INTRODUCTION
Duodenal stump fistula (DSF) occur mainly in patients who undergo Billroth II or Roux-en-Y reconstruction after gastrectomy. It is characterized by the formation of a fistula at the duodenal stump, leading to leakage of digestive juices and a series of clinical complications. Although DSF is a relatively rare complication, with an incidence of only 1.6%-5%, its mortality rate can reach 16%-40%[1-5]. DSF is mainly treated conservatively, yet 40% of patients require surgical treatment[4], including direct fistula repair[3], duodenostomy[4], duodenojejunostomy[6], rectus abdominis flap repair of the fistula[7,8], pancreaticoduodenectomy[9], endoscopic treatment[10,11], and external bile drainage[12]. This article reports a case of DSF complicated by sepsis, which was cured and followed by discharge within a short period after T-tube duodenostomy combined with jejunal feeding tube placement. Based on the literature, this article discusses the diagnosis, risk factors, and treatment of this disease, aiming to further optimize its management.
CASE PRESENTATION
Chief complaints
A 69-year-old Chinese male patient experienced severe abdominal pain and bile-like fluid discharge from the duodenal stump drainage tube three days after the initial surgery.
History of present illness
The patient presented with severe abdominal pain, bile-like fluid draining from the duodenal stump, rapid breathing, and tachycardia. He was emaciated, with a body mass index (BMI) of 16.42 and a body weight of 41 kg.
History of past illness
Three days earlier, the patient had undergone laparoscopic subtotal gastrectomy plus gastrojejunostomy due to vomiting and abdominal distension. Preoperative gastroscopy showed a pyloric ulcer with stenosis and gastric retention. During the operation, edema of the gastric antrum and duodenum was observed. Purse-string reinforcement sutures were placed on the duodenal stump. The operation proceeded smoothly. He had a history of hypertension, common bile duct stones, and a duodenal ulcer. He had previously undergone common bile duct surgery.
Personal and family history
There was no personal or family history of acute or chronic illness.
Physical examination
The patient appeared acutely distressed, with diffuse abdominal tenderness, rebound tenderness, abdominal muscle tension, and decreased bowel sounds.
Laboratory examinations
Laboratory data showed that the white blood cell count, neutrophil percentage, C-reactive protein, albumin, and lactate levels were 1.89 × 109/L (3.5-9.5 × 109/L), 90% (40-75%), 186.21 mg/L (0-3 mg/L), 26 g/L (40-55 g/L), and 5.97 mmol/L (0.63-2.44 mmol/L), respectively.
Imaging examinations
Abdominal ultrasound showed patchy fluid accumulation in the interintestinal spaces, suggestive of sepsis. Due to the acute nature of the condition, no further examinations were performed.
FINAL DIAGNOSIS
The patient presented with severe abdominal pain and bile-like fluid draining from the duodenal stump drainage tube, raising suspicion of a DSF. Due to diffuse peritonitis, the patient was in critical condition and did not undergo a preoperative computed tomography (CT) examination. Emergency laparoscopic surgery was performed immediately, and surgical instruments were inserted through the initial surgical port. During the operation, we found extensive bile-like ascites in the abdominal cavity with a large amount of purulent coating. A fistula with a diameter of approximately 2 mm was visible at the duodenal stump, with significant edema of the surrounding tissues. Based on intraoperative findings, a DSF was confirmed (Figure 1A).
Figure 1 Intraoperative and postoperative displays.
A: Bile can be seen gushing out of the duodenal stump; B: A T-shaped biliary drainage tube is inserted through the fistula and adequately secured; C: Inserting a feeding tube from the jejunum; D: The patient was discharged from the hospital with a tube.
TREATMENT
We performed extensive peritoneal irrigation and inserted a 14-gauge T-shaped biliary drainage tube directly through the fistula (size: 14Fr) (Figure 1B), which was then fixed to the right abdominal wall. Simultaneously, under laparoscopic guidance, we selected a segment of jejunum 10 cm distal to the intestinal anastomosis site and placed a jejunal feeding tube (Figure 1C). The feeding tube was fixed using the Witzel tunnel technique. The feeding tube used was an inexpensive and minimally invasive nasogastric tube (Folka, outer diameter 3.33 mm).
OUTCOME AND FOLLOW-UP
On the first postoperative day, the patient began slow instillation of liquid through the jejunal nutrition tube to achieve early enteral nutrition. The patient was discharged from the hospital with the tubes in place 17 days after the operation (Figure 1D), and the T-tube and jejunal nutrition tube were removed 2 months after discharge. The patient has now been followed up for 12 months without any discomfort, and the BMI is 21.63 (54 kg).
DISCUSSION
Treatment options
Despite improvements in surgical techniques and perioperative management, DSF is still unavoidable. A multicenter retrospective analysis involving 3785 cases by Italian scholars found that the incidence rate of DSF-related complications is 75%, with sepsis being the most common complication[4]. This case was diagnosed with sepsis. Early detection and early treatment often lead to good outcomes. In terms of conservative treatment, appropriate drainage, infection control, and nutritional support are fundamental[13,14]. The average healing time of DSF is 31.2 ± 19.7 days[15], and the probability of fistula closure is between 28% and 92%[16-18]. This approach is fraught with uncertainties and requires long-term fasting, which often disrupts intestinal mucosal barrier function and ultimately wastes medical resources. In the presence of toxemia with or without hemodynamic instability, immediate surgical intervention is required. In most cases, fistula closure can be achieved within a short period.
