Management of gastrojejunocolic fistula

MANAGEMENT

OF GASTROJEJUNOCOLIC

FISTULA*

GILBERT B. TEPPER, M.D. AND THEODORE B. MASSELL, M.D. LOS ANGELES, CALIFORNIA

A

LTHOUGH gastrojejunocolic fistma today is no Ionger a rare entity, it stiI1 presents one of the most formidabIe of surgica1 probIems. As recentIy as 1923, Verbrugge6 was abIe to find in the Iiterature 0nIy ninety-five cases of gastrojejunocoIic IistuIa resuhing from gastrojejunal uIcer whiIe he recorded 121 cases of gastrocoIic fistuIa secondary to maIignancy of the stomach or coIon. Owing to earIier diagnosis and treatment the maIignant type of fistula is now rarely seen, whereas the type secondary to peptic uIcer of the jejunum is reIativeIy much more common, Bornstein and Weinshe12 cohected reports of 322 cases in their review of May, 1941, an addition of 227 to Verbrugge’s origina ninety-five in a IittIe over fifteen years. The presence of gastrojejunocoIic fistuIa may be suspected in any patient, especiaIIy a maIe, who presents the picture of diarrhea, fou1 beIching, anemia, and progressive emaciation anywhere from a few weeks to severa years after a gastroenterostomy frefor peptic uIcer. Pain or burning, quentIy severe in jejuna1 uIcer, generaIIy disappears with the formation of a IistuIa. The cIinica1 picture may resembIe peIIagra or non-tropica sprue. The diagnosis may be established by roentgenogram or by demonstrating the gastrocoIic short circuit by a coIor enema or one containing readiIy recognizabIe particuIate matter such as Iamp bIack. In the roentgenographic demonstration of the JistuIous tract a barium enema is preferabIe to an upper gastrointestina1 series since a fistuIa may often not be apparent when barium studies are made of the stomach and smaI1 intestine. Missed diagnoses are unIikeIy if the barium mass is watched under the fluoroscope as it passes up through the Iarge boweI. * From the Department

of Surgery,

Obviously the first consideration in the treatment of gastrojejunocolic fistuIa concerns the prevention of this compIication. Every fistuIa of this type represents a gastrojejuna1 uIcer and aImost every instance of the Iatter represents a patient who shouId not have had a gastroenterostomy. It is unfortunate that there is so much disagreement in the Iiterature with regard to the end results of gastrojejunal anastomosis for peptic uIcer. However, even the most enthusiastic advocates of this procedure now agree that it should be avoided in males in whom uIcer is associated with high acid vaIues. WaItersi deduces from the extremely Iow incidence of jejuna1 uIcer in women that, “gastroenterostomy is a safe and usuaIIy a satisfactory procedure for the treatment of duodena1 uIcer in the femaIe.” In view of the higher mortaIity of the gastric resection in eIderIy uIcer patients, some surgeons stiI1 prefer gastrojejunostomy for this group, especiaIIy when the acid vaIues are Iow. WhiIe Waiters and his coIIeagues,3 of the Mayo CIinic, stiI1 retain this beIief, it is interesting to note that in their recent series of fifty gastrojejunocoIic fistulas, fifteen of the patients (30 per cent) were over fifty years of age. Hence it wouId seem that gastrojejunal anastomosis may not be any more satisfactory in the oIder age group than in young patients. CertainIy the most important step in the prevention of this type of fistuIa is a marked Iimitation in the previous overenthusiastic use of gastroenterostomy for duodena1 uIcer. Moreover, when the Iatter procedure is performed, it should not be accompanied by pyIoric excIusion. Lahey4 has pointed out that surgica1 excIusion of duodena1 contents from the stomach predisposes to uIcer around the anastomosis.

Ross-Loos

434

MedicaI

Group, Los Angeles,

California.

Apparently even partial gastrectom) fails to guarantee an ulcer cure. Lahey reports five jejunal ulcers in 200 patients with subtotal resection of the stomach. Thus adequate prevention of gastrojejunocolic fistula invoIves not only carefu1 selection of operative procedure but also the realization that the operation is only part of the treatment, not in itself the complete cure. Long carefu1 follow-up with dietary regulation and the usua1 hygienic precautions of medical therapy for ulcer are a necessary seque1 to operation. Jejunal ulceration and fistma are to be expected if patients regard postoperative recovery as the prelude to dietary excesses, bad eating habits, excessive use of tobacco and alcohol. Once gastrojejunocolic fistula has developed the treatment is surgical for nonoperative therapy carries essentially a too per cent mortaIity. To be sure a careful preoperative medical regime is necessary to restore the depleted nutritiona state, combat dehydration and increase the hemogJobin to a point at which operation can be tolerated. This involves bed rest, high caloric and high vitamin feedings of readily assimilated material, Iarge venoclyses of fluid and electrolytes, transfusion of plasma and whole blood. Even with the best preoperative regime the operative mortality is high because poor risk patients are subjkcted to the double hazards of operation on the stomach and on the colon. Choice of operative procedure must necessarily vary with the patient’s general condition and the IocaI conditions in the operative held. Excision of the fistula is a necessary part of every procedure and under ideal conditions should be combined with gastric resection at a suffrcientIy high level to include most of the acid bearing glands. The futihty of another gastrojejunostomy without an attempt to obliterate the source of the previous jejunal uIcer should be apparent. On the other hand, excision of the fistuIa, separation of the gastroenteric anastomosis and restoration of the origina aIimentary continuity may be regarded only as a first stage to be

