Treatment of external duodenal fistula

TREATMENT OF EXTERNAL DUODENAL FISTULA JOHN

I.

PERL, M.D.

CHICAGO, ILL.

E

XTERNAL duodenal Ii&as can be cIassified from the cIinica1 point of view and from the standpoint of pathoIogica1 anatomy. When regarded from the cIinica1 viewpoint there are: I. SmaII fistuIas; they have very IittIe drainage, a sIight irritation of the skin about the externa1 opening and practicaIIy no impairment of the patient’s genera1 condition. 2. Large fistuIas; they have a copious drainage of duodena1 content with serious tissue destruction in and about the external opening. LocaI symptoms are accompanied with rapidIy deveIoping dehydration, grave changes in bIood pIasma and a resuhant toxemia. When regarded from the pathoIogicanatomica viewpoint externa1 duodena1 fistuIas are divided into: I. TerminaI fistuIas; i.e. wherein the interna opening takes its origin ‘from the stump of the transverseIy divided bowe1. 2. LateraI fistulas; wherein the interna opening of the fistuIa results from a defect of the duodena1 waI1, but where the continuation of the duodenum itseIf is not interrupted. TerminaI fistuIas are usuaIIy Iarge. They may deveIop as a postoperative compIication subsequent to the BiIIroth 2 type of gastric resection and from the cIosed end of the duodena1 stump. The first, or superior part of the duodenum is rather short. Its Iength seIdom exceeds 5 cm.; and its transverse diameter varies from 3.75 to 5 cm. The bIood suppIy of the post-pyIoric part is comparativeIy poor. These factors, in conjunction with either fauIty technique or an unfavorabIe pathoIogica1 give rise to. termina1 fistuIa situation, For instance the avaiIabIe formation. duodena1 stump may be so short that

adequate cIosure cannot be carried out effrcientIy, or, the suturing may be so tight that a subsequent ischemia, necrosis and “ bIow out ” of the inverted part of the bowe1 resuIts. PIacing drains in contact with suture Iine of duodenum is a predisposing factor. LateraI IistuIas deveIop from various causes, among which perforation from an uIcer, pressure necrosis from drain-tubes, circuIation disturbances foIIowing separation of adhesions, operations on the pyIorus or on the duodenum proper, accidental injuries of the duodenum during operations on the gaI1 bIadder, coIon, stomach, pancreas and kidneys pIay an important r61e. Before the fistula becomes manifest, there is always a preIude within the abdomen. This commences with the formation of an opening on some part of the duodenum, from causes aIready mentioned, with a subsequent escape of duodena1 Auid into the abdomina1 cavity. A fata peritonitis may foIIow before the cause is reaIized. OnIy when the patient survives this dangerous shock and hours or days Iater either artificia1, or spontaneous drainage demonstrates the presence of devastating enzyma1 activity of duodena1 juice in the rapidIy enIarging opening; then we are facing the dreaded duodena1 fistuIa. On the other hand, if the opening on the duodenum is smaI1, the escaping duodena1 content sIowIy worms itseIf between the aIready preformed adhesions and a IocaIized abscess may deveIop. This coIIection may reach the surface spontaneously, or the fistuIa wiI1 be compIeted by artificia1 means through surgica1 intervention. Why does the duodena1 fistuIa show so, IittIe tendency to heaI? In the Iiterature we read much of the effect of pancreatic 176

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enzymes on tissue and on skin; but littIe, if anything is said about mechanical causes such as peristaIsis, intraintestinal pressure, etc. Yet, if we anaIyze the problem, what a duodena1 fistuIa presents us, we cannot disregard severa factors in the motibty of the gastrointestina1 tract which, without doubt, pIay a very important rGIe in sustaining the fistuIa and deIaying its healing. In the average case of duodenal fistula large quantity of duodenal content is escaping through the externa1 opening. We know that there is an opening on the duodenai waII, but why do we get such an enormous amount of drainge through this reIativeIy smaI1 opening? The size of the hoIe on the duodena1 waI1 in most instances is stiI1 much smaIIer than the Iumen of the bowe1. Why does the duodenal content prefer the smaI1 fistuIous tract, instead of the comfortabIy wide, free avenue downward toward the jejunum? The answer for the foregoing questions is evident in the folIowing estabhshed and generaIIy accepted physioIogica1 facts : I. The norma intraduodena1 pressure is equivaIent to 15 cm. of water. This pressure is higher during increased peristaltic action of the duodenum. 2. “The movements of the duodenum show some specia1 features, viz. contraction of the first part (duodena1 cap), peristaIsis of the second and third parts, antiperistaIsis of the second and third parts and segmenting movements. NormaIIy the contents are passed to and fro a few times in the duodenum before passing on into the jejunum, but once they have passed on they do not return. Anti-peristaIsis is most definite in the second part of the duodenum, and Ieads to periodic fiIIing of the duodena1 cap, or even regurgitation into the stomach. Very rapid mixing of the contents with the digestive juices results from this to and fro movement.“l Taking these statements into consideration, it u’iI1 be clear that, if we have an opening on the Jrst, or second part of the duodenum and this opening has a jree

