Duodenal Fistula Research Articles

Endoscopic purse-string suture and naso-jejunal tube feeding for duodenal cutaneous fistula and gastric cutaneous fistula.

The Endoscopic Purse-string Suture (EPSS) technique has gained attention for its potential in closing large defects following gastrointestinal procedures. However, its application in fistula closure is not as widely reported. This study aims to evaluate the safety and efficacy of EPSS and naso-jejunal tube feeding in the closure of duodenal cutaneous fistulas and gastric cutaneous fistulas. This single-center retrospective study, conducted from September 2020 to September 2023 at Tongji University in Shanghai, China, examined the outcomes of EPPS and nasojejunal feeding for patients with gastric and duodenal cutaneous fistulas (n = 10). Demographic data, fistula characteristics, procedure technique and outcomes were evaluated. In this study, the average size of a fistula opening was 7.9 ± 4.6mm. The operations took an average of 25.8 ± 5.6min. Patients typically needed naso-jejunal tube feeding for a median of 14.0days, with an interquartile range (IQR) of 7.7-19.0days. The median duration of hospital stay post-operation was 16.5days, with an IQR of 7.0-25.0days. Nine patients were successful in their initial fistula closure using the EPSS technique. The other patient underwent a second EPSS and, ultimately, all patients experienced complete healing and fully recovered. There were no major adverse events reported. EPSS and naso-jejunal tube feeding are a safe and effective treatment option for duodenal and gastric cutaneous fistulas. Larger, prospective studies are needed to validate these findings and establish the long-term safety and efficacy of this approach.

A Path Less Traveled: Xanthogranulomatous Pyelonephritis Presenting with Thoracic Empyema and Complicated By Rare Pyeloduodenal Fistula

Xanthogranulomatous pyelonephritis (XGP) is a rare and diffusely destructive variant of pyelonephritis. Diagnosis is made using the characteristic radiological findings of renal enlargement with pelvicalyceal dilatation (the ‘bear paw’ sign) with histological analysis demonstrating replacement of renal parenchyma with foamy lipid-laden histiocytes. Treatment of XGP invariably requires nephrectomy. Two particularly rare complications of XGP are thoracic empyema and pyeloduodenal fistula; this case, to our knowledge, is the first such instance of XGP complicated by both. The patient underwent chest drain placement for treatment of empyema, and, following the identification of the pyeloduodenal fistula on antegrade pyelography, underwent surgical treatment with partial right-sided colectomy, radical nephrectomy, and primary duodenal fistula closure. XGP was subsequently identified on pathological analysis of the removed kidney.

Double Half Purse-String Sutures Plus "8" Pattern of Stitching for Prevention of Duodenal Stump Fistula after Laparoscopic Gastrectomy.

Background: Duodenal stump fistula represents an infrequent but serious complication after laparoscopic radical gastrectomy with Billroth II or Roux-en-Y reconstruction for gastric cancer. The present study was designed to evaluate the effectiveness of laparoscopic double half purse-string sutures plus "8" pattern of stitching for reinforcement of duodenal stump. Methods: The data of patients undergoing laparoscopic radical gastrectomy with Billroth II or Roux-en-Y reconstruction were retrospectively analyzed between August 2022 and June 2023. According to the different reinforcement methods of duodenal stump, included patients were subdivided into three groups as follows: Group A, duodenal stump was treated with double half purse-string sutures plus "8" pattern of stitching; Group B, duodenal stump was reinforced by continuous suture using a barbed suture; and Group C, duodenal stump without any additional processing. The incidences of duodenal stump fistula between three groups were documented and compared. Moreover, the independent risk factors associated with duodenal stump fistula were analyzed using the logistic regression analysis. Results: No postoperative duodenal stump fistula occurred in Group A, which was significantly different from Group B and Group C (P = .007). In the multivariate analysis, age (odds ratio [OR], 1.191; 95% confidence interval [CI], 1.088-1.303), body mass index (OR, 0.824; 95% CI, 0.727-0.935), and American Society of Anesthesiologists score (OR, 4.495; 95% CI, 1.264-15.992) were the risk factors for duodenal stump fistula. Conclusion: Double half purse-string sutures plus "8" pattern of suture can be conducted in a relatively short operation period and could prevent the incidence of duodenal stump fistula to some extent.

Transduodenal robotic ampullectomy: tips and tricks and strategies for postoperative duodenal fistula management (with video).

