Gastrojejunocolic fistula

GASTROJEJUNOCOLIC ARKELL M.

VAUGHN,

M.D., L. C.

FISTULA*

HOLLISTER, M.D. AND F. A.

LAGORIO, JR.,

M.D.

Chicago, Tllinois

A

fistuIa is GASTROJEJUNOCOLIC an abnorma1 opening connecting the stomach, jejunum and coIon, thus ahowing ingested food to pass directIy from the stomach into the coIon, and in turn aIso aIIowing feca1 contamination of the stomach and smaI1 bowe1. The irritating presence of feces in the upper gastrointestina1 tract produces a vicious diarrhea which Ieads to dehydration, anemia and further impairment of digestion and absorption. This condition may be seen as a complication of gastric cancer or more rareIy as a comphcation of chronic uIcerative coIitis. l Etiology. GIickman2 has stated that the causes of gastrocolic fistuIas before the widespread use of gastro-enterostomy were, in order of frequency: cancer, ulcer, abscess in the peritonea1 cavity, tubercuIosis and congenita1 anomaly. Bornstein and WeinsheI3 present a very incIusive Iist of secondary and precipitating factors, stating that a gastrojejuna1 uIcer, and primariIy a duodena1 uIcer, is responsibIe for the formation of a gastrojejunocoIic IistuIa, and that factors precipitating the marginal uIcer are (I) foca1 infection, trauma, tubercuIosis or syphiIis; (2) marked hyperacidity, inasmuch as the jejunum which is accustomed to an aIkaIine medium is now exposed to an acid one, as shown by the experiments of Mann and WiIIiamson;4 (3) operative trauma to the mucosa from the improper use of cIamps; (4) use of nonabsorbabIe sutures and Murphy buttons; (3) foreign body inclusions; (6) indiscretion in diet too soon after surgery; (7) careIessness in medica supervision; (8) excessive smoking, aIcohoIism and use of condiments; (9) fatigue or exposure; (IO) arterio* From the Department

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of Surgery,

sclerosis; (I r ) resoIution of hematomas; (12) fauIty surgica1 technic, e.g., placing the anastomosis too high, and (13) the same causes which produced the original uIcer. Pathology. A gastrojejunocoIic fistuIa usuaIIy connects the jejunum with the transverse colon; rareIy does the stomach connect directIy with the colon. The fistuIa is usually existent cIose to the anastomosis and generaIIy inferior to it and is located on the dista1 loop of the jejunum. The fistuIous tract is lined with smooth, gIistening mucous membrane, whiIe the mucosa of the surrounding tissue (gastric, jejuna1 and coIonic) may show evidence of marked infIammation. Symptomatology. The outstanding symptom of a gastrojejunocoIic fistula is diarrhea. The stoo1 is watery, semisoIid, fatty and generaIIy contains many undigested food particIes. It has a pungent, fou1 odor and faiIs to respond to the usual medica treatment. It is acid in reaction due to the admixture of gastric secretions. Pfeiffer5 attributes the diarrhea and chemicaI imbalance in these cases to the regurgitation of coIonic materia1 into the upper gastrointestinal tract causing rapid peristaIsis throughout the ,smaII intestine with Iittle or no absorption of food. There is marked emaciation, weakness and dehydration if the condition has existed for any Iength of time. Eructation of a. stertorous smeIIing gas is another of the more aggravating symptoms, and the administration of enemas wiI1 increase the frequency and degree of this condition. Vomiting is frequentIy present; and is usuaIIy feca1 in nature. This is increased by Iarge enemas and decreased by frequent

Mercy HospitaI and Stritch III.

