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New technique in treatment of duodenal fistula
NEW TECHNIQUE IN TREATMENT OF DUODENAL FISTULA REPORT OF CASE LEONARD R. T HOMF’SON,M.D. SAN PEDRO, CALIFORNIA
T
HIS case is reported because it demonstrates a new use for the cap% Iary drain reported by Thompson and
effluent soIution is handled. In the case herewith detaiIed, neutraIization was repIaced by diIution, and suction was used,
FIG. I. Note catheter Iying in wound. Zinc oxide on skin, oiIed siIk next, then rubber ring. Wound at time of cIosure of fistula.
Wright,’ and aIso because with this techempIoying the capiIIary drain. It is not my nique the time required for cIosing of the purpose to criticize neutralization as a fistuIa is much more rapid than with other principle. In this case it was not needed. techniques reported in the Iiterature. CASE REPORT The genera1 consideration of duodena1 A male, age 44, on June 10, 1937, arose at fistuIa has been we11 presented in papers by 3 ZOO A.M. After taking a drink of water, he was Potter,2 KitteIson,3 and others. This paper, stricken with a sudden pain, so severe that he therefore, mentions onIy the work which feII to the floor and was unabIe to return to bed. used principIes embodied in the technique MedicaI attention was quickly obtained and a herein described. diagnosis of gallstone colic was made. Large Erdman4 in 1921 advocated jejunosamounts of pain-reIieving medicine were used, tomy, suction, and Iarge amounts of water but the pain Iasted for about four days, foIIowby mouth. Potter advocated irrigation of ing which the patient suffered from nausea and the f?stuIa with >io norma hydrochIoric compIete Ioss of appetite. At the end of three acid, 20 to 60 drops per minute, and the weeks, he was stiI1 suffering, and at this time use of the duodena1 tube by mouth. In his a gaII-bladder x-ray revealed a gaII-bladder papers he does not mention how the which filled and emptied, with no stones visual783
784
American Journal of Surgery
Thompson-Duodenal
ized. The patient was referred to the writer at this time. He had had nausea and epigastric pains at
FistuIa
MARCH, ,939
ture. Four successive pictures showed the lesser curvature constant in outline and the greater curvature variabIe. The leucocyte
FIG. 2. Fiat gauze over wound to filter out &ids
in wound secretions. capiIIary drain pIaced on gauze.
End of
FIG. 3. Gauze turned in to be entireIy within the rubber ring. Zinc oxide ointment spread around ring.
intervaIs for three years, for which he used Sippy powders. The temperature was IOI’F. There were epigastric sphnting and tenderness. An intravenous pyeIogram was negative. X-ray examination of the stomach reveaIed that the Iesser curvature was fixed. PeristaItic waves were visibIe only on the greater curva-
count was ig,ooo, with 94 per cent polymorphonuclears. On the basis of these findings a diagnosis was made of ruptured duodena1 uker with residua1 abscess at the Iesser curvature of the stomach. At operation on JuIy 2, the abscess containing about 4 ounces of pus, was found. The galI-
New SEHIG
VOL.
XLIII,
No. 3
Thompson-Duodenal
bladder was surrounded by adhesions, but was otherwise normal. In the vicinity of the duodenum there was a granuIating area, but no
Fistula
American
Journal
<,I Surgrry
785
was dressed with powdered milk. On JuIy 8, the wound was not improved and the dressing method was changed. The capillary drain, as
FIG. 1. A second, smaIIer sheet of oiled siIk covers other parts of dressing. Zinc oxide covers capillary drain whew it leaves the oiled siIk.