Transduodenal Ampullectomy (TA) is a procedure for resecting low-malignancy ampullary tumors, with postoperative fistula as a notable complication. This study aims to clarify the indications for TA, outline the surgical robotic technique, and emphasize the importance of comprehensive complication management alongside the surgical approach. This multimedia article provides a detailed exposition of the robotic TA surgical technique, including the most important steps involved in exposing and reimplanting biliary and pancreatic ducts. The procedure encompasses the mobilization of the hepatic flexure of the colon, an extensive Kocher maneuver for duodenal mobilization, and ampulla exposure through a duodenal incision. Employing retraction loop sutures enhances surgical field visibility. Reconstruction involves securing pancreatic and biliary ducts to the duodenal mucosa, each tutored with a silicon catheter, and suturing for ampullectomy completion. The total operative time was 380min. Final histopathology disclosed high-grade dysplasia with an isolated focus of adenocarcinoma (pT1), accompanied by clear resection margins. A postoperative duodenal fistula occurred, managed successfully through conservative treatment, utilizing subcutaneous drainage. Despite accurate robotic TA execution, complications may arise. This study underscores the importance of a comprehensive approach, incorporating meticulous surgical technique and effective complication management, to optimize patient outcomes.

Double secondary aorto-enteric fistula: a case report

Introduction: Endoprothesis infections (EIs) are rare postoperative complications of endovascular procedures, with incidence ranging from 0.2% to 0.7%. Secondary aorto- enteric fistulas presents a mortality rate of approximately 60%, featuring more prevalence the association with the duodenum (70%) and displays a rare association when endovascular procedures are performed. Case report: This study reports the case of a 72-year-old male patient who developed a duodenal aorto-enteric fistula associated with a fistula in the sigmoid colon and left common iliac artery after undergoing by stent implantation for aortic aneurysm repair. Successful treatment and surgical correction was performed. Conclusion: Aorto-enteric fistulas after endovascular approach correspond to a rare complication with high mortality, being extremely important the early diagnosis and effective therapeutic approach.

Endoscopic repair of duodenal fistula occurring as a rare complication of abdominal drainage following partial hepatectomy.

Endoscopic repair of duodenal fistula occurring as a rare complication of abdominal drainage following partial hepatectomy.

Laparoscopic necrosectomy for acute necrotizing pancreatitis: mesocolon-preserving approach and outcomes.

The surgical treatment of acute necrotizing pancreatitis has significantly evolved in recent years with the advent of enhanced imaging techniques and minimally invasive surgery. Various minimally invasive techniques, such as video-assisted retroperitoneal debridement (VARD) and endoscopic transmural necrosectomy (ETN), have been employed in the management of acute necrotizing pancreatitis and are often part of step-up approaches. However, almost all reported step-up approaches only employ a fixed minimally invasive technique prior to open surgery. In contrast, we implemented different minimally invasive techniques during the treatment of acute pancreatitis based on the extent of pancreatic necrosis. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, we performed mesocolon-preserving laparoscopic necrosectomy for debridment. The quantitative indication for pancreatic debridment in our institute has been described previously. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, mesocolon-preserving laparoscopic necrosectomy was performed for debridment. To safeguard the mesocolon, the pancreatic bed was entered via the gastrocolic ligament, and the left retroperitoneum was accessed via the lateral peritoneal attachments of the descending colon. Of the 77 patients requiring pancreatic debridment, 41 patients were deemed suitable for mesocolon-preserving laparoscopic necrosectomy by multiple disciplinary team and informed consent was acquired. Of these 41 patients, 27 underwent percutaneous drainage, 10 underwent transluminal drainage, and 2 underwent transluminal necrosectomy prior to laparoscopic necrosectomy. Two patients (4.88%) died of sepsis, three patients (7.32%) required further laparotomic necrosectomy, and five patients (12.20%) required additional percutaneous drainage for residual infection. Three patients (7.32%) experienced duodenal fistula, all of which were cured through non-surgical treatments. Nineteen patients (46.34%) developed pancreatic fistula that persisted for over 3weeks, with 17 being successfully treated non-surgically. The remaining two patients had pancreatic fistulas that lasted over 3months; an internal drainage procedure has been planned for them. No patient developed colonic fistula. Mesocolon-preserving laparoscopic necrosectomy proved to be safe and effective in selected patients. It can serve as a supplementary procedure for step-up approaches or as an alternative to other debridment procedures such as VARD, ETN, and laparotomic necrosectomy.