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communication with the body surface, then the normally existing intraduodenal pressure, plus the digestive activity of the escaping jluid will sufice to keep this Jistula open. To remedy this situation we must first reduce the intraduodenal pressure and second, decrease the digestive potency of the escaping duodena1 content to a possible minimum. These necessary prerequisites to close the hstula are usualIy possible, at Ieast in the lateral type. In the IateraI duodenal fistuIa wherein the origina passage from stomach to duodenum is patent, one shouId pass a Rehfuss tube into the latter. Through this tube the duodenal content shouId be continuaIIy aspirated, a minima1 intraduodena1 pressure sustained and the escape of the digestive fluid into the fistuIa prevented, or at least diminished. One shouId try to pass a second tube into the jejunum. If this is successfu1, and if x-ray determines its position in the jejunum, the patient can not onIy be fed, but the aspirated duodena1 content can be re-in jetted through this jejunal tube. The external opening shouId be dressed frequentIy with wellsaturated compresses of 5 per cent tannic acid soIution and as Iong as the crater is large it shouId be flushed simuItaneousIy. When the discharge has been reduced to :I negIigibIe amount, the tannic acid compresses can be repIaced with dressings of 5 per c,ent tannic acid ointment in which aquaphor, because of its adherent property, is used as a base. If we are successful in passing a second tube into the jejunum, we have soIved the probIem of feeding the patient. Beyond the duodenojejuna1 junction peristaItic movements are defIniteIy of the forward type. Danger of regurgitation into the duodenum is negIigibIe and anyway we have in the duodenum a constant safety valve in the form of aspiration. If unsuccessful with the jejunal tube, the patient must be suppIied with normal salt soIution and gIucose by intravenous injections and hypodermocIysis.

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Tbe situation is entirely di.erent in cases of terminal Jistulas. As pointed out previously, this type of fistula occurs after Rillroth 2 type gastric resections, wherein the stump “ bIow-out” resuIting occasionaIIy in an opening, which corresponds with the entire Iumen of the gut. Here the patient can be nourished if the end-to-side gastroenterostomy works, but aspiration through a duodenal tube, as just suggested, is impossible. SurgicaI cIosure of such a fistula should be entireIy out of the question. If the suture line did not hoId at the original operation, it would be a dangerous effort to subject this extremeIy debiIitated patient to a second surgica1 intervention, where the mobilization and secondary suture of the duodena1 stump in an infected fieId may cause far more damage than one cares for. Treatment shouId be general and local. Morphine and atropine in copious doses, hypodermocIyses and intravenous infusions of norma salt, glucose and buffer salts soIutions every four to five hours in the first three or four days. The amount depends on ora intake and the amount of discharge through the fistula. A Levine tube introduced into the stomach is always of vaIue unti1 the new anastomosis proves itself properIy functioning. If the latter works SatisfactoriIv the parentera administration of ffu;ds can be diminished and finaIIy stopped. In the matter of local treatment we must reaIize that in these termina1 fistulas we are unabIe to prevent the escape of duodena contents by reducing the intraduodena pressure. However, by producing a counter-pressure from the outside, tbrougb the external opening, we can prevent, or at least diminisb tbe JIow of the discbarge caused by tbe pressure witbin tbe bowel. With a 15 cm. pressure of water in the duodenum our probIem is to raise the Ievel of the externa1 opening of the fistuIa near, or if possibIe higher, than 15 cm. from the We do this because interna opening.