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SchooI of Medicine of Loyola University,

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gastric Iavage and administration of a constipating diet. In the absence of intestinal obstruction, Bornstein and WeinsheP believe that feca1 vomiting is pathognomonic of gastrojejunocoIic fistuIa. There is aIways weight Ioss which is generaIIy marked and rapid in onset. Anorexia is usua1 aIthough occasionaIIy there is an unimpaired or increased appetite and intake of food. Abdomina1 pain to the Ieft and beIow the umbilicus may or may not be present and, if present, may cease after the formation of the fistufa. The patient generally shows some degree of anemia which is generally due to the failure to absorb iron or else the inabiIity to absorb the anti-anemic factor of Castle. Atwater, Butt and PriestIey6 found in reviewing their series of thirtynine cases that 14 per cent of these patients showed a macrocytic type of anemia. Hemorrhage may be present during the existence of the margina uIcer and persists foIIowing the formation of the fistuIous tract. A Iow serum protein is generaIIy present in patients who have suffered for some time with the disease and may be manifested by a nutritiona edema. Diagnosis. The diagnosis of this condition is based upon a history of previous peptic uIcer which had been treated surgicaIIy by gastro-enterostomy which had afforded temporary reIief. This is foIIowed by a period of abdominal discomfort or vomiting or hemorrhage pain, nausea, which in turn is foIIowed by diarrhea, stertorous eructation, weight Ioss and cachexia. Physical examination of the patient may prove negative except for maInutrition, apparent anemia and the presence of an abdomina1 scar. A mass is seIdom feIt and, if present, is due to adhesions or a regiona inffammation. Examination of the stoo1 may reveaI bIood, occuIt or fresh, and may aIso revea1 many undigested food particIes. The empIoyment of dyes either rectahy or oraIIy, and their recovery by gastric Iavage or enema, may be heIpfu1 in the determination of the presence of a fistuIa. RoentgenoIogic examination with barium medium

FistuIa

showing direct passage between the stomach, jejunum and coIon estabIishes the diagnosis with a certainty. However, both a barium meal and enema shouId be empIoyed. Prognosis and Mortality. The prognosis of a patient suffering from a gastrojejunocoIic fistuIa must aIways be considered grave and, without surgica1 intervention, the course is one of continued maInutrition and emaciation which usuaIIy resuIts fatahy. The operative mortaIity varies considerably. Marshall7 reports an operative mortaIity of 7.1 per cent occurring in the surgica1 treatment of fourteen patients. Pfeiffer5 repoits a mortaIity of 6.6 per cent; Ransoms 14 per cent; whiIe other reports in the Iiterature show varying percentages up to 63 per cent. Treatment.. The treatment of these patients is primarily surgica1 but the preoperative care necessary to bring them up to a somewhat norma IeveI is most adequateIy handIed as reported by Gray and Sharpe.g Many different surgical technics have been empIoyed in the treatment of this condition, and the method of choice seems to be that which is appIicabIe to the pathoIogica1 condition found at operation. Evans and Skinner10 state that in instances of extensive induration and adhesion formation, resection en bloc may be the onIy procedure. FindIayll has advocated using the MikuIicz procedure in a multiple-stage operation exteriorizing the coIon and attached jejunaI stump. Fina one-stage operation sterer12 preferred but states that a two-stage operation is indicated in those individuaIs in whom a simpIe cIosure of the fistuIa is impossibIe because of its size. Pfeifferl3 advises a preliminary proxima1 Ioop coIostomy with jejunostomy. Lahey and Swinton14 and aIso MarshaI17 advocate a technic whereby the terminal iIeum as a preliminary measure is cut across, the dista1 end cIosed and the proxima1 end anastomosed to the descending coIon as a first-stage procedure. Then at the end of two weeks the ascending colon, American

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FIGS. I and 2. Case I. Roentgenograms taken January 8, 1945, before surgery. In Figure I barium meal reveals gastro-enterostomy and defect of cap. Figure 2 is a roentgenogram taken five hours after barium meal. Note (I) barium in stomach; (2) barium in transverse colon; (3) barium in distal iIeum; (4) absence of barium in cecum and ascending coIon.

the remaining termina1 iIeum, the fistuIa, the jejunum and the portion of the stomach to be resected are removed en bloc, and the end of the transverse coIon dista1 to the fistuIa cIosed, with the feca1 stream aIready diverted and estabIished. The jejunum is reunited by an end-to-end anastomosis and then anastomosed to the resected stomach. CASE

