Comparative evaluation of treatment methods for fistulas in patients operated on for complicated gastric and duodenal ulcers

Background. Suture failure after surgery for complicated gastric and duodenal ulcers occurs in 11–15% of patients, with mortality rates reaching 50–70%, necessitating the search for effective treatment methods.
Aim. To compare the effectiveness of various surgical treatment methods for duodenal and gastric fistulas that developed after operations for perforated ulcers, gastroduodenal bleeding, and pyloroduodenal stenosis.
Materials and Methods. The study analyzed treatment outcomes in 97 patients (73 men, 24 women, aged 18-95 years) with gastric and duodenal fistulas that developed after suturing of perforated ulcers and gastric resection using Billroth I and Billroth II methods. Fistulas were classified according to V.I. Belokonev and E.P. Izmailov (2005), peritonitis according to V.N. Chernov and B.M. Belik (2002), and intestinal failure according to V.A. Koryachkin and V.I. Strashnov (2002). The following treatment methods were employed: fistula suturing (n=10), external drainage of the insufficiency zone (n=7), fistula obturation with Foley catheter (n=14), through-and-through drainage of the upper gastrointestinal tract (n=14), drainage of subhepatic abscess (n=20), conservative treatment of type III fistulas (n=27), and fistula closure with vascularized muscle flap (n=5).
Results. Overall mortality was 45.4% (44 of 97 patients). Mortality by fistula type: type I — 62.2% (28 of 45), type II — 30% (6 of 20), type III — 33.3% (9 of 27), type IV — 33.3% (1 of 3), type V — 0% (0 of 2). Mortality by treatment method: fistula suturing — 70% (7 of 10), external drainage — 85.7% (6 of 7), Foley catheter obturation — 50% (7 of 14), through-and-through drainage of upper GI tract — 42.8% (6 of 14), subhepatic abscess drainage — 30% (6 of 20), conservative treatment of type III fistulas — 33.3% (9 of 27), muscle flap closure — 20% (1 of 5).
Conclusion. Postoperative mortality in patients with gastric and duodenal fistulas remains high and depends on fistula type and treatment method. Throughand-through drainage of the upper gastrointestinal tract via duodenal fistula demonstrates the lowest mortality (42.8%) among surgical methods for treating type I-II duodenal fistulas. Drainage of subhepatic abscesses in type II fistulas provides 30% mortality. Conservative treatment of typeIII fistulas is effective with adequate drainage (mortality 33.3%).

1. Luft VM, Kostyuchenko AL, Leiderman IN. Clinical guidelines for nutritional support of critically ill patients. St. Petersburg; 2008.

2. Barrat C, Catheline JM, Rizk N, Champault GG. Treatment of gastroduodenal ulcer perforations using laparoscopy. Ann Chir. 2005;130(10):608-613. doi:10.1016/j.anchir.2005.07.010

3. Bertleff MJOE, Lange JF. Perforated peptic ulcer disease: a review of history and treatment. Dig Surg. 2010;27(3):161-169. doi:10.1159/000264653

4. Belokonev VI, Izmailov EP. Classification of gastrointestinal fistulas and their surgical treatment. Samara; 2005.

5. Puchkov KV, Filimonov VB, Ivanov VV, et al. Laparoscopic suturing of perforated gastroduodenal ulcers. Endoscopic Surgery. 2010;16(1):3-10.

6. Krasnov OA, Tarbaev IS, Khomyakov EA, et al. Duodenal stump failure after gastrectomy in patients with peptic ulcer disease of the stomach and duodenum. Creative Surgery and Oncology. 2012;(3):49-57.

7. Søreide K, Thorsen K, Harrison EM, et al. Perforated peptic ulcer. Lancet. 2015;386(10000):1288-1298. doi:10.1016/S0140-6736(15)00276-7

8. Lau JY, Barkun A, Fan DM, et al. Challenges in the management of acute peptic ulcer bleeding. Lancet. 2013;381(9882):2033-2043. doi:10.1016/S0140-6736(13)60596-6

9. Chernov VN, Belik BM. Classification and principles of treatment of acute purulent peritonitis. Surgery (Khirurgiia). 2002;(4):52-56.

10. Koryachkin VA, Strashnov VI. Intensive care for life-threatening conditions. St. Petersburg; 2002.

11. Søreide K, Thorsen K, Søreide JA. Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. Br J Surg. 2014;101(1):e51-e64. doi:10.1002/bjs.9368

12. Sanabria A, Morales CH, Villegas MI. Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database Syst Rev. 2013;2013(2):CD004778. doi:10.1002/14651858.CD004778.pub3

13. Lohsiriwat V, Prapasrivorakul S, Lohsiriwat D. Perforated peptic ulcer: clinical presentation, surgical outcomes, and the accuracy of the Boey scoring system in predicting postoperative morbidity and mortality. World J Surg. 2009;33(1):80-85. doi:10.1007/s00268-008-9796-1

14. Tsugawa K, Koyanagi N, Hashizume M, et al. The therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age. Hepatogastroenterology. 2001;48(37):156-162.

