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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 58-61

Duodenocutaneous fistula: An innovative management with triple tube drainage


Department of General Surgery, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission05-Sep-2017
Date of Acceptance26-Oct-2017
Date of Web Publication25-May-2018

Correspondence Address:
Jacob Jayakar Raju Mandapati
Department of General Surgery, Pondicherry Institute of Medical Sciences, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_51_17

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  Abstract 


Treatment of duodenocutaneous fistula is an expensive and time-consuming proposition, but in the absence of complicating factors, 74% of these fistulas close over a 9–12-week period of time. When complicated with sepsis, distal obstruction, and biliary peritonitis, the cost of treatment and length of hospital stay are increased along with high mortality associated with it. We present a patient who was reoperated with a technique using 3 tube (gastrostomy, duodenostomy, and feeding jejunostomy) which enhanced his recovery and speedy discharge from hospital at a lesser cost compared to traditional methods of treatment. Managing high output enterocutaneous fistula is difficult. Our technique ameliorates the nutrition, improves the fluid and electrolyte balance, decreases the morbidity, and evades the mortality when compared to existing management methods in literature.

Keywords: Duodenocutaneous fistula, giant duodenal ulcer, triple tube drainage, triple tube ostomy


How to cite this article:
Palaniappan NK, Raju Mandapati JJ, Gurusamy T. Duodenocutaneous fistula: An innovative management with triple tube drainage. J Curr Res Sci Med 2018;4:58-61

How to cite this URL:
Palaniappan NK, Raju Mandapati JJ, Gurusamy T. Duodenocutaneous fistula: An innovative management with triple tube drainage. J Curr Res Sci Med [serial online] 2018 [cited 2018 Jul 18];4:58-61. Available from: http://www.jcrsmed.org/text.asp?2018/4/1/58/233197




  Introduction Top


Emergency abdominal operations are one of the leading causes of enterocutaneous fistulas (ECF).[1],[2],[3] Most retrospective reviews (1960–2009) and collected data with operative repair of ECF show a high mortality within 30 days of surgery which is between 3% and 22%.[4] Duodenocutaneous fistulas are complex and difficult to manage when compared to other enteric fistulas. When nonoperative management fails, surgical diversion and decompression of duodenum is the definitive therapy which can reduce the mortality.


  Case Report Top


A 28-year-old male, underwent Grahams patch closure for anterior first part duodenal ulcer perforation, had a biliary leak through upper midline incision. He presented to us with persistent enterocutaneous fistula discharging bile on postoperative day (POD 20) [Figure 1].
Figure 1: Open fistula draining bile seen on presentation of the patient to the casualty

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The patient presented with sepsis (fever 101°f, tachycardia [138/min], tachypnoea [34/min], metabolic acidosis [6.19]), GI effluent (high output fistula >600 ml discharging bile through main wound), on inotropic support (noradrenaline (2 mg/min), and dopamine (15 μg /kg/min).


  Procedure: Triple Tube Technique Top


The patient was taken up for relaparotomy. Intraoperatively, a giant (2.5 cm), leaking (bile) duodenal ulcer was noted. Duodenum was kocherized. Ulcer edges were trimmed [Figure 2] and [Figure 3]. A 14 fr Foley catheter was introduced through narrowed ulcer which drain bile and gastric juice and control the effluent, fixed by inflating the balloon in the antrum of the stomach functioning as gastrostomy (Tube-1), perforation narrowed with 2-0 silk simple interrupted sutures around Foley catheter [Figure 4]. A 10 fr feeding tube introduced retrograde from 5 cm distal to the ligament of Treitz in jejunum and positioned into c loop of duodenum for decompression for draining biliopancreatic juices (duodenostomy [Tube-2]). This tube prevents stasis and leak of bile and pancreatic juices through narrowed perforation until the patient recovers from ileus [Figure 5]. 16 fr Ryles tube introduced 10 cm distal to the entry point of feeding tube in jejunum and placed distally for enteral feeding (jejunostomy [Tube-3]). A 16 fr nasogastric tube drain positioned in the stomach for decompression of stomach and drainage of saliva. Right hepatorenal pouch/Morison Gutter drained with 30 fr flexocath tube drains to collect the spilled and peritubal-leaked effluent from perforation and free peritoneal cavity [Figure 8]. Abdomen was closed with tension retention sutures [Figure 6].
Figure 2: Intraoperative picture showing the giant duodenal ulcer

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Figure 3: Reperforated duodenal ulcer trimmed

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Figure 4: Giant ulcer narrowed and obliterated with Foley catheter

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Figure 5: Feeding jejunostomy tube placed in jejunum

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Figure 8: Schematic diagram showing the position of drainage tubes

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Figure 6: Patient with three tubes in position (jejunostomy/Foley/flexocath drain) and on regular dressing with wound care

