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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 51  |  Issue : 4  |  Page : 158-161

Surgical treatment for duodeno-reno-cutaneous fistula


Department of Surgery, Division of General Surgery, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan

Date of Submission27-Sep-2017
Date of Decision10-Nov-2017
Date of Acceptance12-Dec-2017
Date of Web Publication22-Aug-2018

Correspondence Address:
Dr. Jiann-Ming Wu
Department of Surgery, Division of General Surgery, Far Eastern Memorial Hospital, No-21, Sec. 2, Nanya S. Rd, Banqiao District, New Taipei City 220
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_152_17

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  Abstract 

We report the case of a 58-year-old man diagnosed as having right renal stones and who had undergone shock wave lithotripsy several times. However, residual stones persisted and resulted in pyelonephritis and renal abscess. Percutaneous nephrolithotomy (PCNL) was performed. However, bile content discharge from the PCNL wound was observed later. Abdominal computed tomography revealed multiseptated right renal abscess with the right psoas muscle involvement and obscure plane between the right kidney and the duodenum. A fistulogram demonstrated the presence of duodeno-reno-cutaneous fistula. He underwent right nephrectomy and wedge resection of the duodenum for the closure of the fistula. The postoperative course was smooth, and the PCNL wound healed spontaneously during the admission. He remained asymptomatic 6 months after the operation. This report includes a literature review on the etiology, diagnosis, and treatment of the renoduodenal fistula.

Keywords: Duodeno-reno-cutaneous fistula, percutaneous nephrolithotomy, surgical treatment


How to cite this article:
Hsi KY, Wu JM, Chen KH. Surgical treatment for duodeno-reno-cutaneous fistula. Formos J Surg 2018;51:158-61

How to cite this URL:
Hsi KY, Wu JM, Chen KH. Surgical treatment for duodeno-reno-cutaneous fistula. Formos J Surg [serial online] 2018 [cited 2018 Nov 17];51:158-61. Available from: http://www.e-fjs.org/text.asp?2018/51/4/158/239559


  Introduction Top


Renoduodenal fistula is an uncommon disease. Most cases occur spontaneously because of chronic inflammation of the urinary tract, more than 50% of which result from nephrolithiasis. The most commonly involved area is the middle part of the right kidney and the second or third portion of the duodenum due to anatomical proximity and fixation of the duodenum. Patients with renoduodenal fistula usually present with flank pain and urinary tract infection. Computed tomography (CT) and fistulography, if feasible, are the most useful diagnostic tools to confirm the presence of the fistula. The mainstay of treatment for renoduodenal fistula is still surgical intervention, including nephrectomy and closure of the fistula by partial resection of the affected duodenum. However, the diagnosis and treatment of renoduodenal fistula remain clinical challenges both for urologists and general surgeons.


  Case Report Top


A 58-year-old man who had diabetes mellitus and a surgical history of laparoscopic cholecystectomy for acute cholecystitis had been diagnosed as having right renal stones since 2006. He had undergone shock-wave lithotripsy several times, but residual stones persisted and resulted in pyelonephritis with renal abscess formation in 2015. He underwent percutaneous pigtail drainage for renal abscess in September 2015.

He had intermittent right flank pain during the next few months. Percutaneous nephrolithotomy (PCNL) was performed in January 2016 for the persistence of pyelonephritis. Owing to the suspicion of malignancy on the basis of the CT findings, renal mass biopsy was performed in July 2016, and the pathological examination revealed no evidence of malignancy.

