GASTRO-JEJUNO-COLIC FISTULAS : REMARKS ON SIX CASES.

804

GASTRO-JEJUNO-COLIC FISTULAS : REMARKS ON SIX CASES.

BY IAN MACDONALD, THE

gastro-jejunal

or

M.D. EDIN. & PARIS.

anastomotic ulcer in

approxi-

every fifth male patient slowly perforates into the colon. The onset of this dire sequel of gastro-

mately

enterostomy is announced by four cardinal symptoms -diarrhoea, faecal vomiting, foul eructations, and variable pain. Pain may be absent ; diarrhoea is often the initial and continuous symptom. The clinical diagnosis is seldom doubtful; confirmation may be obtained by X ray examination, when the most important sign is rapid emptying of the stomach and immediate filling of the transverse colon. The pitiable state of the emaciated patients and their profound weakness may simulate malignancy, but the horrible vomiting with its characteristic odour leaves no doubt as to the diagnosis. Operation in view of the fatal prognosis is imperative; its extent will depend the permeability or otherwise of the pylorus and the state of the patient. If after the original operation the pylorus is patent the minimum operation may be performed, separation and closure of the three cavities. If the pylorus is still obstructed a new gastric outlet must be provided. Gastro-duodenostomy may be possible or partial gastrectomy may be selected, but the state of the patient may compel the surgeon to another gastroenterostomy. Theoretically gastro-enterostomy, the cause of the gastro-jejunal ulcer, should be banned ; practically it may be necessary.

6 to 8 oz. of aper cent. solution of novocaine without adrenalin in the wall and peritoneum. In our last three cases we have used this method ; a trifling amount of chloroform or ether has been necessary to close the abdominal incision. If the original incision has been right paramedian we have found it best to open the abdomen in the middle line or slightly to the left, for the inflammatory mass is anchored towards that side by the short loop. After examination of the parts and separation of any superficial omental adhesions the dissection of the

FiG. 1.

on

Difficulties of Operation. The difficulties inherent to these operations and the risk of sepsis fully recognised by all surgeons make Pauchetl recommend in difficult cases the removal en masse of the right colon and the fistula, the right half of the stomach, and the jejunal loop without opening any of their cavities. He advocates this method as easier for the surgeon and safer for the patient in cases where the inflammatory mass is large and the colon strictured, when the ascending colon is dilated, and if the middle colic artery is accidentally injured. After a Polya-gastrectomy and the removal of the colon, to save time in weak patients, he advises that the sections of the terminal ileum and transverse colon should be left in the wound after Mikulicz’s method. The artificial anus is closed some weeks later. We have no experience of this immediate radical operation, though in one case a wound of the middle colic artery forced us to a segmental resection of the transverse colon. The pathology of these fistulas varies considerablv. If adhesions are few the attached viscera are easily defined, but they may be buried in an inflammatory mass, so that resection of a portion of the transverse colon may be the minimum operation possible. The condition of the colon is important, for a certain degree of stricture may occur at the fistula ; distally, then, the bowel is narrowed while the proximal portion is dilated and full of feces. If resection of the colon becomes necessary the disparity between the two portions may render axial anastomosis difficult and inadvisable. The jejunal loop also contains fasces, and during its separation from the colon precautions must be redoubled to avoid soiling of the operative area.

Technique. In the complicated operation necessary personal methods and experience will guide the surgeon. In the preoperative treatment lavage of the stomach with weak iodine solution has given us the best results. For some days previously opium is given, and the patient is allowed full diet up to the day before the operation. The anaesthetic will be selected in view of a prolonged operation in a debilitated patient. No anaesthesia has given us such satisfaction as intravenous somnifene by Fredet’s2 method combined with

