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Case Reports
. 2010 Oct 23;4(3):476-483.
doi: 10.1159/000322027.

Unusual Development of Iatrogenic Complex, Mixed Biliary and Duodenal Fistulas Complicating Roux-en-Y Antrectomy for Stenotic Peptic Disease of the Supraampullary Duodenum Requiring Whipple Procedure: An Uncommon Clinical Dilemma

Francesco A Polistina  1 , Giorgio Costantin, Alessandro Settin, Franco Lumachi, Giovanni Ambrosino
Affiliations
Case Reports

Unusual Development of Iatrogenic Complex, Mixed Biliary and Duodenal Fistulas Complicating Roux-en-Y Antrectomy for Stenotic Peptic Disease of the Supraampullary Duodenum Requiring Whipple Procedure: An Uncommon Clinical Dilemma

Francesco A Polistina et al. Case Rep Gastroenterol. .

Abstract

Complex fistulas of the duodenum and biliary tree are severe complications of gastric surgery. The association of duodenal and major biliary fistulas occurs rarely and is a major challenge for treatment. They may occur during virtually any kind of operation, but they are more frequent in cases complicated by the presence of difficult duodenal ulcers or cancer, with a mortality rate of up to 35%. Options for treatment are many and range from simple drainage to extended resections and difficult reconstructions. Conservative treatment is the choice for well-drained fistulas, but some cases require reoperation. Very little is known about reoperation techniques and technical selection of the right patients. We present the case of a complex iatrogenic duodenal and biliary fistula. A 42-year-old Caucasian man with a diagnosis of postoperative peritonitis had been operated on 3 days earlier; an antrectomy with a Roux-en-Y reconstruction for stenotic peptic disease was performed. Conservative treatment was attempted with mixed results. Two more operations were required to achieve a definitive resolution of the fistula and related local complications. The decision was made to perform a pancreatoduodenectomy with subsequent reconstruction on a double jejunal loop. The patient did well and was discharged on postoperative day 17. In our experience pancreaticoduodenectomy may be an effective treatment of refractory and complex iatrogenic fistulas involving both the duodenum and the biliary tree.

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Figures

Fig. 1
Fig. 1
Abdominal CT scan showing a wide paraduodenal fluid collection. The images were acquired upon the patient's admission.
Fig. 2
Fig. 2
Fistulography showing the presence of a wide damage on the coledochal lateral wall.
Fig. 3
Fig. 3
Non-contrast-enhanced abdominal CT scan showing necrosis of the right colonic wall and diffuse but not periduodenal abdominal fluid collections.
See this image and copyright information in PMC

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