Intermittent right flank pain persisted during follow-up in the outpatient department. Bile content discharge from the PCNL wound was observed later. Follow-up CT scans showed multiseptated right renal abscess with right psoas muscle involvement and obscure plane between the right kidney and duodenum. It suggested a duodeno-reno-cutaneous fistula. Fistulography with contrast medium injected through the PCNL wound tract demonstrated communication with the duodenal lumen [Figure 1]. The duodeno-reno-cutaneous fistula was proved. Surgical intervention for definite treatment was suggested, but he hesitated and preferred conservative treatment.
Figure 1: Posterior view of the fistulogram. The contrast medium injected through the percutaneous nephrolithotomy wound tract demonstrated communication with the duodenal lumen. It suggested the presence of a duodeno-reno-cutaneous fistula

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However, intermittent right flank pain and bile content discharge from the PCNL wound persisted. He finally decided to accept surgical treatment. Preoperative CT scans showed residual renal stones, renal abscess with right psoas muscle involvement, and unclear margin between the right kidney and third portion of the duodenum [Figure 2]. He underwent right nephrectomy, wedge resection of the duodenum for the closure of the fistula, and feeding jejunostomy through a midline laparotomy wound on May 10, 2017. Jejunostomy feeding with glucose water was started the next day after the operation. It was shifted to tube feeding diet, and the amount was increased gradually. He resumed tolerable oral intake 8 days after the operation. The postoperative course was smooth. No evidence of duodenal stenosis, leak, or intra-abdominal infection was found. The PCNL wound healed spontaneously during the admission. The pathological examination revealed a renal abscess with necrotizing and granulomatous inflammation, consistent with renoduodenal fistula. He was discharged uneventfully 10 days after the operation. The jejunostomy tube was removed when the patient revisited our outpatient department for postoperative follow-up. He remained asymptomatic 6 months after the operation. Postoperative abdominal CT scans [Figure 3] revealed status post right nephrectomy and wedge resection of duodenum. There is no evidence of residual psoas abscess or fistula.
Figure 2: Abdominal computed tomography scan with contrast. (a and b) Axial computed tomography images showing ill-defined heterogeneous soft tissue at the middle part of the right kidney, suggesting right renal abscess with the involvement of the right psoas muscle. (c and d) Unclear margin between the right kidney and the third portion of the duodenum, indicating a renoduodenal fistula

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Figure 3: Postoperative abdominal computed tomography scans. (a-d) Axial images of computed tomography scans revealed status post right nephrectomy and wedge resection of duodenum (arrow, suture line of autosuture device). There is no evidence of residual psoas abscess or fistula

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  Discussion Top


Renoduodenal fistula (also known as pyeloduodenal fistula) is an uncommon disease. The first documented case was reported in 1893.[1] So far, nearly 100 cases have been reported in the literature.[2] Most cases of renoduodenal fistula occurred spontaneously owing to chronic inflammation of the urinary tract, of which more than 50% resulted from nephrolithiasis,[3] similar to our case. Other causes of renoduodenal fistula included trauma, foreign body ingestion,[4] tuberculosis, malignancy,[5] inflammatory bowel disease, pancreatitis, and iatrogenic procedures such as nasogastric tube[6] or nephrostomy tube insertion.[7] The etiology of renoduodenal fistula is summarized as shown in [Table 1].
Table 1: The etiology of renoduodenal fistula

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Nowadays, nephrolithiasis is the leading cause of spontaneous renoduodenal fistula.[3] It is not difficult to imagine that any reason leading to obstruction of the urinary tract will result in a series of inflammatory changes. Superimposed infection and subsequent abscess formation may occur. Repeated infection and chronic inflammation persist sometimes may result in fistula formation between the diseased kidney and the adjacent bowel tract. The most commonly involved area is the middle part of the right kidney and the second or third portion of the duodenum, similar to our case. In addition to the anatomical proximity, this part of the duodenum is relatively immobile.[8]

Patients with renoduodenal fistula usually present with flank pain and urinary tract infection. Gastrointestinal bleeding presenting as hematemesis is rare but had been reported before.[9] A renoduodenal fistula is difficult to recognize on plain radiography. Even for intravenous pyelography and retrograde pyelography, the sensitivity for correct diagnosis is not satisfactory.[3],[10] Intravenous pyelography may be helpful for diagnosis in patients whose diseased kidney still has function. Upper gastrointestinal series with a water-soluble contrast medium could also be considered. In rare circumstances, esophagogastroduodenoscopy may be useful for the diagnosis of renoduodenal fistula due to gastrointestinal origin such as foreign-body penetration.[10] CT and fistulography, if feasible, are the most useful diagnostic tools to confirm the presence of fistula.[11],[12],[13]

