External duodenal fistula following closure of duodenal perforation.
OBJECTIVE
Retrospective analysis of experience with management of external duodenal fistula (EDF) without using total parenteral nutrition (TPN).


METHODS
Medical records of 31 patients with EDF following closure of duodenal ulcer perforation, treated over a 7-year period (1994-2001), were studied. Twenty-one patients (68%) had evidence of sepsis at presentation or during the course of treatment. None could afford TPN for optimum time. All patients received hospital-based enteral nutrition through nasojejunal tube, besides supportive medical treatment and/or surgery. Peritonitis or failure to insert nasojejunal tube for enteric alimentation led to early surgery.


RESULTS
Two patients died of septicemia and multi-organ failure within 48 hours of admission. Fourteen patients (48.3%) initially received conservative treatment (Group I); six of them later required surgery. Fifteen patients (51.7%) underwent early surgery due to peritonitis (n=9) or failure to establish enteral feeding (n=6) (Group II); wound infection, intra-abdominal abscess and septicemia were more common in these patients than those in Group I. Survival rate was higher in Group I than in Group II (86% versus 40%; p< 0.05). Septicemia and gastrectomy were the independent factors associated with high mortality.


CONCLUSIONS
EDF can be satisfactorily managed without TPN. Successful placement of enteral feeding line, supportive treatment and delayed surgery can achieve survival in 85% of patients. Minimum intervention is recommended when early surgery is performed in peritonitis or to establish enteral feeding line.
Verma
G R
GR
Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh. grverma2004@yahoo.co.uk
Kaman
Lileshwar
L
Singh
Gurpreet
G
Singh
Rajinder
R
Behera
Arunanshu
A
Bose
Shashank Mohan
SM
D000328:Adult; D000368:Aged; D004381:Duodenal Ulcer / Q000601:surgery*; D005260:Female; D006801:Humans; D007412:Intestinal Fistula / Q000209:etiology*; D007416:Intestinal Perforation / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome