Duodenal exclusion for management of lateral duodenal fistulas.

The first clinical application of pyloric occlusion with gastrojejunostomy (duodenal exclusion) for management of lateral duodenal fistulas was reported by Berg in 1907. More recently Berne et al. applied this procedure to treat patients with complex pancreaticoduodenal trauma and modified it to include antrectomy with Billroth II reconstruction and tube duodenostomy. Over time the indications for duodenal exclusion have gradually been expanded to include management of actual or anticipated duodenal fistulas arising from operative injury or as a complication of inflammatory or neoplastic diseases. Our recent success using duodenal exclusion and/or diverticularization to manage one patient with duodenal trauma and two patients with nontraumatic forms of duodenal injury resulting in lateral duodenal fistulas caused us to reevaluate the efficacy of this procedure and forms the basis for this report.