FIG. 3. Cellucotton
covers edges of second sheet of oiled silk.
perforation was visible. Drains were placed and the wound cIosed. TweIve hours after operation the dressings were found to be saturated with clear fluid, later folIowed by fluid with a yellowish sediment. Digestion of the wound was not very extensive unti1 JuIy 6, at which time the wound
described by Thompson and Wright’ was used. In twenty-four hours, 1,023 C.C. of drainage was collected. This of course did not incIude fluid saturating the dressing. The capihary drainage had no visible effect on the wound. On July IO, the wound was continuousIy flushed with normal saIt solution
786
American JournaI of Surgery
Thompson-Duodenal
using IZO drops or more to the minute (over IO liters in twenty-four hours). FoIIowing this the wound rapidIy improved in appearance and
FistuIa
MARCH,1939
crater rapidly heaIed, Ieaving a narrow sinus which discharged a smaII amount of pus for six weeks more, then heaIed compIeteIy.
FIG. 6. First sheet of oiled siIk is folded over the dressing. Large sheet of cellucotton placed over entire dressing.
FIG. 7.
Many tailed binder pIaced over dressing. Murphy drip container provides a flow of 120 drops or more to the minute.
four days Iater the duodena1 drainage stopped compIeteIy. At this time the wound was rapidIy granuIating. Urinary output tripIed when the fktuIa cIosed. A puruIent discharge continued for another week unti1 a mass of brownish materia1, interpreted as inspissated duodena1 content, was forced out of the wound. The
DETAILS
DetaiIs
OF DRESSING
of the dressing are ibtrated
Figures I to 7. The capiIIary drain Penrose drain rubber
in
is made by using a tube one yard Iong.
A square yard of gauze is roIIed into a uni-
NEW SERIF..S VOL. XLIII,
No. 3
Thompson-Duodenal
form cylindrica1 roII and drawn through the Penrose rubber tube. The gauze extends 3 or 4 inches beyond the rubber tube at the end which is pIaced on the wound. In the upper angIe of the wound is pIaced a smaI1 rubber tube which carries the Murphy drip sohrtion, and around the wound there is a ring of zinc oxide ointment. A square of oiIed siIk with a circIe cut out at the center is pressed down on the zinc oxide ring, making compIete contact a11 around the wound. On top of the oiled siIk we pIace a ring of rubber tube with the ends heId together by a safety pin (the safety pin part of the ring is pIaced above). Zinc oxide ointment is then packed around the rubber tube and a ffat gauze dressing inserted over the wound inside the circIe of rubber tube. above, is A capiIIary drain, described thoroughIy soaked in steriIe water and is then fixed with one end on the ffat gauze and the other end in the bottle at the side of the bed. Another sheet of oiIed silk, smaIIer in size than the first, covers the dressing and is pressed carefuIIy into the zinc oxide. Around the margins of this square of oiled silk are strips of celIucotton, with the edges of the first piece of oiIed siIk foIded over them. A Iarge pad with Iacings to hoId it in pIace and the usua1 binder, completes the dressing.
Fistula
Amrrican
Journal
of Surgery
787
This rather eIaborate dressing aIIowed constant irrigation of the wound with a fairIy fast flow of norma salt soIution without causing the patient to suffer from the seepage of more than a smaI1 amount of fluid from the dressing. Very often the patient remained compIete-Iy dry, except for the dressing, for hours at a time. CONCLUSION
The capiIIary drain makes use extreme diIution in the duodena1 fistula. Doubtless other conditions which wiI1 be benefited by principIes.
it possibIe to treatment of wiI1 be found use of these
REFERENCES
I. THOMPSON,LEONARD R., and WRIGHT, BURNETT W. A new suprapubic drain. J. ?&ok, 37: 721-724 (May)
1937.
2. POTTER, C. Treatment of duodena1, high intestinal and pancreatic IistuIas. J. Missouri M. A., 29: 374-378 (Aug.) ‘932. 3. KITTELSON, J. A. Treatment
of duodena1 IistuIa; in&ding report of z new cases and report of new buffer soIution. Surg., Gynec. Ed Ok., 56: 1056 1065 (June) 1933. 4. MCEVERS, A. E. Conservative treatment of acute duodena1 tistuIa. Surg., Gynec. TV Obst., 58: 786 790 (ApriI) 1934. 5. ERDMAN, S. Laceration of duodenum: duodenal Iistula; jejunostomy feeding; parotiditis feeding; recovery. Ann. Surg., 73: 793-797 (June) 1921.