REPORTS

CASE I. Mr. W. C. entered Mercy HospitaI February IO, 1945. His chief compIaint was epigastric pain, radiating to the back, coming on two to three hours after eating and reIieved by vomiting, ingestion of food or alkalies, which had been present for the past twenty years, during which time he had been on peptic ulcer management by Sippy powders and diet. EarIy in 1938 he deveIoped symptoms of obstruction. He wouId generaIIy vomit after the second meal of the day and the vomitus wouId consist of undigested food. No bIood was ever noted. His diet was changed to softer foods and soon only Iiquids were toIerated. This reIieved the patient of vomiting to some degree but he suffered a weight Ioss of 40 pounds over

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a six months’ period. In March 1938 the patient underwent surgery and a posterior gastroenterostomy was performed. He did fairIy we11 on a modified diet for the ensuing year. In March 1939 he had an attack of severe pain generalized throughout the abdomen with greater intensity in the right upper quadrant. The right side of the abdomen was exquisiteIy tender but there was no radiation to the right shouIder. Treatment was symptomatic with five weeks of bed-rest. His symptoms graduaIIy subsided. He gained in genera1 heaIth and weight aIthough stiI1 experiencing attacks of vomiting. Genera1 good heaIth was maintained unti1 November, 1944, when he began to notice an increasing amount of fatigue, more frequent attacks of vomiting and a progressive weight Ioss, totaIing 30 pounds over a three months’ period. The month preceding admission to the hospital he noticed that food recentIy eaten would be passed in the bowel movement in a short time practicaIIy unchanged. During this time he had an insatiabIe appetite and thirst, but experienced diarrhea and occasional vomiting.

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The x-ray examination reveaIed (Fig. I) filIing of stomach with passage of barium through oId gastroenterostomy into jejunum but aIso passage of barium into Iarge bowe1. A barium enema (Fig. 2) showed fiIIing of Iarge

FIG. 3. Case I. Diagrammatic sketches A, B, c and D showing steps in the repair of a gastrojejunocolic fistula. A moditied Lahey anterior gastro-enterostomy is shown. A gastric resection instead of the gastroenterostomy is usuaIIy the procedure of choice.

bowe1 with passage of barium into stomach and smaI1 bowe1. The concIusion arrived at was gastro-enterocoIi fistuIa. The Iaboratory work-up reveaIed no apparent anemia due to dehydration; serum protein 4.42. Preoperatively the patient was pIaced on suIfasuxadine, high caIoric diet, muIti-vitamins and bIood and protein repIacement therapy. On February Ig, 1945, under spina anesthesia the patient underwent surgery for repair of the gastro-enterocohc fistuIa. The folIowing steps were done: (I) CIosure of the fistuIa in the transverse colon by a purse-string silk suture, superimposed by interrupted siIk mattress sutures (Fig. 3~); (2) resection of the jejunum proxima1 and dista1 to the fistuIa with a IateraI anastomosis of the remaining jejunum (Fig. 3c) ; (3) resection of a portion of the greater curvature of the stomach with the