Cystic Duct Remnant–Duodenal Fistula following Laparoscopic Cholecystectomy: A Case Report and Literature Review

Laparoscopic cholecystectomy is the most common procedure performed for the management of symptomatic gallstone disease. This, however, can be complicated by the formation of fistulous communications between the biliary tree and the gastrointestinal tract. This abnormal communication allows for the flow of bile and bowel contents between two systems (biliary system and intestine), which can cause abdominal pain, nausea, vomiting, and biliary sepsis. We would like to present a rare case of fistulous communication between the cystic duct stump and duodenum and outline possible contributing factors. The literature review describes the most common interventions for the management of fistulas with emphasis on ERCP and stent preferences to eliminate transpapillary pressure gradient, which directly contributes to fistula closure.

Multifaceted surgical approach of combined thoracoretroperitoneal incision and midline abdominal incision for a secondary aortoenteric fistula

BackgroundWe report a one-stage surgery to the case of secondary aortoenteric fistula (sAEF) after prosthetic reconstruction of abdominal aortic aneurysm, by multifaceted approach.Case presentationA 63-year-old male was admitted to our unit under diagnosed of sAEF after prosthetic reconstruction of abdominal aortic aneurysm, and a pseudoaneurysm of thoracoabdominal aorta due to infection. The patient underwent emergency operation. Firstly, we placed the patient in a modified right lateral decubitus position and performed thoracoabdominal aortic replacement with retroperitoneal approach by thoracoretroperitoneal incision which combined thoracotomy and pararectal incision, and secondly, we changed to a supine position and performed closure of the duodenal fistula and omental flap transposition by midline abdominal incision. The patient was doing well without complications.ConclusionsA one-stage, multifaceted surgical approach covering both prosthetic reconstruction of thoracoabdominal aorta and closure of sAEF with omentopexy is reasonable and useful strategy.

Management of acute necrotizing pancreatitis with duodenal fistula

Severe acute pancreatitis (SAP) is often accompanied by severe infected pancreatic necrosis. Gastrointestinal fistula is a common complication during the infectious period of SAP, with the incidence of duodenal fistula coming in second place after colon fistula and a high mortality rate. Percutaneous catheter drainage (PCD) is the most commonly used surgical technique for necrotizing infection in SAP. However, the traditional PCD method cannot achieve adequate source control in SAP necrotizing infection patients with gastrointestinal fistulas. This report describes a case of SAP necrotizing infection complicated with a duodenal fistula treated with trocar-assisted percutaneous abscess drainage combined with manual irrigation. After treatment with double-lumen catheter irrigation and drainage combined with manual irrigation and other standards of care for SAP, the patient’s infection symptoms were gradually relieved. A review of abdominal computed tomography and gastrointestinal radiography showed that the intra-abdominal infection was gradually relieved, and the duodenal fistula was completely healed.

Left psoas abscess due to duodenal fistula as a late complication of necrotizing pancreatitis treated by endoscopic approach.

Gastrointestinal fistulas can be a complication of severe acute pancreatitis, and their incidence is low and sporadically reported in the literature. The most frequently reported site is in the colon, followed by duodenal fistulas. Psoas abscess is a rare condition. Iliopsoas abscesses are classified as primary or secondary. Secondary abscesses develop by spreading infection from contiguous anatomical structures, such as the gastrointestinal tract. We present the case of a recurrent left psoas abscess secondary to a duodenal fistula as a late complication of necrotizing pancreatitis resolved by endoscopic treatment.

Complex duodenal fistula after cholecystectomy successfully treated with endoscopic suturing.

We reported a 47-year-old female with a history of laparoscopic cholecystectomy presented with a complex duodenal fistula. The bleeding artery embolization and endoscopic suture of the duodenal fistula were performed successfully. We highlight the endoscopic tissue clip suture as a safe and feasible option when surgery is too risky.

Cholecysto - Duodenal Fistula with GI Obstruction and Perforation: A Rare Case Report

Cholecysto - Duodenal Fistula with GI Obstruction and Perforation: A Rare Case Report

Pancreatic Colloid Carcinoma Presenting as a Duodenal Fistula.

Pancreatic Colloid Carcinoma Presenting as a Duodenal Fistula.