1, 2, 3, 4, lines of dissection. A, middle colic artery. m, mesentery,

viscera is begun, the operator’s aim being to reproduce the original opening in the mesocolon by working from the periphery towards the fistula at the centre. The separation may begin by omental-colic cleavage on the upper surface of the colon or, by clearing a space in the gastro-colic omentum, to define the upper surface of the transverse mesocolon from this position. All adhesions should be divided carefully between ligatures to avoid bleeding which obscures the field. The under surface of the mesocolon is then exposed by lifting the colon upwards. The mesocolon is carefully incised or scratched through to the right of the anastomosis, while adhesions between it and the stomach are separated by the gloved finger and the lightest strokes of the knife. The position of the loop of the middle colic artery must ever be kept in mind. If the gastro-enterostomy has been made towards the left in the mesocolon the vessel will be found first to the right of the anastomosis, then it lies hidden under the overhanging colon. The upper edge of the afferent loop should also be well defined and above it an opening may be made in the mesocolon here. As the area of cleavage advances between the mesocolon and the stomach it may be possible to pass the finger from the incision on the right behind the anastomosis to the This manoeuvre is space above the afferent loop. helpful, for the finger takes the place of a supporting clamp. Balfouralso calls attention to its value. The area situated below the afferent and efferent loops should obviously be avoided, for the vessels in the mesentery if injured cause troublesome bleeding. The jejunum is now separated from the colon by an incision along the line of adhesion. The colon when free is turned upwards and at once sutured, the openings in the stomach and jejunum being temporarily closed with a clamp and Chaput’s forceps. A compress is laid in the opening of the mesocolon while the bowel is sutured transversely to avoid narrowing of its lumen. A guide suture is first passed at each end of the rent in the colon ; traction is made on these to define the line accurately. The lowest of these sutures must be carefully placed to The ensure closure of this more inaccessible angle. mucous membrane of the fistulous colon is sometimes thick and oedematous, and is best avoided in the suture

805 Clinical Records. line ; if included, a septic ridge remains in a closed CASE l.-Posteri.or gastro-enterostomy for pyloric stenosis cavity under the serous suture, favouring leakage and disunion. It is therefore inverted by passing the seven years previously. The fistula symptoms were a sutures only through the serous and muscular layers. painless diarrhoea and foul fsecal vomiting. At the operation The suturing of the irregular aperture is possibly done the pylorus was found narrowed. The gastro-enterostomy was free and supple: the fistula was found between the more accurately by separate sutures closely placed ; efferent loop and the colon. Separation of the viscera and the first layer is covered by a second ; the whole closure of each was performed, then a new outlet made by circumference of the colon is then loosely wrapped in anterior gastro-enterostomy with entero-anastomosis. This the in J1 collar of omentum brought through opening patient at the present time, seven years later, is in perfect the mesocolon. The jejunum, separated from the health. CASE 2.-Posterior gastro-enterostomy for pyloric stenosis stomach, is next sutured, also transversely, the angles of the opening being also carefully defined by ten years previously, followed by a gastro-jejunal ulcer five guide sutures. Narrowing is further avoided by the bite of the needle being very near the edges of the FIG. 3. incision. The stomach opening is finally sutured in its long axis by a double or triple line, unless it is required for a new gastro-enterostomy. At this stage, when necessary, the new stomach outlet is made, the method being selected which the surgeon decides is best. The opening in the mesocolon, if not needed for gastro-enterostomy, is closed by a couple of sutures. The important point as to the need of csecostomy now arises ; some surgeons consider it advisable even with simple suture of the colon to avoid tension on the suture line, " when the suture of the transverse colon has been difficult and perhaps imperfect " (Balfour3). We have not yet employed it, but should segmental resection of the colon be necessary we consider

ceecostomy essential, unless, as in our third case, a temporary anus is made near the site of the resection to rapidly terminate an operation already prolonged in a weak patient. Results.

Operations for gastro-jejuno-colic fistulas, in spite of their complexity and the poor condition of the patients, do not show a high mortality, for in 27 cases Transverse suture of colon and jejunum.

FIG. 2.

Resection of the anastomosis and a new posterior gastro-enterostomy with enteroanastomosis were performed ; five years later patient readmitted in a state of extreme cachexia with faecai vomiting and diarrhoea. Separation of the viscera, resection of the entero-anastomosis, a new gastro-enterostomy with entero-anastomosis being made on the opening in the stomach. The pylorus still showed narrowing. This patient six years later reports that he is eating and drinking everything, and is quite free from gastric symptoms. His case illustrates the well-known tendency of certain patients to ulceration. CASE 3.-Posterior gastro-enterostomy ten years before for pyloric stenosis ; readmitted complaining of profound weakness, foul vomiting, and diarrhoea. At the operation some ascites was found and peritoneal tuberculosis commencing. During the separation of the viscera the middle colic artery was injured and resection of about six inches of the transverse colon became necessary. The narrowed distal end towards the splenic flexure was closed by a purse-string suture. The much dilated proximal portion was anastomosed laterally about four inches from its section to the distal part already closed, and its open end shut by a Kocher’s forceps fixed in the abdominal wound. The forceps were removed 36 hours later, but the bowel functioned freely through the anastomosis 48 hours after the operation. No feces passed by the artificial anus for ten days. One month later the artificial anus was closed by an extraperitoneal operation. This patient returned two years later looking well, but with a considerable ventral hernia and evident gastric retention from a narrow pylorus. The hernia was repaired, the dilated attached colon separated from the wall, and an anterior Polya-gastrectomy with entero-anastomosis was performed. The patient made a good recovery. CASE 4.-Two years previously posterior gastro-enterostomy and entero-anastomosis for duodenal ulcer adherent to the liver. A year later began to complain of pain, profuse diarrhoea, and wasting without vomiting. At the operation the colon was found fixed to the abdominal wall. The efferent loop was much inflamed, a thickened mass fixing it to the colon ; from this point a slight hardness passed along the anastomosis. Separation and closure of the viscera. The ulcer and peri-duodenal adhesions were still present and in addition we discovered a large dilatation of the third part of the duodenum overlooked at the previous operation. The patient’s state on the table prevented further measures being taken at the time. He recovered from the operation but continued to have some gastric discomfort. years after the anastomosis.