FistuIa

former gastro-enterostomy stoma and attached jejuna1 segment, including jejunal ulcer (Fig. 3c); (4) anterior gastro-enterostomy of jejunum dista1 to site of IateraI anastomosis, and to dista1 end of greater curvature of the stomachLahey anterior gastro-enterostomy. (Fig. 3~.) His postoperative course was not remarkabIe and he was discharged on the twenty-first postoperative day. X-rays taken six months postoperativeIy reveaIed (I) after a barium enema (Fig. 4) a norma Iarge bowe1; after a barium mea1 (Fig. 5) a functioning gastro-enterostomy. The Iaboratory findings eight months postoperativeIy showed red bIood count 4,3go,ooo, hemogIobin 12.3 Gm., serum protein 6.0. Gastric anaIysis one year postoperatively showed free hydrochIoric acid 28’, total acid 36”; no bIood present. At the present time he weighs 185 pounds whiIe weighing onIy 130 pounds at the time of surgery. He is now working daiIy at his trade. CASE II. Mr. R. B., aged forty, entered Mercy HospitaI on December 3, 1946, compIaining of nausea, vomiting, diarrhea, weight Ioss and generaIized colicky abdominai pains which had been present for the past year. The foIIowing past history was obtained: In August, 1940, the patient was operated upon and hospitalized for twenty-one days in a Chicago hospita1 with a diagnosis of a ruptured peptic uIcer. His postoperative course was uneventfu1 except that foIlowing his reIease from the hospita1 he was unabIe to tolerate food and had %feeIing of epigastric fulness. In May, 1941, he suffered a second perforation of a peptic uIcer and folIowing ceIiotomy was informed that, besides the ruptured uIcer, he also had a “bowe1 obstruction” and that a posterior gastro-enterostomy had been done. His postoperative course was uneventful except that his wound faiIed to hea1, and he was discharged from the hospital twenty-eight days Iater with an open skin wound which heaIed three months foIIowing discharge. SubsequentIy an incisiona hernia had deveIoped. This hernia was repaired in November, 1943, and he returned to work as an eIectrician six months later. WhiIe at work in the summer of 1944, he was accidentaIIy struck in the abdomen by a wrench. This was foIIowed by sharp, coIicky pains in the upper abdomen, associated with nausea. He was aIso aware of a sweIIing in the American

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4 5 FIGS. 4 and 5. Case 1. Roentgenograms taken October 8, 1945, after surgery. In Figure 4 note that there is no reffux into stomach and normal Iumen of bowe1 on barium enema study. Figure 3 shows diminished size of stomach and new gastro-enterostomy.

6 7 FIGS. 6 and 7. Case II. Photographs taken at time of operation; Figure 6 shows reIations of transverse colon (which is retracted upward), stomach and jejunum. Note absence of adhesions or inflammatory reaction. Figure 7 reveaIs relations of transverse coIon (which is retracted downward), stomach and jejunum.

Vaughn et aI.-GastrojejunocoIic region of his incision and was again hospitalized and a Iarge abscess was drained. He was discharged in nine days but a purutent drainage continued for the next year. The patient returned to work six months folIowing incision and drainage 01 the abscess, but he now compIained of fatigue and night sweats. Sinus tract at site of old

Y-7

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Z.Lateral anastomosis of colon completed (Colon raised to show structures beneath) ---_

4 Jeiuno-

J

I

line cc’

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Stomach Compfeted New qastro ejunostomy

\

(anterior)

distal to je/uno jsjunostomy

FIG. 8. Case II. Diagrammatic sketches A, B, c, D, E and F showing steps in the repair of a gastrojejunocolic fistula. A modified Lahey anterior gastro-enterostomy is shown. End-to-end anastomosis of the transverse coIon and of the jejunum is quicker but it is a matter of opinion as to whether end-to-end or IateraI anastomosis shouId be used.

In November, 1943, he had a sudden onset of epigastric pain accompanied by nausea, vomiting and diarrhea. His stools at this time were at first tinged with bright red bIood and Iater became tar-colored. He was again hospitalized for twenty-eight days during which time he was pIaced on Lextron and a bland diet. Upon discharge he was without symptoms. In March, 1946, the patient suffered another remission with nausea, vomiting and bIoody diarrhea. Since that time he had frequent attacks of nausea and belching which he described as fecal smelIing and tasting. He aIso

