THE CONSERVATIVE TREATMENT OF

ACUTE DUODENAL FISTULA*

CASE REPORT
M. JORDAN THORSTAD, M.D.
DETROrr, Micir.

A PROFUSELY DRAINING DUODENAL FISTULA is a serious and disconcerting

complication of certain types of upper abdominal surgery. It carries an
exceedingly high mortality rate, variously reported as from 27 to 6o per
cent, or an average mortality rate including all forms of treatment of
36.o per cent.3 Duodenal fistulae may be classified into two main groups:
(I) The lateral type, in which an opening develops in the wall of the duo-
denum, with the continuity of the gastro-intestinal tract intact, as follows gall-
bladder surgery, repair of perforated peptic ulcer, etc.; and (2) the end type,
following the surgical closure of the amputated duodenal stump in gastric
resection.'
The outstanding principles of therapeutics advocated in the treatment of
this disease have been (i) jejunostomy and jejunal feedings, as described
by McGuire and Erdman; (2) suction, as introduced by Carmen, Lahey,
Potter, etc.; (3) neutralization of the intestinal juices as advocated by
Potter; and (4) the blood chemistry changes, as demonstrated by various
authors.
Acute postoperative duodenal fistulae have been reported in the literature
in approximately I30 patients, and to this group we wish to add another case
which made a remarkable recovery on a conservative plan of therapy.
Case Report.-Harper Hosp., No. 248275: A 64-year-old white male was admitted,
March 28, 1943, with a history of gradual, painless jaundice of two months duration,
clay-colored stools, weight loss and dark urine. In February, 194I, he had undergone
a transurethral resection of the prostate and the removal of a diverticulum of the urinary
bladder and, in July, I942, a cholecystectomy and common duct drainage. Physical exam-
ination revealed a moderate jaundice, a slightly enlarged liver, atrophy of the small muscles
of the hands, and glossitis. Laboratory data: Hb. 67.0 per cent; R.B.C. 3,620,000;
W.B.C. 8,500; urine loaded with pus; blood N.C.N. 29.0 mg.; icteric index 30;
and a prothrombin time of go per cent. Preoperative Diagnzosis: Postoperative stricture
of common duct; rule out carcinoma of the head of the pancreas.
Exploratory celiotomy, April 6, 1943, disclosed a stricture of the common duct where
it passed behind the first portion of the duodenum. A longitudinal incision was made
through the wall of the common duct at the stricture and closed transversely over a
T-tube to enlarge the diameter of the duct. During this procedure the duodenum was
torn by a Deaver retractor. It was immediately repaired with catgut and covered
with a tab of omentum.
* Submitted for publication January 7, 1944.
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During the third postoperative night there occurred a profuse, greenish, bile-stained
and foul-smelling mucus discharge from the wound. The discharge continued to increase
in amount and Wangensteen suction with a Levine tube was started in an attempt to
advance the tube through the duodenum and beyond the perforation. This procedure was
unsuccessful and was discontinued. The discharge macerated the skin, digested the
wound, and seriously dehydrated the patient. A suction unit, of my construction, for
draining sinuses was placed in the wound and all the drainage was collected before
it 'reached the skin surface (Fig. i). An attempt was made to refeed the secretions

Pi "11;"
Pill-
.\

FIG. i.-Photograph of the patient with the drainage unit inserted into the
healing duodenal fistula. The jejunostomy tube is closed with a clothespin, and
lies to the patient's left.
Insert.-A pyrex glass model of the drainage unit, with a piece of string
entering the 'U'-arm and leaving the tube, the course of aspirated fluids. A
removable rubber cap at the opposite end enables one to clean the tube easily.
or administer them in the form of retention enemata. The patient, however was entering
a state of alkalosis which would SOOii become irreversible. On April I5, I943, under
local anesthesia, Witzel j ej unostomy was established, and for the next 40 days he
received the collected drainage from the fistula through this tube. On the 5oth post-
operative day the duodenal fistula had closed spontaneously and the j ej unostomy tube
was removed. On the 65th postoperative day he was discharged, completely healed.
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May, 1944