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The patient was monitored in Intensive Care Unit. On POD (0-3) intravenous fluid administered calculating the basic metabolic requirement and loss of bilio gastric juices through controlled drains. Enteral feeding started on day 3 through Ryles tube (2600 kcal/80 g protein/24 h). Nasogastric tube was removed on day 5 when abdominal girth and bowel sounds were normal, inotropes and vasopressors are tapered sequentially (day 1–5). Duodenal decompression and Foley catheter pancreatobilio-enteric juices were collected under sterile precautions and reintroduced in feeding (Ryles) tube to compart the loss of electrolytes. The patient was ambulated. Duodenostomy Foley catheter was removed on POD 14 (week-2) after a close follow-up of occlusion and no peritubal and general peritoneal cavity extravasation. Flexocath drain tube removed when there was nil drainage on POD 18. Duodenal decompression tube occluded from day 16 along with feeding jejunostomy. The patient was started on soft diet. On POD-21, the gastrograffin study shows no extravasation of contrast and closure of fistulous tract. There was no leak from perforated site. Retrograde duodenal decompression and feeding jejunostomy tube were removed on day 22. The patient resumed on normal diet on day 22 and discharged on day 27 [Figure 7].
Figure 7: Tubes removed sequentially, showing healing of the site (Patient was discharged, on normal diet on 3rd week following admission)

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  Discussion Top


Patients with enterocutaneous fistula (ECF), the majority will close spontaneously within 6 weeks, if not closed by 12 weeks, it is unlikely to close. The average time for definitive repair of fistula to develop into a hostile abdomen is upto 6 months. Four cardinal principles as described by chapman et al. for the healing of ECF which are correction of intravascular volume deficit, drainage of abdominal abscess, control of fistula, and skin protection are to be followed regardless of etiology.[5] Various surgical and nonsurgical methods are defined in literature for the management of duodenocutaneous fistulas. Mortality due to ECF remains 10% to 30% even in modern era and present with complications of sepsis, malnutrition, and electrolyte abnormalities.[6] Timing of operative intervention is important as various reports show poor outcome when surgery is performed within time period of 2–3 weeks to 3 months.[7],[8] The role of nutritional support and controlled diversion of GI contents significantly decrease the mortality and increase the chance of spontaneous closure.[9]

Combined approach with proximal diversion distal enteral nutrition, sepsis control with broad-spectrum antibiotics, fluid resuscitation, and wound care decreases the timeline of morbidity due to ECF and allows spontaneous closure which evades mortality.[10] When a ECF develops the usual practice is to reoperate and washout the peritoneal cavity, close the defect and redo anastomosis if conditions are feasible. In cases of extensive peritoneal soiling and critically ill patients, close the abdomen with drains. Attempting for the definitive closure and extensive surgeries in decompensated patient increase the mortality.[11] We treated our patient following the principles of biliary diversion, decompression (retrograde duodenostomy (7 fr feeding catheter), 16 f Foley catheter (through narrowed anterior duodenal wall perforation), and both the tubes were exteriorized. Thus, diverting the highly autodigestive pancreatic and biliary secretions helps in early healing of surrounding tissues around perforation and prevents inflammatory edema. Early enteral nutrition started through jejunostomy, once the abdominal distention is less with active bowel sounds after 72 h which takes care of patients' basic energy requirements. Malnutrition due to loss of protein-rich enteral contents through fistula associated with sepsis results in significant patient morbidity and mortality. Enteral feeding helps the patients to improve immune functions, promote wound healing and early closure of perforation. In the presence of many alternative procedures, the simple tube drainage will enhance the recovery and is suitable for patients who are in decompensated metabolic state and not fit to undergo major surgical intervention.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Soeters PB, Ebeid AM, Fischer JE. Review of 404 patients with gastrointestinal fistulas. Impact of parenteral nutrition. Ann Surg 1979;190:189-202.  Back to cited text no. 1
    
2.
Reber HA, Robert C, Way LW. Management of external gastrointestinal fistulas. Ann Surg 1978;188:460.  Back to cited text no. 2
    
3.
Aguirre A, Fischer JE, Welch CE. The role of surgery and hyper alimentations in therapy of gastrointestinal cutaneous fistulae. Ann Surg 1974;180:393.  Back to cited text no. 3
    
4.
Brenner M, Clayton JL, Tillou A, Hiatt JR, Cryer HG. Risk factors for recurrence after repair of enterocutaneous fistula. Arch Surg 2009;144:500-5.  Back to cited text no. 4
    
5.
Chapman R, Fovan R, Dunphy JE. Management of intestinal fistulas. Am J Surg 1964;108:157-64.  Back to cited text no. 5
    
6.
Evenson AR, Fischer JE. Current management of enterocutaneous fistula. J Gastrointest Surg 2006;10:455-64.  Back to cited text no. 6
    
7.
Lynch AC, Delaney CP, Senagore AJ. Clinical outcome and factors predictive of recurrence after entreocutaneous fistula surgery. Ann Surg 2004;240:825.  Back to cited text no. 7
    
8.
Fazio VW, Coutsoftides T, Steiger E. Factors influencing the outcome of treatment of small bowel cutaneous fistula. World J Surg 1983;7:481-8.  Back to cited text no. 8
    
9.
Lloyd DA, Gabe SM, Windsor AC. Nutrition and management of enterocutaneous fistula. Br J Surg 2006;93:1045-55.  Back to cited text no. 9
    
10.
Gribovskaja-Rupp I, Melton GB. Enterocutaneous fistula: Proven strategies and updates. Clin Colon Rectal Surg 2016;29:130-7.  Back to cited text no. 10
    
11.
Joyce MR, Dietz DW. Management of complex gastrointestinal fistula. Curr Probl Surg 2009;46:384-430.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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