Arch Surg. 1948;57(5):637-641. doi:10.1001/archsurg.1948.01240020646005.
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NONE methods suggested hitherto for suturing and burying the duodenal stump is able to prevent in every case the formation of a postoperative duodenal fistula. Not infrequently the fistula presents itself after operations in the course of which no technical difficulties arose in dealing with the stump; peritonization is rendered difficult on account of inflammatory, scarring and adhesive processes in the neighborhood of the ulcer. Besides the insufficiency of the secretion accumulating in the stump, there are peristaltic changes directed toward the anastomosis after operation, ischemia due to the occasional ligation of the pyloric and gastroduodenal arteries and diminished resistance of the duodenal wall owing to inflammatory and scarring processes.

Among the 96 cases collected by Kittelson1 fistula was due to a previous operation performed on the gallbladder in 30 and to perforation of the duodenal ulcer in 22, whereas acute appendicitis played a role in 7, traumatic rupture


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