15. Boey J, Choi SK, Poon A, Alagaratnam TT. Risk stratification in perforated duodenal ulcers. A prospective validation of predictive factors. Ann Surg. 1987;205(1):22-26. doi:10.1097/00000658-198701000-00005

16. Christensen S, Riis A, Nørgaard M, et al. Short-term mortality after perforated or bleeding peptic ulcer among elderly patients: a population-based cohort study. BMC Geriatr. 2007;7:8. doi:10.1186/1471-2318-7-8

17. Siu WT, Leong HT, Law BK, et al. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg. 2002;235(3):313-319. doi:10.1097/00000658-200203000-00001

18. Lunevicius R, Morkevicius M. Systematic review comparing laparoscopic and open repair for perforated peptic ulcer. Br J Surg. 2005;92(10):1195-1207. doi:10.1002/bjs.5155

19. Hermansson M, Staël von Holstein C, Zilling T. Surgical approach and prognostic factors after peptic ulcer perforation. Eur J Surg. 1999;165(6):566-572. doi:10.1080/110241599750006622

20. Buck DL, Møller MH. Influence of body mass index on mortality after surgery for perforated peptic ulcer. Br J Surg. 2014;101(8):993-999. doi:10.1002/bjs.9496

21. Møller MH, Adamsen S, Thomsen RW, Møller AM; Peptic Ulcer Perforation (PULP) trial group. Preoperative prognostic factors for mortality in peptic ulcer perforation: a systematic review. Scand J Gastroenterol. 2010;45(7-8):785-805. doi:10.3109/00365521003783320

22. Svanes C. Trends in perforated peptic ulcer: incidence, etiology, treatment, and prognosis. World J Surg. 2000;24(3):277-283. doi:10.1007/s002689910045

23. Ng EK, Lam YH, Sung JJ, et al. Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: randomized controlled trial. Ann Surg. 2000;231(2):153-158. doi: 10.1097/00000658-200002000-00001

24. Bhandari V, Chhabra S, Lal P, et al. Duodenal perforation: different management strategies. Trop Gastroenterol. 2020;41(1):29-34.

25. Nagpal P, Soni H, Haribhakti S. Management of duodenal stump leak after gastrectomy for carcinoma. Indian J Gastroenterol. 2021;40(1):3-12. doi: 10.1007/s12664-020-01127-0

26. Kumar A, Mukewar S, D'Souza N, et al. Pancreaticoduodenectomy: anastomotic failure and role of percutaneous drainage. Updates Surg. 2019;71(1):97-102. doi: 10.1007/s13304-018-0595-y

27. Chambrier C, Sztark F; Société francophone de nutrition clinique et métabolisme (SFNCP), et al. French clinical guidelines on perioperative nutrition. Update of the 1994 consensus conference on perioperative artificial nutrition for elective surgery in adults. J Visc Surg. 2014;151(Suppl 1):S3-S17. doi: 10.1016/j.jviscsurg.2014.07.002

28. Berry SM, Fischer JE. Classification and pathophysiology of enterocutaneous fistulas. Surg Clin North Am. 1996;76(5):1009-1018. doi:10.1016/s0039-6109(05)70495-3

29. Kaushal M, Carlson GL. Management of enterocutaneous fistulas. Surg Clin North Am. 2014;94(3):627-643. doi:10.1016/j.suc.2014.02.012

30. Evenson AR, Fischer JE. Current management of enterocutaneous fistula. J Gastrointest Surg. 2006;10(3):455-464. doi:10.1016/j.gassur.2005.08.011

31. Hollington P, Mawdsley J, Lim W, et al. An 11-year experience of enterocutaneous fistula. Br J Surg. 2004;91(12):1646-1651. doi:10.1002/bjs.4788

32. Schecter WP, Hirshberg A, Chang DS, et al. Enteric fistulas: principles of management. J Am Coll Surg. 2009;209(4):484-491. doi: 10.1016/j.jamcollsurg.2009.05.025

33. Draus JM Jr, Huss SA, Harty NJ, et al. Enterocutaneous fistula: are treatments improving? Surgery. 2006;140(4):570-576; discussion 576-578. doi: 10.1016/j.surg.2006.07.003