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according to the laws of hydrodynamics no duodenal content will escape if the weight of the fluid in the fistulous canal equals or surpasses the pressure within the gut. The distance between the interna and externa1 openings of the fistula wiI1 vary according to individuals. This depends not onIy on the thickness of the abdominal wall, but also to the relative location of both internal and external openings. In the average case where the external opening of the fistuIa is located somewhere on the anterior abdominal wall the level of the opening wiII be 6-8 cm. higher than the interna opening. The patient is, of course, in a recumbent position. This position should be maintained. But if the fistulous tract has a downward oblique tendency, a moderate Trendelenburg position is recommended. However, where the opening is situated on the right lumber region or perhaps is located posteriorly, the patient shouId lie on his Ieft side with head Iowered slightly. In any case he shouId be in such a position that the externa1 fistulous opening is at the highest point above the internal opening. The IocaI treatment of the fistulous crater must not consist of applying dry dressings! They are absorbent, and faciIitate the drainage, which is just contrary to what we want! The crater should be covered with very thick pads of weII-saturated gauze, or better yet thick water-Iogged cotton pads in order to increase the weight of the fluid in the fistulous canal (creating “headpressure”) and so to counteract the intraduodena1 pressure. This dressing should be changed frequentI: and the crater flushed simultaneousI>-. Physiologically we have also to combat the destructive action of digestive ferments. Potter used N/IO HCI and beef juice.? Warshaw employed N,;ro HCI with a IO per cent Witte’s peptone solution as continuous irrigation and dressings.” One per cent citric acid solution has also been recommended.4 In the folIowing case

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distaI part of the stomach the adhesions between the posterior prepyIoric region and the head of the pancreas were divided between The patient (F. N.), forty-nine years oId, Iigatures and the duodenum was aIso mobiIized was brought into the EvangeIicaI Deaconess I >i” from the pyIorus. HospitaI with a massive hemorrhage from a duoThe duodenum was divided between four dena uIcer. A Levine tube was introduced into artery forceps across the uIcer. Using No. o the stomach and the gastric contents were doubIe chromic continuous catgut suture the aspirated every hour, foIIowed by injections stump was inverted and two rows of interof 8 C.C. of 50 per cent gIucose soIution. OraI rupted siIk sutures were used to compIete the feedings were withheId for three days durcIosure of the bowe1. During this phase of the ing which time the patient received 4000 C.C. operation a regrettabIe incident occurred. per day of norma saIt solution with 5 per cent AI1 the Nos. 6, 8 and IO siIk stitches, which glucose and >i gr. of morphine every six hours. were to be used as Lembert sutures to cIose the Six days after the hemorrhage 500 C.C. of whoIe stump, broke whiIe being tied. (The siIk was blood were transfused. The patient recovered either damaged by over-steriIization or by from the effects of the hemorrhage and in the traces of suIfurous acid remaining in the steriIfourth week after his admittance into the izer after steriIizing rubber gloves.) hospita1 an x-ray examination reveaIed a Iarge In order to avoid the somewhat damaged duodena1 ulcer. In view of the patient’s comseromuscuIar areas we had to put the first plaint of uIcer symptoms for the past eIeven row of No. I 2 siIk stitches in the pIace intended years an operation was decided upon. for the second row and the second row had to Operation November 24, 1934. Three C.C. be placed stiI1 farther down. This resuIted in an of spinocaine for spina anesthesia was used. apparently very satisfactory closure, aIthough This was suppIemented with ether toward the it was rather tight. An omenta1 tag was fastend of the operation. The abdomen was opened ened over this suture line for further security. A sIit was then made on the mesocoIon and and expIored with a midIine incision between the first jejuna1 Ioop was puIIed through it the xyphoid process and the umbilicus. No masses were paIpabIe aIong the coIon. The into position for side-to-end anastomosis with appendix was short, freeIy movabIe and with the stomach. This Iatter was performed with a no adhesions around it. The jejunum and iIeum continuous through-and-through chromic catappeared to be normal. The stomach was of gut, and siIk was used for the serosa. The edges norma size and no scar formations were noted of the sIit on the mesocoIon were fastened with on its anterior surface. The pyIorus easiIy interrupted siIk stitches 0.5 cm. above the permitted a finger. Just beyond the pyIoric new stoma, two cigarette drains were placed ring there was a Iarge steIIar scar which in the vicinity of the duodenal stump and the extended downward aIong the greater curvature abdomina1 wound was cIosed. On compIeting of the duodenum. There were membranous the operation 700 C.C. of whoIe bIood were given adhesions present between the duodenum and to the patient. the gaI1 bIadder. No stones were paIpabIe either Iavage was Postoperative Course: Stomach in the gal1 bIadder or in the common biIe duct. done subsequent to the operation after which A slit was made in the gastrohepatic Iigament a Levine tube was passed into the stomach and and the lesser peritoneal cavity was expIored. the patient given the usua1 routine care. It was found to be free excepting the posterior Morphine, hypodermocIysis with 5 per cent pyIoric antrum which was adherent to the gIucose, frequent aspiration of the gastric pancreas. A BiIIroth 2 type resection with contents and an occasiona flushing with retrocohc Polya modification was decided norma saIt soIution were given. Temperature upon. The vesseIs of the gastrohepatic Iigacame down to 99.8%. with a strong rhythmic ment were ligated, after which the gastrocoIic puIse of IOO. The patient was getting on very Iigament was divided so that more than haIf satisfactoriIy when on November 28 at 2.45 of the dista1 part of the stomach became mobiIA.M. he awoke with a vioIent pain in the epiized. Two Payr cIamps were appIied on the gastrium. A hypodermic injection of fi gr. of stomach, paraIIe1 with the Iong axis of the body morphine did not reIieve him. He became of the patient and the stomach was divided extremeIy restIess, his puIse rose to 140 and with the radiocauterodyne. By hoIding up the the temperature went up to 103.8%. during