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had spontaneous attacks of vomiting and stated that the vomitus Iooked, smeIIed and tasted Iike feces. He had been having four to six Ioose, watery stools daiIy and at times noticed undigested food particles in his feces. He .had Iost 20 pounds in weight during the past year; his origina weight was 136 and his admission weight was I 16 pounds. He stated that his appetite was exceIIent and he couId not understand why he had been unabIe to gain weight and control the diarrhea. Laboratory findings on admission reveaIed red bIood ceIIs 4,000,000, hemogIobin 12.59 Gm. (81 per cent), tota protein 4.62. Preoperative x-rays were poor due to extreme discomfort of the patient. Preoperative care consisted of a high caIoric diet. muIt-vitamins, bIood and protein repIacement therapy. The operative procedure was performed with fractiona spinal anesthesia. A Ieft upper rectus muscIe spIitting incision was made and the peritonea1 cavity found to be free from adhesions. The fistulous tract was easiIy fotind and was free of any dense adhesions or inffammatory reactions. (Figs. 6 and 7.) The fistulous tract was of a Iarge diameter. (Fig. 8A and B). Due to the Iarge size of the tract it was obvious that extensive resections had to be empIoyed. The jejunum proxima1 and dista1 to the tract was resected and united by IateraI anastomosis. (Fig. 8~ and E.) The greater curvature of the stomach bearing the fistuIa and the remnant of the former gastro-enterostomy was then resected. (Fig. 8~.) FoIIowing this, the portion of the transverse coIon invoIved in the fistuIa was also resected and reunited by IateraI anastomosis. (Fig. 8c and D.) This was foIIowed by an anterior gastro-enterostomy of the Lahey type, and the portion of the jejunum dista1 to the site of the previous IateraI anastomosis yeas used for the anastomosis between the jejunum and the greater curvature of the stomach. (Fig. 8~.) The patient’s postoperative course was not remarkable and he Ieft the hospital on the forty-third postoperative day. His stay in the hospita1 was greatIy Iengthened by a probIem of SociaI Service disposition since he was unempIoyed. Postoperative x-rays showed the foIIowing: After a barium mea1 (Fig. 9) a functioning gastro-enterostomy; after a barium enema a norma appearing coIon with evidence of anastomosis in the transverse coIon. American

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At the time of discharge his weight was pounds while at the time of surgery it was I 15 pounds.

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COMMENTS

The management of gastrojejunocolic fistma is one of surgica1 necessity, but the proper preoperative management of these patients cannot be stressed too greatIy. Today with our increased knowIedge of nitrogen baIance and intravenous corrective therapy, these patients usuahy can be brought to surgery in optimum condition. Since the advent of suIfa drugs, penicilIin, pIasma and extensive empIoyment of whoIe bIood, in addition to improved technic in anesthesia, especiaIIy spina1, the operative procedure can usuaIIy be performed in one stage. In the presence of marked inflammation about the site of the disorder, we can readily understand the vaIue of a preliminary coIostomy as advocated by Pfeiffer and Kent. l3 Resection of the fistuIa en bloc folIowed by a subtota1 gastric resection and reestabIishment of the gastrointestina1 continuity is the procedure of choice. This procedure shouId reduce the gastric acidity suffrcientIy to prevent the recurrence of a margina uIcer. Since the operation is one of great magnitude, usuaIIy requiring severa hours and associated with a high operative mortaIity, an anterior Lahey type of gastroenterostomy can be used to re-estabIish the gastrointestina1 continuity, Iessen the operative time and thus Iower the mortaIity. For the above mentioned reasons this procedure was carried out in the two cases herein reported. In the patient of older age with a Iow gastric acidity the possibility of a future recurrence of a margina uIcer must be weighed against the possibiIity of an operative mortality. We chose the first aIternative, fuIIy realizing that a subtota1 gastrectomy was theoreticaIIy the operation of choice. Likewise, our choice in the use of a Iateral anastomosis July,

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FIG. g. Case II. Roentgenogram taken five hours after the meal shows smal1 amount of barium stiI1 in the stomach and duodena1 cap. The remainder of meal is irreguIarIy scattered throughout the smaI1 bowel and coIon. The bowel shows typical cobbIestone appearance of vitamin deficiency; x-ray aIso shows a functioning gastro-enterostomy.

was one of confidence in personal surgica1 technic. RecentIy in view of the work done by Dragstedt15 and his associates upon the effects of the vagus nerves on gastric secretion, motiIity and acidity, we beIieve that another beneficia1 procedure has been pIaced in the hands of the surgeons for the treatment of margina uIcers and for the prophyIaxis of gastrointestina1 uIceration by means of section of the vagus nerves. Since the patient in Case II had experienced two previous peptic uIcer perforations and deveIoped a jejuna1 ulcer with resuItant perforation into the transverse coIon, we beIieve that he is a candidate for future gastrointestinal uIceration and shouId be foIIowed very closely. In the event that such a condition arises, we are of the opinion that supradiaphragmatic section of the vague nerves is the procedure of choice; and the patient, being we11 aware of his uIcer tendency, has aIready agreed to