Viscera separated, opening in mesocolon reproduced. " S " stomach.

,

I

quoted by Bolton and Trotter4 only six died. More recently in 20 operations at the Mayo Clinic5 four6 died after the operation. But according to Loewy’s statistics in 63 operations of all kinds there were 61-9 per cent. of cures, 11.1 per cent. definite rences, and 27 per cent. of mortality.

recur-

The six cases under our care all recovered, but two further radical measures. The fistulas in all cases followed posterior gastro-enterostomy, in two cases performed elsewhere, and in two cases an enteroanastomosis had also been made. Two fistulas were jejuno-colic, in the others the colon opened directly into the anastomosis. The youngest patient was 26, the oldest 58. Their clinical histories and the operations performed for their relief are briefly recorded below. I am indebted to Mr. A. K. Maxwell for the sketches.

required

Q2

806 CASE 5.-Gastro-enterostomy two years previously for duodenal ulcer. Ten months after this operation had an attack of pain accompanied by melsena. The symptoms of the fistula were frequent diarrhoea and fsocal eructations without vomiting. At the operation the pylorus and duodenum seemed normal, so the viscera were simply separated and closed. The patient a year later was in excellent health and had gained about a stone in weight. CASE 6.-Posterior gastro-enterostomy seven years previously for duodenal stenosis. Very soon after the operation discomfort began, which gradually increased till the symptoms changed to diarrhoea and foul fsecal eructations. Vomiting was rare. The patient had been washing his stomach without benefit. X ray examination showed immediate passage of the barium meal into the transverse colon. At the operation the pylorus seemed permeable ; a small superficial white spot marked the site of the original ulcer. Separation of viscera, with separate suture of each. As the separation of omental adhesions and the dissection of the adherent viscera had produced some oozing, a small split rubber tube was left at the lower end of the incision for 24 hours. The patient left the clinic free from symptoms.

man’s head, whilst the patient became extremely emaciated and progressively weaker. He died on June 18th, 1927, about 11 weeks after the first symptoms of the disease were complained of. At the end there was a small non-sanguineous. serous effusion in the right pleura. The diagnosis of lymphogranulomatosis maligna was further confirmed a little before the patient’s death by the development of intense general cutaneous pruritus with scratching. Owing to occult blood in the frees the presence of intestinal ulceration of lymphogranulomatous nature had been likewise suspected. Following are blood-counts made during life :—

References. 1. 2. 3. 4. 5. 6.

Pauchet, V.: Prat. Chir. Illust., Fasc. ix. Macdonald, I.: Brit. Med. Jour., 1926, ii., 301. Balfour : Annals of Surgery, September, 1925. Bolton, C., and Trotter, W.: Brit. Med. Jour., 1920, i., 757. Verbrugge : Archives of Surgery, November, 1925. Loewy: Thèse Paris, 1921. Huelva, Spain. A CASE OF

ABDOMINAL LYMPHOGRANULOMATOSIS MALIGNA (HODGKIN’S DISEASE), WITH HIGH BLOOD-EOSINOPHILIA AND LYMPHOGRANULOMATOUS INFILTRATION OF THE EPIDURAL FAT.

BY F. PARKES WEBER, M.D. F.R.C.P. LOND., SENIOR PHYSICIAN TO THE GERMAN

CAMB.,

HOSPITAL, LONDON ;

AND

O.

BODE, M.D. BERLIN, M.R.C.S. ENG., HOUSE PHYSICIAN TO THE HOSPITAL.

to be described was that of a young W. M., a printer, aged 36 years, admitted to the German Hospital on April 23rd, 1927.

THE

case

Englishman, H.