EGS P27 Twice Recurrent Gallstone Ileus Requiring 3 Laparotomies – A Case Report

Abstract Background Gallstone ileus is a well-known and not an uncommon complication of gall stone disease, with standard management being an enterotomy and extraction of the obstructing gallstone with management of the gallbladder and the billio-enteric fistula being deferred to an interval procedure if indicated. Recurrent gallstone ileus are not unheard of, but are quite rare and are the reason cited by the proponents of a single stage procedure. While a single stage procedure is possible - involving an enterotomy as well as a challenging cholecystectomy and the management and closure of a duodenal fistula – more commonly than not it is not performed. Methods Twice recurrent gallstone ileus is extremely rare and on performing a literature review only 1 published case report has been identified. Here we present the case of an 87-year-old Caucasian female, presenting with 3 incidences of gall stone ileus in a 30 day period requiring 3 laparotomies. Initial presentation to our institution was in November 2022 with a CT proven localised Gallbladder perforation. The first presentation with gallstone ileus was on 21/03/2023 with symptoms of bowel obstruction and CT proven obstructing 23mm gallstone 8 cm from the ileocaecal valve as well as pneumobillia and two other stones in the gallbladder. Results The index laparotomy was performed and no transition point was found, and bowel run-through from DJ to ICV revealed no intraluminal gall stones and the caecum was full of fluid. The gallstone had passed into the colon spontaneously and no enterotomy was performed. Two subsequent laparotomies were required due to CT proven incidence of recurrent Gallstone ileus on 30/03/2023 and 20/4/2023, were enterotomies were performed and the obstructing stones extracted each time. An informed decision not to tackle the gallbladder and the duodenal fistula was taken by a consensus of 3 consultant surgeons due to the frailty of our patient. Conclusions Our patient made a meaningful recovery after developing an entero-cutaneous fistula that resolved with conservative management and was discharged home on 15/05/2023. While our patient's frailty and previous gallbladder perforation made the decision not proceed with a cholecystectomy and repair of the duodenal fistula a straightforward one, the incidence of twice recurrent gallstone ileus in the span of a month raises questions as to whether other techniques should be considered in a more fit patient such as a single stage operation or a Cholecystolithotomy.

Gastrointestinal Fistulas in Necrotizing Pancreatitis Receiving a Step-Up Approach Incidence, Risk Factors, Outcomes and Treatment.

Necrotizing pancreatitis (NP) complicated by gastrointestinal fistula is challenging and understudied. As the treatment of necrotizing pancreatitis changed to a step-up strategy, we attempted to evaluate the incidence, risk factors, clinical outcomes and treatment of gastrointestinal fistulas in patients receiving a step-up approach. Clinical data from 1274 patients with NP from 2014-2022 were retrospectively analyzed. Multivariable logistic regression analysis was conducted to identify risk factors and propensity score matching (PSM) to explore clinical outcomes in patients with gastrointestinal fistulas. Gastrointestinal fistulas occurred in 8.01% (102/1274) of patients. Of these, 10 were gastric fistulas, 52 were duodenal fistulas, 14 were jejunal or ileal fistulas and 41 were colonic fistulas. Low albumin on admission (OR, 0.936), higher CTSI (OR, 1.143) and invasive intervention prior to diagnosis of gastrointestinal fistula (OR, 5.84) were independent risk factors for the occurrence of gastrointestinal fistula, and early enteral nutrition (OR, 0.191) was a protective factor. Patients who developed a gastrointestinal fistula were in a worse condition on admission and had a poorer clinical outcome (p<0.05). After PSM, both groups of patients had similar baseline information and clinical characteristics at admission. The development of gastrointestinal fistulas resulted in new-onset persistent organ failure, increased open surgery, prolonged parenteral nutrition and hospitalization, but not increased mortality. The majority of patients received only conservative treatment and minimally invasive interventions, with 7 patients (11.3%) receiving surgery for upper gastrointestinal fistulas and 11 patients (26.9%) for colonic fistulas. Gastrointestinal fistulas occurred in 8.01% of NP patients. Independent risk factors were low albumin, high CTSI and early intervention, while early enteral nutrition was a protective factor. After PSM, gastrointestinal fistulas resulted in an increased proportion of NP patients receiving open surgery and prolonged hospitalization. The majority of patients with gastrointestinal fistulas treated with step-up therapy could avoid surgery.