T
HIS case is reported because it demonstrates a new use for the cap% Iary drain reported by Thompson and
effluent soIution is handled. In the case herewith detaiIed, neutraIization was repIaced by diIution, and suction was used,
FIG. I. Note catheter Iying in wound. Zinc oxide on skin, oiIed siIk next, then rubber ring. Wound at time of cIosure of fistula.
Wright,’ and aIso because with this techempIoying the capiIIary drain. It is not my nique the time required for cIosing of the purpose to criticize neutralization as a fistuIa is much more rapid than with other principle. In this case it was not needed. techniques reported in the Iiterature. CASE REPORT The genera1 consideration of duodena1 A male, age 44, on June 10, 1937, arose at fistuIa has been we11 presented in papers by 3 ZOO A.M. After taking a drink of water, he was Potter,2 KitteIson,3 and others. This paper, stricken with a sudden pain, so severe that he therefore, mentions onIy the work which feII to the floor and was unabIe to return to bed. used principIes embodied in the technique MedicaI attention was quickly obtained and a herein described. diagnosis of gallstone colic was made. Large Erdman4 in 1921 advocated jejunosamounts of pain-reIieving medicine were used, tomy, suction, and Iarge amounts of water but the pain Iasted for about four days, foIIowby mouth. Potter advocated irrigation of ing which the patient suffered from nausea and the f?stuIa with >io norma hydrochIoric compIete Ioss of appetite. At the end of three acid, 20 to 60 drops per minute, and the weeks, he was stiI1 suffering, and at this time use of the duodena1 tube by mouth. In his a gaII-bladder x-ray revealed a gaII-bladder papers he does not mention how the which filled and emptied, with no stones visual783
784
American Journal of Surgery
Thompson-Duodenal
ized. The patient was referred to the writer at this time. He had had nausea and epigastric pains at
FistuIa
MARCH, ,939
ture. Four successive pictures showed the lesser curvature constant in outline and the greater curvature variabIe. The leucocyte
FIG. 2. Fiat gauze over wound to filter out &ids
in wound secretions. capiIIary drain pIaced on gauze.
End of
FIG. 3. Gauze turned in to be entireIy within the rubber ring. Zinc oxide ointment spread around ring.
intervaIs for three years, for which he used Sippy powders. The temperature was IOI’F. There were epigastric sphnting and tenderness. An intravenous pyeIogram was negative. X-ray examination of the stomach reveaIed that the Iesser curvature was fixed. PeristaItic waves were visibIe only on the greater curva-
count was ig,ooo, with 94 per cent polymorphonuclears. On the basis of these findings a diagnosis was made of ruptured duodena1 uker with residua1 abscess at the Iesser curvature of the stomach. At operation on JuIy 2, the abscess containing about 4 ounces of pus, was found. The galI-
New SEHIG
VOL.
XLIII,
No. 3
Thompson-Duodenal
bladder was surrounded by adhesions, but was otherwise normal. In the vicinity of the duodenum there was a granuIating area, but no
Fistula
American
Journal
<,I Surgrry
785
was dressed with powdered milk. On JuIy 8, the wound was not improved and the dressing method was changed. The capillary drain, as
FIG. 1. A second, smaIIer sheet of oiled siIk covers other parts of dressing. Zinc oxide covers capillary drain whew it leaves the oiled siIk.
FIG. 3. Cellucotton
covers edges of second sheet of oiled silk.
perforation was visible. Drains were placed and the wound cIosed. TweIve hours after operation the dressings were found to be saturated with clear fluid, later folIowed by fluid with a yellowish sediment. Digestion of the wound was not very extensive unti1 JuIy 6, at which time the wound
described by Thompson and Wright’ was used. In twenty-four hours, 1,023 C.C. of drainage was collected. This of course did not incIude fluid saturating the dressing. The capihary drainage had no visible effect on the wound. On July IO, the wound was continuousIy flushed with normal saIt solution
786
American JournaI of Surgery
Thompson-Duodenal
using IZO drops or more to the minute (over IO liters in twenty-four hours). FoIIowing this the wound rapidIy improved in appearance and
FistuIa
MARCH,1939
crater rapidly heaIed, Ieaving a narrow sinus which discharged a smaII amount of pus for six weeks more, then heaIed compIeteIy.