Clinical History. Three weeks before admission he had begun to suffer from severe pains in the region of the left shoulder, gradual loss of strength and cachexia, with muscular weakness in the arm of the painful side. Previously to that he had apparently enjoyed good health. The Wassermann and Pirquet reactions were negative, and the intracutaneous reaction with an echinococcus antigen was likewise negative. Examination (including Rontgen ray examination) of the thorax showed nothing abnormal. There was considerable general wasting, but the wasting was slightly more marked in the left upper limb than in the right. All the deep " nervous reflexes on both sides were active," but those in the left upper limb rather more so than those in the right. (It should be remembered in this connexion that all the deep reflexes are often exaggerated in chronic cachectic wasting subjects.) The knee-jerks on the two sides were Babinski’s sign was negative on both sides. equal. Ophthalmoscopic examination showed nothing abnormal. In the hospital, owing to the presence of a chronic sometimes remittent and sometimes intermittent type of pyrexia (up to about 101° F. in the afternoons) and a high bloodeosinophilia (up to about 40 per cent. of the white cells), and in the absence of any obvious cause for a high bloodeosinophilia, the possibility of early lymphogranulomatosis maligna was thought of, but enlarged lymphatic glands could not be detected anywhere. The liver was not enlarged and the spleen could not be felt. A few days after admission, however, a rather small, hard, immobile mass could be felt by deep palpation a little to the left of the centre of the abdomen, possibly arising from retroperitoneal lymphatic glands. The pain in the left shoulder and the weakness in the left upper limb were no longer complained of, but in May there was considerable lumbar pain, probably connected with the abdominal " tumour " (which later on, at the postmortem examination, was found firmly adherent to the vertebral periosteum, doubtless having been pressing on " and commencing to erode the vertebrae). The " tumour almost became as as a it until large rapidly increased,

Repeated blood-counts early in May showed an eosinophilia, averaging 40 to 50 per cent. of the total white cells. The thrombocyte-count (May 12th, 1927) was about 270,000 per c.mm. of blood. I The treatment was arsenical. Rontgen ray treatment at another hospital was advised, but when a vacancy ,

occurred he had temporarily left our hospital and missed the chance. He was much worse when readmitted five days before his death. He was away from May 30th to June 13th.

Necropsy. Examination showed a conglomerate mass of enlarged lymphogranulomatous and partly necrotic retroperitoneal lymph glands, firmly adherent to the vertebral column, almost as large as a man’s head, together with two ulcerated lymphogranulomatous plaques in the wall of the jejunum. On section (macroscopically) the conglomerate mass appeared lobulated, and in most parts it was white and hard, but portions were softened and necrotic, and one or two parts were haemorrhagic. The liver (weight 1260 g.), the spleen (weight 240 g.), and the kidneys (weight, together, 350 g.) were apparently not affected by the disease ; nor was the substance of the pancreas, though this organ was included in the above-mentioned large tumour-like conglomerate There was some serous effusion in the peritoneum and mass. right pleura. The lungs appeared normal. There was an antemortem thrombus in the apex of the left ventricle, adherent to a fibrotic patch (microscopical examination) in the heart wall. There was diffuse lymphogranulomatous infiltration of the epidural fat on the dorsal aspect of the whole of the thoracic spinal cord, especially in the upper No tumour-like growth in the bones was found. part. The bone-marrow in the middle of the shaft of the right femur was examined ; it was red. The microscopic structure of all the lymphogranulomatous lesions corresponded to the descriptions of Sternberg, Dorothy Read, Sir Frederick Andrewes, and others. Amongst the cells were many large uninuclear (epithelioid) giant cells, as well as here and there a multinuclear giant cell. No striking local (tissue) eosinophilia was found excepting in the bone-marrow.

Discussion. The special points of interest in the case were : (1) the acuteness of the process and the localisation in the abdomen; (2) the intestinal involvement; (3) the high blood-eosinophilia and the intense pruritus at the end ; (4) the lymphogranulomatous infiltration of the epidural fat. (1) Acuteness of the Process and Local,isation in the Abdornen.—Although the retroperitoneal lymphatic glands were probably affected for some time before the onset of subjective or objective symptoms, the process was extremely acute when compared to most other cases of the disease. Nevertheless, cases of so-called " acute Hodgkin’s disease " have been described by various writers, and by one of us (F. P. W.) many years ago.1 The retroperitoneal lymphatic glands are often affected in lymphogranulomatosis maligna, but they are relatively seldom the first group of glands to be affected. In in which they were apparently primarily cases affected-so-called "abdominal Hodgkin’s disease" -the main symptom during life has sometimes been a periodic pyrexia of the Pel-Ebstein type,2 and the