Duodenal-ileal ratio of digestive enzymes when using different protein supplements in the diet of laying hens

Creation of domestic poultry crosses and development of optimal diets for them is an urgent problem, since in vivo studies using fistula technologies are currently few. The present work presents data on determination of duodenal and ileal activity of digestive enzymes when protein additives of vegetable (soybean meal and cake) and animal origin (fish meal and meat and bone meal) are used in the diet of laying hens. Experiments were performed on laying hens (Gallus gallus L.) of Hisex White cross (n=24, K.A. Timiryazev Russian State Agricultural Academy, 2022,2023) with chronic duodenal and ileal fistula. All chickens were divided by random sampling method into 4 groups: 1) 1 control group - received OR (Table 1); 2) 2 experimental group - 1.5% soybean cake was added to the diet instead of soybean meal; 3) 3 experimental group - 1.5% meat and bone meal was added to the diet instead of soybean meal; 4) 4 experimental group - 1.0% fish meal was added to the OR instead of soybean meal. It was found that protein additives are differently hydrolyzed in the intestine of birds and assimilated by the organism. Thus, the breakdown of soy protein is more intensive in cake than in meal due to the increase of trypsin activity in duodenum by 43.6%, and when fish meal is added, the activity of the enzyme increases by 11.8% against meat and bone meal and 101.5% against soy meal. At the same time, protein digestion increased, accompanied by an increase in trypsin activity in blood when soybean cake was used and in urine when fish meal was added to the diet of chickens. With feces the least loss of trypsin is observed in the group that received meat and bone meal supplementation (9.6% of trypsin activity is excreted), then fish meal - 16.8% and soy cake - 21.7% of activity in duodenum, which indicates the efficiency of exo- and endogenous protein utilization by poultry organism.

S2163 Pancreatic Tuberculosis with Suspected Duodenal Fistula in an Immunocompromised Patient

S2163 Pancreatic Tuberculosis with Suspected Duodenal Fistula in an Immunocompromised Patient

Trocar puncture with modified sump drainage for duodenal stump fistula after radical gastrectomy for gastric cancer: A retrospective controlled study

Duodenal stump fistula (DSF) is a serious complication of radical gastrectomy for gastric cancer. Herein, we illustrated an innovative choice for treating duodenal stump fistulas by placing a modified sump drainage through trocar puncture into the DSF-related abscess (DSF-abscess) cavity. We retrospectively analyzed 974 consecutive patients who underwent gastrectomy for gastric cancer between 2011 and 2021. Of these patients, 34 who developed postoperative duodenal stump fistulas postoperatively were enrolled into our study, and their clinical data were retrospectively assessed. From January 2011 to December 2017, 15 patients received conventional treatments (percutaneous catheter drainage, PCD group) known as the traditional percutaneous method, and 19 patients from January 2018 to December 2021 received new treatments (Troca's SD group) consisting of conventional therapies and placement of a modified sump drainage through trocar puncture into DSF-abscess cavity. The demographics, clinical characteristics and treatment outcomes were compared between two groups. Compared with the PCD group, the rates of postoperative complications, duodenostomy creation, subsequent surgery, fistula healing rates of the DSF, and length of postoperative hospital stay were significantly decreased in the Troca SD group. However, there was no significant difference in the abscess recurrence rate and mortality rates. Trocar puncture with a modified sump drainage is an safe, effective, and technically feasible treatment for duodenal stump fistula after radical gastrectomy for gastric cancer. This novel technique should be further investigated using large-scale RCT research.

A case of duodenal perforation and pancreatic bleeding after flexible ureteroscopy for right renal pelvis UTUC

Upper tract urothelial carcinoma (UTUC) can be managed by flexible ureteroscopy (f-URS) and tumor laser ablation if kidney-sparing surgery is possible. This procedure can be affected by minor to serious complications, including life-threatening sepsis, ureteral strictures, and ureteral and renal pelvis injuries. The case of a 53-year-old man with history of high grade right renal pelvis and bladder tumor who undergone multiple endoscopic treatments and has already refused radical surgery is reported. F-URS and laser ablation with Thulium: YAG laser for UTUC recurrence of the right renal pelvis was performed, but the procedure was stopped due to significant bleeding which impaired vision. Postoperatively, the patient developed hematemesis and hemodynamic instability due to duodenal lesion and active bleeding documented at CT scan. An emergency exploratory laparotomy was performed to drain hemoperitoneum, repair duodenal lesion and concurrent radical right nephroureterectomy was carried out. A second surgery was necessary for repairing duodenal fistula. After 1 week the patient presented again with recurrent hematemesis and hemorrhagic shock. He underwent angiography and selective embolization of the duodenal branch of superior mesenteric artery and as well as branches of gastroduodenal artery successfully and the patient recovered with no other complications. This is the first case of duodenal perforation and pancreatic bleeding due to flexible ureteroscopy and laser ablation of right renal pelvis urothelial carcinoma.