FIG. 6. First sheet of oiled siIk is folded over the dressing. Large sheet of cellucotton placed over entire dressing.
FIG. 7.
Many tailed binder pIaced over dressing. Murphy drip container provides a flow of 120 drops or more to the minute.
four days Iater the duodena1 drainage stopped compIeteIy. At this time the wound was rapidIy granuIating. Urinary output tripIed when the fktuIa cIosed. A puruIent discharge continued for another week unti1 a mass of brownish materia1, interpreted as inspissated duodena1 content, was forced out of the wound. The
DETAILS
DetaiIs
OF DRESSING
of the dressing are ibtrated
Figures I to 7. The capiIIary drain Penrose drain rubber
in
is made by using a tube one yard Iong.
A square yard of gauze is roIIed into a uni-
NEW SERIF..S VOL. XLIII,
No. 3
Thompson-Duodenal
form cylindrica1 roII and drawn through the Penrose rubber tube. The gauze extends 3 or 4 inches beyond the rubber tube at the end which is pIaced on the wound. In the upper angIe of the wound is pIaced a smaI1 rubber tube which carries the Murphy drip sohrtion, and around the wound there is a ring of zinc oxide ointment. A square of oiIed siIk with a circIe cut out at the center is pressed down on the zinc oxide ring, making compIete contact a11 around the wound. On top of the oiled siIk we pIace a ring of rubber tube with the ends heId together by a safety pin (the safety pin part of the ring is pIaced above). Zinc oxide ointment is then packed around the rubber tube and a ffat gauze dressing inserted over the wound inside the circIe of rubber tube. above, is A capiIIary drain, described thoroughIy soaked in steriIe water and is then fixed with one end on the ffat gauze and the other end in the bottle at the side of the bed. Another sheet of oiIed silk, smaIIer in size than the first, covers the dressing and is pressed carefuIIy into the zinc oxide. Around the margins of this square of oiled silk are strips of celIucotton, with the edges of the first piece of oiIed siIk foIded over them. A Iarge pad with Iacings to hoId it in pIace and the usua1 binder, completes the dressing.
Fistula
Amrrican
Journal
of Surgery
787
This rather eIaborate dressing aIIowed constant irrigation of the wound with a fairIy fast flow of norma salt soIution without causing the patient to suffer from the seepage of more than a smaI1 amount of fluid from the dressing. Very often the patient remained compIete-Iy dry, except for the dressing, for hours at a time. CONCLUSION
The capiIIary drain makes use extreme diIution in the duodena1 fistula. Doubtless other conditions which wiI1 be benefited by principIes.
it possibIe to treatment of wiI1 be found use of these
REFERENCES
I. THOMPSON,LEONARD R., and WRIGHT, BURNETT W. A new suprapubic drain. J. ?&ok, 37: 721-724 (May)
1937.
2. POTTER, C. Treatment of duodena1, high intestinal and pancreatic IistuIas. J. Missouri M. A., 29: 374-378 (Aug.) ‘932. 3. KITTELSON, J. A. Treatment
of duodena1 IistuIa; in&ding report of z new cases and report of new buffer soIution. Surg., Gynec. Ed Ok., 56: 1056 1065 (June) 1933. 4. MCEVERS, A. E. Conservative treatment of acute duodena1 tistuIa. Surg., Gynec. TV Obst., 58: 786 790 (ApriI) 1934. 5. ERDMAN, S. Laceration of duodenum: duodenal Iistula; jejunostomy feeding; parotiditis feeding; recovery. Ann. Surg., 73: 793-797 (June) 1921.