Surgical disconnection of high delineated immature debilitating jejunal fistulas using posterolateral access

Abstract

Objective. The aim of the study was to develop the safest technique for surgical disconnection of high, unformed jejunal fistulas, so as to avoid problems with detection the intestine leading to the fistula and to avoid complications of viscerolysis. Material and methods. The authors present their experience in surgical management of 35 patients with high delimited unformed debilitating jejunal fistulas. Of these, 22 patients were included in the comparison group; their fistulas were closed or disconnected with the known methods. Findings obtained from other 172 patients with adhesive intestinal obstruction after infectious complications of laparotomic wounds and topography of visceroparietal planar adhesions of the peritoneum were analyzed. After studying the nature and location of visceroparietal adhesions, the authors could develop a technique for proximal disconnection of high delimited unformed debilitating jejunal fistulas using posterolateral access which was applied in 13 patients from the studied group. Research results. The proposed technique of unilateral disconnection of high unformed jejunal fistulas reduces duration, damage and risk of prolonged bowel deserosing. As a result, a significant decrease in postoperative mortality from 59.1 ± 9.2% to 23.1 ± 11.2% (t=2.5; p<0.05) was registered. Due to the preoperative endoscopic marking showing direction to the fistula of intestinal loop and duodenojejunal junction, intraoperative orientation was more accurate and took much less time than in the comparison group. The posterolateral surgical approach to the fistula in the jejunal loop reduced the risk of its damage, since there was no need for extensive enterolysis anymore. Therefore, postoperative period in patients of the studied group was better and with fewer complications than in the comparison group. Conclusion. The posterolateral access prevented extended viscerolysis and allowed to put a reliable and atraumatic interintestinal anastomosis so as to disconnect the fistula. The unilateral disconnection of the jejunal fistula at postoperative intestinal paresis unloaded the interintestinal anastomosis, similar to Meidl’s definitive jejunostomy. The abovementioned positive aspects of the proposed surgical intervention allowed to significantly decrease postoperative complications and mortality rate, if to compare with outcomes after known surgical interventions with a similar purpose.