A follow-up examination six months later found the patient looking very well,
having gained 40 lbs. in weight and presenting no complaints, except a medium-sized
incisional hernia for which he wears a support. There has been no jaundice, clay-
colored stools or epigastric pain.
COMMENT.-The etiology of this type of lateral duodenal fistula is usually
the unrecognized trauma at operation, resulting in the devitalization of the
tissue followed by spontaneous perforation. Damage in our case was caused
by a Deaver retractor, and the immediate repair of the rent subsequently
broke down. The onset of this complication is acute and is often heralded
by a state of shock, in which the patient becomes pale, cold, clammy, appre-
hensive and covered with beads of perspiration. The drainage from the
duodenum is acrid, foul-smelling, greenish to black seromucus containing
food particles and having an acid reaction.
The drainage attacks and digests the skin, resulting in a red, painful rash
and ultimately extensive ulceration. The skin can be protected by an adhesive
ointment made as follows:
P# Aluminum powder ............... ounces 3
Zinc oxide ............... ounces 6
Petrolatum ...... Qs., ad .ounces 8

This was applied widely about the wound twice a day, and added to the
comfort of the patient.
To control the fluid discharge, a metal drainage unit, a modification4 of
the McCollum tube, was inserted into the wound to collect the secretions.
This unit is so constructed that continuous suction draws the secretions
through the perforation on the inner angle of the U-arm and keeps the
discharge from welling-up on the skin surface. The hole is protected by
the arms of the U and does not become plugged with tissue from the wound
edges. The total collected drainage at first amounted to 3000 cc., or more,
a day, and consisted of fluids taken by mouth, gastric secretions, bile and
regurgitated pancreatic juice.
The jejunostomy tube permitted the free injection of the fistulous drain-
age directly into the intestinal tract, where it could be best utilized by the
body. Also, supplementary tube feedings of a 3000-calorie fluid diet containing
8o units of protein and adequate vitamins was administered three times a day
in amounts of 6 to 8 ounces, or more, depending upon the comfort of the
patient. This diet contained approximately 40 calories per ounce, and the
formula was as follows:
Milk ............. : 1000 cc.
40 per cent cream ............. 400 Gm.
Eggs ............. 6
Orange juice ............. 300 Gm.
Lemon juice ............. 200 Gm.
Sugar ............. 100 Gm.
Brewers yeast ............. 5 Gm.
A progressive high protein diet was given the patient by mouth, beginning
with a soft diet and gradually adding solid food until a full diet was reached.
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The plan was to increase the viscosity of the gastric contents by utilizing
the capacity of proteins to absorb water and to fix the hydrochloric acid. The
more viscid the duodenal contents, the less apt they were to escape through
the perforation. Secondarily, food by mouth increased the confidence and
feeling of well-being of the patient.
The blood chemistry, including the nitrogen level, carbon dioxide com-
bining power, chlorides and protein values, was carefully followed, and all
parenteral therapy was given to maintain these values as close to normal as
possible. The total parenteral supportive medication administered was 3000
cc. of 5 per cent glucose in saline, 4000 cc. of normal saline by clysis, 74,000
cc. of Hartmann's solution, I500 cc. of red blood cells suspended in saline, and
4000 cc. of Amigen. Amigen was used experimentally because of its protein
content but was discontinued due to the untoward side-effects of anorexia,
nausea, vomiting, malaise and severe generalized headaches. During the
most critical phase of the disease five units of regular insulin were admin-
istered three times a day before meals to aid carbohydrate metabolism and
support the liver.
SUMMARY
(i) We have presented a case of postoperative duodenal fistula of the
lateral type which drained 3000 cc., or more, a day, and recovered.
(2) A simple and efficient apparatus is described which will drain wounds
and sinuses and collect the secretions in a vacuum bottle.
(3) A jejunostomy is life-saving in that it makes possible the reinjection
of all the upper intestinal drainage, as well as allowing feeding directly into
the intestine below the site of perforation.
REFERENCES
Bartlett, M. K., and Lowell, W. H.: Acute Postoperative Duodenal Fistula. New
England J. Med., 218, 587. April, 1938.
2 McEvers, A. E.: Conservative Treatment of Acute Duodenal Fistula. Surg., Gynec.
& Obst., 58, 786, I934.
3 Warshaw, D.: Modern Treatment of Duodenal Fistula. Am. J. Surg., 27, 139, 1935.
4 Thorstad, M. J.: An Apparatus To Drain Wounds and Sinuses. Harper Hospital
Bulletin, April, 1942.

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