3 per cent tannic exceIIent resuits.

acid soIution

was used with

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the next six hours. A considerable amount of thin serousl$ischarge appeared on the dressing and this dramage increased so rapidly, that the thick pads became saturated with biIe coIored fluid every two to three hours. This discharge was aIkaIine and on the next day the wound showed evidence of rapid disintegration. The drainage opening became three times its size of the previous day. The surrounding skin was red, raw and bled easily and the patient presented a desperate picture for forty-eight hours. After that, the temperature began to faI1 and the p&e sIowed down. December I the temperature was 99.6%. with a puIse of 106. An aqueous soIution of 2 per cent methyIene blue was injected via the Levine tube to see whether the bIue coIor wouId appear in the fistula; but it did not. The routine ora administration of Iiquids, which had been discontinued when the “bIow-out” occurred, was again resumed. About 150,000 vitamin A and 30,000 vitamin D units per day were given in the form of haIiver oil and viostero1. December I, Iate evening his temperature rose to 103’~. and a sweIIing appeared of the Ieft parotid gland. An ice pack was pIaced over the inffamed parotid and intravenous injections of caIcium chIoride were given (Percy).” The stooIs were clay-coIored. The crater of the fistuIa was then big enough to admit a smaI1 appIe and persistently discharged huge quantities of frothy, biIe-colored duodenal contents with occasiona pieces of necrotic tissue. The skin was covered with thick Iayers of zinc oxide ointment, the dressing was changed every two hours. Later we resorted to basic Iead acetate soIution made into an ointment with aquaphor, and stiI1 Iater we tried siIicate jeIIy (given through the courtesy of Dr. S. Burrows) but nothing seemed to prevent damage to the tissue in and around the fi.stuIa. On December 5, a fair-sized rubber tube was introduced into the fistuIa and the crater about the tube was packed with moist gauze. Continuous aspiration was then started; but very IittIe duodena1 Auid was obtained and because the patient complained of increasing pain in the epigastrium the tube was removed the foIIowing day. The rubber tube was found to be pIugged with a piece of necrotic tissue about the size of a half doIIar. On cIoser examination this proved itseIf to be the sIoughed off inverted part of the duodena1 cap with a11 siIk sutures preserved intact in the suture Iine, Then it was reaIized that not onIy were we faced

