World Journal of Emergency Surgery : WJES · 3 authors, 2 centres
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This study of 50 patients with complex duodenal fistulas found that initial surgical repair with duodenal decompression achieved a 76% closure rate, while nonoperative management succeeded in 5 of 12 patients but often required later surgery. Overall mortality was high at 40%, highlighting the severity of these fistulas. The findings support early surgical intervention as the best approach, with nonoperative management reserved for selected stable patients.
**Background:** External duodenal fistulas are rare but devastating complications, often arising after duodenal surgery or endoscopic procedures. The duodenal contents (bile and pancreatic juice) cause severe tissue damage, leading to local and systemic complications. Management is challenging, with no randomized trials to guide therapy. This study aimed to analyze outcomes of different management strategies for complex duodenal fistulas, focusing on successful fistula closure rates.
**Methods:** This retrospective cohort study included adult patients treated for complex duodenal fistulas at a single academic center from April 1, 2004, to March 31, 2021. A complex duodenal leak was defined as a full-thickness intra- or retroperitoneal perforation of a duodenal suture or anastomotic line, or post-endoscopy perforations initially managed nonoperatively with percutaneous drains. Exclusion criteria included gastric or post-duodenal leaks, peptic/traumatic/iatrogenic perforations managed successfully at initial operation, internal duodenal fistulas, and post-endoscopy perforations managed without intervention. Data were collected on patient demographics, comorbidities (Charlson Comorbidity Index), ASA class, sepsis criteria, and management details. Univariate analyses were performed using Fisher's exact test, Chi-square test, Mann-Whitney U test, or Student's t-test as appropriate. Two-tailed p < 0.05 was considered significant.
**Key Results:** Fifty patients were identified (72% male, median age 63.5 years). The most common underlying conditions were peptic ulcer perforation (32%), severe acute pancreatitis (22%), and iatrogenic/traumatic perforation (22%). The median delay from initial intervention to leak diagnosis was 4 days (IQR 2–8.5). Initial management was operative in 38 patients (76%) and nonoperative in 12 (24%). Among operatively managed patients, procedures included suture closure (30 patients), resection with anastomosis (6), rectus muscle patch (1), and decompression only (1). All had periduodenal drains, and 63% had a feeding jejunostomy. Fistula closure was achieved in 29/38 (76%) of initially operated patients. Among 12 initially nonoperatively managed patients, 5 had fistula closure without surgery (1 died with persistent fistula), and 6 eventually required surgery (closure in 4/6). There was no significant difference in closure rates between initial operative vs. nonoperative management (29/38 vs. 9/12, p = 1.000). However, when considering failed nonoperative management (7/12 patients), the operative group had significantly higher closure rates (29/38 vs. 5/12, p = 0.036). Overall fistula closure was achieved in 38/50 patients (76%). Overall in-hospital mortality was 20/50 (40%). Causes of death included multiple organ failure (11 patients), persistent infection (6), respiratory failure (2), and acute myocardial infarction (1). Among survivors, median ICU stay was 12 days (IQR 4–32), and median hospital stay was 12 days (IQR 4–32).
**Clinical Implications:** This study demonstrates that complex duodenal fistulas carry a high mortality (40%) and require aggressive management. Initial surgical repair with duodenal decompression (via nasogastric/nasoduodenal tubes, T-tube, or tube duodenostomy) and periduodenal drainage offers the best chance of fistula closure (76%). Nonoperative management with percutaneous drainage can be attempted in selected stable patients without generalized peritonitis, but many will eventually require surgery. The study also found that primary intervention was more successful when performed by a full-time emergency surgeon (p = 0.027) and in patients with peptic ulcer perforation (p = 0.041). Limitations include the retrospective design, small sample size, and heterogeneous patient population. Despite these limitations, the findings support early surgical intervention with adequate decompression as the preferred approach for complex duodenal fistulas.