Management of Lateral Duodenal Fistulas: a Study of Fourteen Cases

Fourteen patients with lateral duodenal fistulas were treated over an 8-year period. Fistulas occurred after abdominal trauma (7) or as complications of operations for peptic ulcer (4) and biliary tract disease (3). Six patients with posttraumatic fistulas had had a delay of longer than 24 hours in recognition of the initial duodenal injury. Immediate correction of fluid and electrolyte imbalances, aggressive control of infection with surgical drainage and antibiotics, localization of the fistulous discharge, and early total parenteral nutrition were paramount in treatment. Ten patients had fistulas that persisted despite these measures; they required definitive operation. Surgical treatment consisted largely of diversion and decompression of the involved duodenum (8 patients); duodenorrhaphy reinforced with a jejunal serosal patch and resection of the involved bowel was done once each. Definitive operations performed in the presence of uncontrolled infection and with inadequate duodenal decompression were followed by fistula recurrence (3 patients). There was one fistula-related death (a 7% mortality rate). These results suggest that (1) lateral duodenal fistulas have a low rate of spontaneous closure; (2) when maximal nonoperative management fails, operative diversion and decompression of the duodenum can simplify management and reduce the mortality rate; and (3) definitive therapy is best reserved for situations in which infection is controlled.