Duodenal fistula: With special reference to choledochoduodenal fistula complicating duodenal ulcer

Abstract

The subject of duodenal fistula has been reviewed. During a fifteen-year period at Charity Hospital and Touro Infirmary, New Orleans, Louisiana, forty-three duodenal fistulas were recorded with a 37.2 per cent mortality. Four deaths occurred in twenty-one internal fistulas and twelve deaths in twenty-two external fistulas. There was a 66.6 per cent mortality in the end type of external fistula. The average onset of the end type of fistula was eight days after surgery. This type occurred more frequently in men. There was a 40 per cent mortality in the lateral type of external fistula. The average onset of the lateral type was five days after surgery. No sex preponderance was noted in this type. Interruption of intestinal continuity produced by external duodenal fistula leads to loss of contents and destruction of the abdominal wall. Adequate replacement of fluids and electrolytes and constant removal of drainage from the fistula by suction are important considerations in the care of these patients. Internal duodenal fistulas often communicate with the gallbladder. Rarer is the choledochoduodenal fistula which usually arises from duodenal ulcer which perforates onto the common duct. Most duodenocolic fistulas are due to carcinoma. Slightly less frequent in causation is duodenal ulcer. The demonstration of duodenocolic fistula is best accomplished by barium enema. The treatment of malignant duodenocolic fistula is radical resection in one or two stages, and duodenocolic fistula due to benign ulcer, subtotal gastrectomy and closure of colonic opening. Regurgitation of duodenal contents into the common duct is ordinarily prevented by the oblique course of the common duct through the pancreas and duodenal wall, the valve-like folds in the ampulla of Vater and the sphincter of Oddi. The presence of air in the biliary tract is of great value in diagnosis of patients who are seen for the first time during the phase of intestinal obstruction since gallstone ileus usually has its beginning with a duodenobiliary communication. The possibility of developing an abnormal communication between the biliary tract and duodenum due to biliary tract disease is a strong argument for removal of the gallbladder in all cases of cholelithiasis. Once the fistula is present, it must be attacked, the opening in the bowel closed, gallbladder removed and the common duct explored. Five case reports of choledochoduodenal fistula complicating duodenal ulcer are presented. There is a twofold problem in the management of this condition: to rid the patient of his fistula and to cure him of his ulcer. The preferred method of handling the fistula would appear to be reimplantation of the common duct into the duodenum or jejunum, and subtotal gastrectomy combined with vagotomy.