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Discussion |
G.E. A. KHAIRY*, A. AL-SAIGH*, N.S.
TRINCANO*, S. AL-SMAYER# and S. AL-DAMEGH#
*Department of Surgery, King Saud University, King Khalid University Hospital and #Radiology Department, King Khalid
University Hospital
High output external duodenal fistula is a difficult condition to treat and despite the advances in nutritional care, morbidity and mortality remain high. Although, non surgical methods (e.g. endoscopy, fistuloscopy and percutaneous injection of substances) have been reported sporadically in the treatment of enterocutaneous fistulae, gelfoam has not been tried. We present a case of duodenal fistula following blunt abdominal trauma which persisted for 14 weeks on conservative management. Percutaneous obliteration of the duodenal fistula was successfully performed using gelfoam injection through a catheter. This procedure is simple, safe and cheap and further experience may demonstrate that it is an easy and more practical tool in dealing with this problem.
Keywords: duodenal fistulae,gelfoam, percutaneous injection
J.R.Coll.Surg.Edinb., 45,October 2000, 342-344
The relatively low frequency of duodenal trauma (and hence traumatic duodenal fistulae), compared with injuries of other abdominal organs, renders this entity difficult to study.1
Enterocutaneous fistulae arising from the stomach and duodenum are associated with significantly greater morbidity and mortality as the surrounding tissues are exposed to large volumes of enzyme rich secretions.2 The reported mortality rates in these patients are 32-33%.3,4 To the best of our knowledge, percutaneous closure of a duodenal fistula using gelfoam has not been reported in the literature. However, alternative studies, employing endoscopy, fistuloscopy, percutaneous obliteration using other materials, have been reported as non-surgical methods of treating duodenal fistulae.
A 21-year-old male, involved in a road traffic accident, sustained blunt abdominal trauma. Two weeks later, the patient developed abdominal pain and fever, ultrasound of the abdomen showed a huge collection in the upper abdomen. Computerised tomographic (CT) scan of the abdomen showed a huge cystic mass occupying the epigastric and right upper quadrant of the abdomen (Figure 1).
Figure 1: CT abdomen axial cut at the L1 vertebra level showing a huge cystic lesion with its mass effect on liver and kidney
Ultrasound guided percutaneous drainage was done and the catheter was left in situ. Aspirated fluid showed a high amylase (73,840u/l) level and E. coli organisms on culture. Although the patient's symptoms disappeared, and follow up CT of the abdomen showed substantial reduction of the cavity, the catheter continued to drain 1000cc a day. A cavitogram showed communication with the duodenum (Figure 2). Endoscopic retrograde cholangiopancreatography (ERCP), was normal. The patient was treated as a case of duodenal fistula for 14 weeks but the fistula persisted, although the output was reduced. A cavitogram was performed via the drain and gelfoam mixed with contrast was injected to plug the communication between the cavity and the duodenum. The gelfoam (10 x 20 x 7mm pieces) was dissolved in 5mls of contrast (omnipaque 300) and divided into approximately 3 x 3mm pieces. The total quantity injected was about 5 mls of the mixture through a 12F catheter.
Figure 2: Cavitogram through the drain tube showing communication of the cavity with the duodenum
On the first day following gelfoam injection, there was no drainage and an oral gastrografin study showed complete closure of the fistula. A cavitogram performed on the seventh day post gel foam injection showed complete collapse of the cavity and no connection to the duodenum (see Figure 3). The patient was started on a normal diet the same day, the drain was removed the next day and the patient was discharged 2 days later. The patient was seen 3 months later in the clinic with no complaints.
Figure 3: Cavitogram on the seventh day post-gelfoam injection showing no contrast medium in the cavity or duodenum
A high output external duodenal fistula is a difficult condition to treat.2 Despite advances in metabolic and nutritional care, morbidity and mortality from both prolonged parenteral nutrition and surgical intervention in the treatment of external duodenal fistulae are high.2,3,4 To avoid this, some alternative methods have been tried. Percutaneous management of entero-cutaneous fistulas has been advocated as an alternative to surgery.5-8 Marco, et al (1987) published a case of obliteration of an oesophagobronchial fistula by injecting cyanoacrylate endoscopically.9 Percutaneous obliteration of a chronic duodenal fistula, using the same substance failed because the acrylate adhered to the catheter, and was extracted on removal of the catheter.10 Prolamine, an amino acid polymer, failed to close the fistula on the first attempt and was claimed to be successful on the same patient, on subsequent injection.10 A new way of treating post-operative fistulae without surgery was described in patients who underwent elective intubation of fistulae using transparietal abdominal endoscopy.11 This procedure was claimed to permit fast closure of the fistula. Endoscopic trials of closing duodeno-cutaneous fistulae have been reported using fibrin tissue sealant (TISSUCOL).12-14 However, in cases where the intestinal opening of the fistula was not accessible, such treatment was impracticable.15
Fistuoloscopy as an adjuvant technique for sealing gastrointestinal fistulae has been described.15 Complications in this series were caused by fibrin glue injection into the fistulae under pressure and one patient died of an air embolism. The procedure was very tedious as elevation of the air pressure in the fistula system should be strictly avoided.
A preliminary evaluation has been published by Brady and his colleagues16 who used Tisseel, a fibrin sealant, to close fistulae, sinuses and interventional catheter tracts in 24 patients. Tisseel is a two component fibrin sealant. The first component comprises a human protein concentrate and a bovine protein and the second component consists of a solution of human thrombin in calcium chloride. The substance is not approved for use in the United States and the technique is difficult as the two components of Tisseel should be introduced separately via a double-lumen catheter to form a fibrin gel at the point of contact. In our case, in view of the complexity which the surgical treatment of this persistent fistula would present, we used percutaneous gelfoam injection with excellent results. Gelfoam is a gelatin sponge, and widely used as embolic material; it has not been used in treatment of enterocutaneous fistulae. It is easy to use, readily available, is not expensive and has no toxicity.17 In conclusion, percutaneous obliteration of a chronic duodenal fistula using gelfoam is simple, safe and cheap. Further experience with this technique and substance may demonstrate that morbidity and complex surgical interventions are avoidable in the treatment of chronic entero-cutaneous fistulae.
ACKNOWLEDGMENT
The authors would like to thank Ms Mary Arlene Dasco for her expert secretarial assistance in typing this manuscript.
Copyright date: 26 December 1999
Correspondence: Dr. Gamal Eldin A. Khairy, Department of Surgery, King Khalid University Hospital, P.O. Box 7805, Riyadh 11472, Saudi Arabia
©2000 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.