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this procedure if at any time we think it advisabIe. However, two and one-haIf years have eIapsed without further symptoms and the gastric acidity is stiI1 within norma range. CONCLUSIONS I. Two successful one-stage operations for gastrojejunocoIic f%tuIa are reported. 2. A partia1 review of the literature is presented. 3. Improved methods of anesthesia are an aid in permitting this operation to be done in one stage. 4. Pre- and postoperative care is directed toward the correction of imbaIanced physioIogy. 5. The Lahey anterior gastro-enterostomy was used successfuIIy in both cases. 6. A macrocytic type of anemia was not present in either case. 7. Both cases occurred in maIes whose average age was forty-four years. 8. The margina uIcer, with subsequent fistuIa formation, foIIowed previous posterior gastro-enterostomies. g. In Case I the fistuIa deveIoped six and one-haIf years foIIowing formation of the marginal uIcer, whiIe in Case II the time interva1 was four months. IO. Four years and two and one-haIf years, respectively, have eIapsed since surgery with no recurrence of symptoms.

FistuIa REFERENCES

1. BARGEN, J. A., KERR, J. G., HAUSNER, E. P. and WEBER, H. M. Rare compIications of chronic uIcerative coIitis, coIonic intussusception; colojejunogastric fistula. Proc. .%a$ Meet., Mayo Clin., 12: 385, 1937. 2. GLICKMAN, L. G. Diverticulum of duodenum. Radiology, 23: 609-614, 1934. 3. BORNSTEIN, M. and WEINSHEL, L. GastrojejunocoIic fistma; coIIective review. Internat. Abstr. surg., 72: 459465, 1941. 4. MANN, F. D. and WILLIAMSON, C. S. The experimentaI production of peptic ulcer. Ann. Surg., 77: 409. 1923. 5. PFEIFFER, DAMON B. The surgica1 treatment of gastrojejunocolic IistuIae. Surg., Gynec. Ed Obst., 72: 282-289, 1941. 6. ATWATER. J. S.. BUTT. H. R. and PRIESTLEY. J. T. Gastrojejunocolic Iistulae, with specia1 reference to associated nutritiona deficiencies and certain surgica1 aspects. Ann. Surg., I 17: 414-426, 1943. 7. MARSHALL, S. F. PIan for surgical management of gastrojejunocotic fistuIa. Ann. Surg., 121: 620633, 1945. 8. RANSOM, H. H. Surgery, GastrojejunocoIic Iistula. 18: 177-190. 1945. 9. GRAY, HOWARD K. and SHARPE, WENDELL S. Preoperative management of gastrojejunocolic fistuIae. Arch. Surg., 43: 850-857, 1941. 10. EVANS, A. G. and SKINNER, H. L. Gastrojejunocolic iistula. Hosp. News, 7: 1-12, 1940. 11. FINDLAY, F. M. Treatment of gastrojejunocoIic fistma by muItipIe stage operations. Arch. Surg., 32: 896-906, 1936. 12. FINISTERER. HANS. ResuIts of repeated operations upon stomach especiaI1.y for gastrojejunal uIcers. Shg., Gynec. Eddbst., 68: 334z-346, 1939. 13. PFEIFFER. DAMON B. and KENT. EDWARD M. The value of preIiminary colostomy in the correction of gastrojejunocolic fistulae. Ann. Surg., I IO: 659-668, 1939. 14. LAHEY, F. H. and SWINTON, N. W. GastrojejunaI uIcer and gastrojejunocoIic Iistula. Surg., Gynec. Ed Obst., 61: 599, 1935. 15. THORNTON, T. F., STORER, E. H. and DRAGSTEDT, L. R. Supradiaphragmatic section of the vagus nerves. f. A. M. A., 130: 764. 1946.

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