Diagnostic modalities
Research has shown that DSF usually occurs early, often 2-5 days after surgery, and delayed fistula is also relatively common[19]. In this case, it occurred on the third postoperative day. Patients with DSF usually present with severe abdominal pain as the first symptom. Other manifestations include the discharge of bile-like or turbid fluid from nearby drainage tubes, accompanied by sepsis-related symptoms and signs, and even transient shock[1,20]. Patients with the above symptoms should raise strong suspicion for DSF and undergo blood tests as soon as possible. Laboratory examinations, such as routine blood tests, combined with abdominal CT demonstrating effusion in the right upper quadrant, are used for diagnosis. For patients with external fistula formation, water-soluble contrast agents can be injected through the fistula opening; if contrast is observed entering the duodenum, the diagnosis of DSF can be confirmed. In clinical practice, early diagnosis is challenging. In our case, sudden severe abdominal pain occurred, and bile-like fluid was discharged from the drainage tube. Emergency surgery confirmed the presence of a DSF. Therefore, we believe that sudden severe abdominal pain and abnormal drainage fluid are more reliable signs of DSF.
Risk factors
An in-depth understanding of the risk factors for DSF helps to identify it early and to take effective preventive measures before surgery to reduce its incidence. The patient’s nutritional status is closely related to the occurrence of DSF, including weight loss of more than 10%. In particular, a low preoperative serum albumin level (< 30 g/L) and lymphocyte count appear to be associated with a high incidence of postoperative DSF and are specific risk factors[15]. Multiple studies have reported that preoperative comorbidities can also influence the occurrence of this complication. Conditions such as liver cirrhosis and heart disease have been confirmed as important risk factors for the development of DSF[15,21]. However, in a retrospective analysis of more than 1110 cases, age could not be considered an independent risk factor[22].
Although there was early controversy about whether stump reinforcement can prevent the occurrence of DSF, Sano et al[23] conducted a multicenter study involving 475 patients in 57 centers and used logistic regression and other analytical methods to confirm that reinforced suturing can significantly reduce the incidence of DSF (0.70% vs 1.65%, P = 0.047). Shao et al[24], in a retrospective study involving more than 2000 cases, found that the purse-string suture showed greater advantages. At the same time, duodenal wall edema also affects stump healing. This patient had long-term malnutrition and pyloric obstruction before surgery, which likely led to duodenal wall edema and may have contributed to the development of the postoperative DSF.
Role of T-tube duodenostomy
In almost all cases requiring surgical intervention, toxemia and/or hemodynamic instability are present, with current data indicating a success rate of 71.5%[3,4,25,26]. Surgical procedures vary and depend on the surgeon’s judgment. However, significant intraoperative intestinal edema disrupts normal anatomical layers, increasing the risk of bleeding and collateral damage. Direct repair of the fistula carries a high risk of postoperative recurrence, which may lead to more severe complications. Therefore, laparoscopic T-tube duodenostomy is a relatively favorable surgical procedure for damage control and for reducing intraduodenal pressure[27]. Zizzo et al[28] reported on 157 patients who underwent surgery for DSF; 36.9% of these patients underwent duodenostomy. Nutritional support is fundamental to the treatment of DSF. Compared with parenteral nutrition, enteral nutrition can also protect the intestinal mucosal barrier and prevent bacterial translocation. Furthermore, DSF is a high-level, high-output intestinal fistula[27], with approximately 300-1000 mL of intestinal fluid lost per day. Performing duodenostomy alone may lead to substantial loss of digestive secretions. Simultaneously, laparoscopic jejunal feeding tube placement was performed[29,30]. This approach not only allows for early enteral nutrition support but also effectively reinfuses intestinal fluid, preventing electrolyte imbalances and digestive enzyme loss. When the patient presents with toxemia with or without hemodynamic instability, emergency surgery should be performed. The surgical instruments should be introduced through the previous operative incision to minimize damage to the abdominal wall. As marked tissue edema is often present, duodenostomy with placement of a jejunal feeding tube should be performed directly. Postoperative, antimicrobial therapy should be reinforced and internal homeostasis maintained. Removal of the T-tube and jejunal feeding tube 2 months after surgery is considered safe and can be performed earlier if necessary. This case combined the advantages of both methods, promoting rapid patient recovery and shortening the hospital stay.
CONCLUSION
T-tube duodenostomy combined with jejunal feeding tube placement appears to be a favorable surgical approach for treating DSFs, balancing surgical risk reduction with patient benefit. Current research is mostly retrospective, and this case report lacks a comparative analysis, which limits its value. More high-quality prospective studies are needed to promote standardized diagnosis and treatment of DSFs.
ACKNOWLEDGEMENTS
We sincerely appreciate the patient and his family for their cooperation in obtaining information, receiving treatment, and following up.
Peer review: Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific quality: Grade A, Grade A
Novelty: Grade A, Grade B
Creativity or innovation: Grade A, Grade B
Scientific significance: Grade A, Grade A
P-Reviewer: Peruhova M, MD, Assistant Professor, Bulgaria; Torun M, MD, FACS, FESC, Türkiye S-Editor: Qu XL L-Editor: A P-Editor: Yu HG
