Department of General Surgery, Northampton General Hospital, Northampton, UK.
Surgeon. 2013 Jun;11(3):158-64. doi: 10.1016/j.surge.2012.12.006. Epub 2013 Feb 1.
Paradigms in the management of duodenal fistula have evolved over the last half a century. Despite advances, morbidity and mortality still remain high. This paper provides a comprehensive, up to date, systematic review in the management of duodenal fistula, classifying the various strategies in the management of duodenal fistula
A review was performed on Medline, Embase and Cochrane library databases using the Cochrane systematic reviews methodology. A final population of 42 studies reported on 349 patients, with a median (range) number of patients per study of two (1-68). The manuscripts were broadly divided in to "non-interventional" and "interventional". The interventional group was subdivided in to "minimally invasive" and the "open surgical approach".
A total of 147 patients were treated conservatively (non-interventional group), with a median duration of 28 days (range 13-42 days) with 13 (9%) deaths recorded in this group. No deaths were reported in the 8 reports on minimally invasive approach.166 patients had open surgical approach with a mortality rate of 30% (50 patients).
In the absence of randomised controlled trials, no one interventional modality can be considered superior. Initial multidisciplinary conservative approach with sepsis control and nutritional augmentation should be for 6 weeks. It would seem reasonable, in those fistulae that fail to close spontaneously, to attempt a low risk "minimally invasive" intervention where necessary expertise is available. More risky open surgical approaches should clearly be reserved for those that fail and are best performed in specialist centres.
在过去的半个世纪中，十二指肠瘘的治疗模式发生了演变。尽管取得了进步，但发病率和死亡率仍然很高。本文提供了一种全面，最新的系统评价，用于治疗十二指肠瘘，将各种治疗策略分类为十二指肠瘘的管理
使用 Cochrane 系统评价方法在 Medline，Embase 和 Cochrane 图书馆数据库中进行了综述。最终有 42 项研究报道了 349 名患者，每项研究的中位数（范围）患者人数为 2 人（1-68 人）。这些文献大致分为“非介入性”和“介入性”。介入组进一步分为“微创”和“开放式手术方法”。
共有 147 名患者接受了保守治疗（非介入组），中位数为 28 天（范围 13-42 天），该组中有 13 例（9％）死亡。微创方法的 8 份报告中未报告死亡。166 例患者接受了开放式手术治疗，死亡率为 30％（50 例）。
在没有随机对照试验的情况下，不能认为任何一种介入方式都具有优势。最初应进行多学科的保守治疗，包括控制败血症和营养增强，持续时间应为 6 周。在那些未能自行闭合的瘘管中，似乎可以合理地尝试在必要的专业知识可用的情况下进行低风险的“微创”干预。更危险的开放式手术方法显然应保留给那些失败的患者，并且最好在专科中心进行。
