Management of postoperative peritonitis due to gastric and duodenal fistulas

Background. A leak from the anastomosis or gastroduodenal suture or the duodenal fistula after endoscopic sphincterotomy are a very serious complication of supramesocolonic surgery and at this regard multifocal or disseminated peritonitis is a much more serious situation than a possible gastroduodenocutaneous fistula. Methods. The treatment of 21 cases of postoperative supramesocolonic peritonitis is discussed. It is proposed a procedure of diluition, neutralization and aspiration of digestive secretions with an intraluminal three routes drainage associated to a system of perivisceral drainage. A Witzel jejunostomy is performed in order to provide continous high energy enteral support. Results. Mortality rate has been 28.6% (6 patients: 1 case of pulmonary embolism, 1 case of massive haemorrhage and 4 cases of MOF). The external fistula created by this technique healed spontaneously in an average time of 32 days (range 16-46); in two cases a late surgical procedure was required. The late complications involve only the abdominal wall (13 patients out of 21). Conclusions. This procedure prevents the recurrence of intrabdominal sepsis and local complications due to enzymatic action of digestive secretions.