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with a duodena1 fistuIa, but that the whore bowe1 was open in its transverse diameter. On December 7, the patient comprained of pain in the thorax over the Ieft side and examination reveaIed a slight duIIness over the Ieft Iower Iobe posteriorly, where a few &es were audibIe, with sharp bronchia breathing. In the meantime the drainage from the fistuIa increased furiousIy and the skin about the crater looked as if it had been burned. The badIy irritated surface reached to the edge of the dressings, to both flanks and some distance below the umbiIicus. We decided to irrigate the crater with a 5 per cent tannic acid soIution and thick pads saturated with a simiIar soIution were applied over the opening. This was repeated every one to two hours. Twenty-four hours after this tannic acid treatment (Dec. IO) the skin looked remarkably better, the crater was cIeaner, and the patient was cheerfu1 because he was reIieved of the continuous burning and pain about the wound. In a week’s time the major part of the crater was fiIIed up with heaIthy granuIations. The stooIs darkened day by day. The drainage subsided to such a, moderate point that dressings were onIy appIied twice a day. The treatment of the fistuIa now consisted of irrigation and compresses with 5 per cent tannic acid soIution, and the skin was covered with 5 per cent tannic acid ointment in which aquaphor was used as the base. On December 26 the drainage stopped entireIy and the only evidence of a fistuIa was a Iess than dime sized skin defect. Dry dressings were applied thereafter. The patient was aIIowed to sit up in a chair on December 30. On January 2 a moderate amount of bilestained fluid again appeared with an ominous skin irritation around the opening. The patient was pIaced horizontaIIy in bed and tannic acid compresses were again applied. In a few days the discharge ceased and on January IO the site of the fistuIa was heaIed compIeteIy. The patient was kept in bed for another week and on January 2 I was discharged from the hospita1. He reports weekIy to the of&e and has no compIaint. He has regained his preoperative weight of 156 pounds. This case is interesting from several viewpoints. First, there was a fistula from a transversaIIy open originating duodenum and, second, this grave condi-

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tion was complicated with a surgica1 parotitis which aIone has a mortaIity of from 20 to 40 per cent, and Iater he had an infarct in the Ieft lung. The patient’s recovery in spite of these comphcations can be attributed to: I. OraI feeding was possibIe. 2. Large doses of vitamin A were given throughout the postoperative period. 3. In tannic acid solution and its applications we have found an effective treatment which proved itseIf in the management of duodena1 f%tuIa. NaturaIIy, we must reahze that insofar as hydrodynamic considerations are concerned in the treatment of duodena1 fistuIa, we have in water, or in any other indifferent crystaIIoid soIution something which would serve the purpose. But in tannic acid solution we have a medium which wiI1 reduce the aIkaIinity of the duodena1 fluid and interferes with its enzyma1 activity. Tannic acid soIution does not burn and it causes no discomfort to the patient, as wouId be the case with the N/IO HCI empIoyed by Potter. On the contrary its pain-reducing qualities are well estabIished in the treatment of burns.

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2. Attention is caIIed to intraduodenal pressure which susta:n duodena1 fistuIas. 3. In the treatment of “IateraI” duodenal fistuIas the IogicaI approach to the treatment shouId be to Iower intraduodena1 pressure b\- means of continuous aspiration through a duodena1 tube and thereby remove the duodenal content hefore it escapes via the fistuIa. 4. In a11 cases a patient with duodena1 fistuIa shouId be pIaced in such a position that the externa1 opening of the fistula is at the highest IeveI above the internal opening. 5. Continuous aspiration of the duodena1 contents through the fistuIa shouId be reserved to suitabIe cases of “terminal” fistuIas where the ora route of aspiration is impossibIe. 6. Frequent irrigations, and applications of weII-saturated dressings with 5 per cent aqueous soIution of tannic acid, proved highIy satisfactory in the treatment of a case of large termina1 fistuIa. KEFERENCES I. 2.

SUMMARY I. ExternaI duodena1 fistuIas are classified from pathologic-anatomica point of view into “termina1” and “ IateraI ” groups.

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Cited from Starhng. Principks of 1 human Physiology. Ed. 5, pp. 57-592. POTTER, C. The treatment of duodenal, high intestinal and pancreatic fistuIas. J. Missouri Al. A., 29: 374-378 (Aug.) 1932. WARSHAW, D. Modern treatment of duodenal fistula. AM. J. SURG., n.s. 27: 139-144 (Jan.) 1935. JOHANSON, N. A. Duodenal fistula with cast report. Nortbwest Med., 26:56 (Feb.) 1927. PERCY N. M. Personal communications.

BOLTON.