A new technique for treatment of duodenal fistulae. Am. J. Surg., 43: 783, 1939. VoN GECKOVIC, M.: Ueber fisteln des duodenum. Arch. f. klin. Chir., 69: 843, 1903. ZUCKERMAN, I. C., KoGuT, B., JACOBI, M. AND COHEN, J.: Studies in human biliary physiology, 111. Am. J. Digest. Dis., 6: 332, 1939.