The mainstay of treatment for renoduodenal fistula is still surgical intervention, including nephrectomy and closure of the fistula by partial resection of the affected duodenum. Endoscopic closure of the fistula may be successful in highly selected patients.[14] For patients with trauma-related renoduodenal fistula, trying to preserve the affected but still functioning kidney would be reasonable during the operation.


  Conclusion Top


The diagnosis and treatment of renoduodenal fistula remain clinical challenges both for urologists and general surgeons. Surgical treatment is an effective and feasible method to manage this unusual condition in patients with failed medical treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cohen MH, Becker MH, Hotchkiss RS. Pyeloduodenal fistula: Report of a case and review of the literature. J Urol 1966;95:678-80.  Back to cited text no. 1
    
2.
Hui Wu J, Xu Y, Qiang Xu Z, Yang K, Qiang Yang S, Shun Ma H, et al. Severe anemia and melena caused by pyeloduodenal fistula due to renal stone-associated squamous cell carcinoma. Pak J Med Sci 2014;30:443-5.  Back to cited text no. 2
    
3.
Poon JT, Tam PC, Chu KM. Pyeloduodenocolic fistula. Asian J Surg 2003;26:186-8.  Back to cited text no. 3
    
4.
Newman B. Duodenorenal fistula. Pediatr Radiol 2004;34:343-7.  Back to cited text no. 4
    
5.
Hernandez DJ, Schaeffer EM, Allaf ME. Pyeloduodenal fistula due to advanced upper tract malignancy. Urology 2007;69:1206-7.  Back to cited text no. 5
    
6.
Agarwala S, Dave S, Gupta AK, Mitra DK. Duodeno-renal fistula due to a nasogastric tube in a neonate. Pediatr Surg Int 1998;14:102-3.  Back to cited text no. 6
    
7.
Morris DB, Siegelbaum MH, Pollack HM, Kendall AR, Gerber WL. Renoduodenal fistula in a patient with chronic nephrostomy drainage: A case report. J Urol 1991;146:835-7.  Back to cited text no. 7
    
8.
Fedorko M, Linhartová M, Pacík D, Němcová E. Pyeloduodenal fistula due to proximal ureterolithiasis and its successful conservative management. Urolithiasis 2013;41:541-4.  Back to cited text no. 8
    
9.
Francesco VD, Castellucci F, Balzano S, Zullo A. An unusual case of hematemesis: Spontaneous reno-duodenal fistula. J Dig Endosc 2014;5:37-8.  Back to cited text no. 9
  [Full text]  
10.
Kitagawa T, Sato K, Maetani I. Pyeloduodenal fistula diagnosed by esophagogastroduodenoscopy. Ann Gastroenterol 2015;28:287.  Back to cited text no. 10
    
11.
Atalla MA, Tajkarimi K, Vinh D, Guarnaccia SP. Pyeloduodenal fistula. J Urol 2009;181:2733-4.  Back to cited text no. 11
    
12.
Lang EK, Hanano A, Rudman E. Pyeloduodenal fistula diagnosed on parenchymal excretory phase computerized tomography. J Urol 2010;184:334.  Back to cited text no. 12
    
13.
Lang EK, Hanano A, Zhang K, Thorner D. Duodenal-renal fistula. J Urol 2011;185:2350.  Back to cited text no. 13
    
14.
Lee KN, Hwang IH, Shin MJ, Lee SB, Kim IY, Lee DW, et al. Pyeloduodenal fistula successfully treated by endoscopic ligation without surgical nephrectomy: Case report. J Korean Med Sci 2014;29:141-4.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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