34. Visschers RG, Olde Damink SW, Winkens B, et al. Treatment strategies in 135 consecutive patients with enterocutaneous fistulas. World J Surg. 2008;32(3):445-453. doi: 10.1007/s00268-007-9351-9

35. Lloyd DA, Gabe SM, Windsor AC. Nutrition and management of enterocutaneous fistula. Br J Surg. 2006;93(9):1045-1055. doi: 10.1002/bjs.5396

36. Rahbour G, Siddiqui MR, Ullah MR, et al. A meta-analysis of outcomes following use of somatostatin and its analogues for the management of enterocutaneous fistulas. Ann Surg. 2012;256(6):946-954. doi: 10.1097/SLA.0b013e3182764fcd

37. Martineau P, Shwed JA, Denis R. Is octreotide a new hope for enterocutaneous and external pancreatic fistulas closure? Am J Surg. 1996;172(4):386-395. doi: 10.1016/s0002-9610(96)00185-5

38. Manuilov VM, Shcherbuk AN, Tsarev DA, et al. Cholecystoduodenal fistula accompanied by upper gastrointestinal bleeding (clinical case). Bulletin of the Medical Institute "Reaviz": Rehabilitation, Doctor and Health. 2025;15(1):123-129.

39. Khabibullina LR, Razumovsky AYu, Shcherbakova OV. Complications and functional outcomes after formation of pelvic ileal reservoirs in children. Experience of one center. Russian Bulletin of Pediatric Surgery, Anesthesiology and Intensive Care. 2023;13(3):329-339.

40. Martinez JP, Hogan GJ. Mesenteric ischemia. Emerg Med Clin North Am. 2004;22(4):909-928. doi: 10.1016/j.emc.2004.05.001

41. Bae SO, Shim KN, Kim N, et al. Incidence and short-term mortality from periampullary tumors in the USA. Scand J Gastroenterol. 2012;47(12):1464-1471. doi: 10.3109/00365521.2012.722676

42. Bhandari V, Garg P, Rathi V, Agarwal V. Outcomes of laparoscopic repair of perforated peptic ulcer: a new perspective. J Minim Access Surg. 2018;14(1):22-28. doi: 10.4103/jmas.JMAS_135_16

43. Thorsen K, Søreide JA, Kvaløy JT, et al. Epidemiology of perforated peptic ulcer: age- and gender-adjusted analysis of incidence and mortality. World J Gastroenterol. 2013;19(3):347-354. doi:10.3748/wjg.v19.i3.347

44. Lohsiriwat V. Perforated peptic ulcer: clinical presentation, surgical outcomes, and the accuracy of the Boey scoring system in predicting postoperative morbidity and mortality. World J Surg. 2009;33(1):80-85. doi: 10.1007/s00268-008-9796-1

45. Søreide K, Thorsen K, Søreide JA. Predicting outcomes in patients with perforated gastroduodenal ulcers: artificial neural network modelling indicates a highly complex disease. Eur J Trauma Emerg Surg. 2015;41(1):91-98. doi: 10.1007/s00068-014-0417-4

46. Kocer B, Surmeli S, Solak C, et al. Factors affecting mortality and morbidity in patients with peptic ulcer perforation. J Gastroenterol Hepatol. 2007;22(4):565-570. doi: 10.1111/j.1440-1746.2006.04500.x

47. Malkov IS, Zaynutdinov AM, Veliyev NA, Merrell RC. Laparoscopic and endoscopic management of perforated duodenal ulcers. J Am Coll Surg. 2004;198(3):352-355. doi:10.1016/j.jamcollsurg.2003.10.011

48. Wilhelmsen M, Møller MH, Rosenstock S. Surgical complications after open and laparoscopic surgery for perforated peptic ulcer in a nationwide cohort. Br J Surg. 2015;102(4):382-387. doi: 10.1002/bjs.9753

49. Varcada M, Duta C, Dobrescu A, et al. Laparoscopic repair of perforated peptic ulcer - a systematic review of prognostic factors for morbidity and mortality. Chirurgia (Bucur). 2021;116(3):257-268. doi: 10.21614/chirurgia.116.3.257

50. Byrge N, Barton RG, Ennis TM, Nirula R. Mortality after emergent trauma laparotomy: a risk factor analysis. Am J Surg. 2014;207(5):766-772. doi: 10.1016/j.amjsurg.2013.06.012

51. Babaev AP, Belokonev VI, Kharin IV. Method of duodenostomy in case of duodenal stump failure after Billroth II gastric resection. Russian Federation Patent RU 2533016 C1. Published November 20, 2014.

52. Belokonev VI, Pushkin SYu, Kharin IV, Gulyaev MG. Method for closing a fistula in case of stump failure. Russian Federation Patent RU 2565996 C1. Published October 20, 2015.