followed after a brief interval by gastrectomy. Many patients who might be unable to survive the entire procedure at one operation would withstand the divided operation, especiaIIy if the technic of aseptic anastomosis described by Arthur Allen’ is used in the first stage. There are numerous reports of cases in the literature in which only the first of continuity, operation, i.e., restoration but the recurrence rate was performed, of the origina duodenal ulcer is high under these circumstances. The following case iIIustrates the rationaIe of following restoration with gastrectomy : CASE

REPORT

On April I 3, 1939, a fifty-two year old male was admitted to the Queen of Angels Hospital because of diarrhea, progressive sleight loss despite voracious appetite, fetid breath, and regurgitation of a very foul material, al1 of some six months’ duration. In 1925, a posterior gastroenterostomy had been performed elsewhere for duodenal uIcer. Shortly after this operation, he began to have cramp-like pains in his left upper quadrant, not affected by dietary therapy. In 1934, an operation for abdominal adhesions had been performed without alleviation of cramps. An examination of the patient revealed emaciation and moderate dehydration. His slightly distended abdomen was tympanitic and showed hyperactive peristalsis. A secondary anemia was partly masked by dehydration. A gastrointestinal series revealed findings suggestive of gastrojejunocolic fistula, but definite confirmation was obtained bv barium enema. (Figs. I and 2.) After a preliminary period of intensive preoperative preparation Tepper performed a Iaparotomy under spinal anesthesia. A fistulous opening was found bet\veen the jejunum and transverse colon opposite the stoma of a posterior gastroenterostom;. The fistula first was separated and repaired after which the gastrojejunostomy was dissected free and Recovery was uneventful and the repaired. patient was discharged on the fourteenth postoperative day. He failed to co-operate for postoperative folIow-up, but returned on February 25, 1941

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American

Journal

of Surgery

Tepper,

~asseI~-FistuIa

complaining of recurrence of pain in his left upper quadrant and of marked constipation. Physical findings at this time were noncon-

a blood transfusion, his condition improved temporariIy; however, bleeding continued and despite two more transfusions his hemogIobin

___-__-_

___-TRAN&VERSI

SMALL

COLON

INTESTINE

B

A

FIG. I. A and B, gastrointestinal series fails to reveal a fist& definitely, but there is general hypermotility the stomach empties rapidJy and barium appears almost at once in the transverse colon.

G~STRDJEJUNAL

JEJ UNOLOLIC

FIG. z.

A

and

B,

bariu:

so that

STOMA

FISTLILA

enema; barium may be foIJowed from the transverse eoJoz through the fistuia into the stomach by way of the gastrojejuna1 stoma.

tributory except for abdominal hyperperistaIsis. A carefu1 Iaboratory and roentgenogram examination incIuding a gastrointestinal barium series failed to demonstrate any cause for his pain. (Fig. 3.) On March 5, rg;2r, whiIe under observation, he vomited about 600 cc. of fresh bIood and went into a. state of circulatory collapse. With appIication of appropriate therapy, including

dropped to 28 per cent, and his red cell count to below two miIIion by March Q, 1941. Another 1,500 cc. of whole bIood was given on that date and an operation was performed on the foIIowing day. A duodena1 ulcer was found which penetrated the posterior waI1 and had eroded into the pancreas and the pancreaticoduodena~ artery. Considerable gastritis was noted. A subtotal

gastrectomy was performed with anterior P6lya anastomosis. The operation was foIIowed by two more transfusions.

Ewald test meal on November 1, 1941, revealed complete absence of free hydrochloric acid and total gastric acidity of only sixteen degrees.

.4

I;!(;. 3. A and

B, gastrointestinal

I3

series

after

restoration of normd normal.

alimentary

continuity.

Dudend

cap appears

.JEJLJNUIQ A I:IL.

4. A

and B, gastrointestinal

B

series after gastric resection. Barium passes Phlya anastomosis into the jejunum.

The patient’s recovery was uneventful and he was discharged on his twenty-first postoperative day. In the subsequent folIow-up the patient states that he is free of abdominal pain for the first time in fifteen years. A gastroscopy on October 16, 1941, showed smooth gastric and iejunal mucosa with no evidence of gastritis or ulceration. Gastrointestinal roentgenograms on October 30, 1941, corroborated the gastroscopic findings. (Fig. 4.) An

readily

from the gastric

>~ump through

This case illustrates the desirability of early gastrectomy after repair of gastrojejunocolic fistula. Although this patient was fifty-two years old, the original etiologic factors causing his duodena1 ulcer were still present. Consequently, the recurrence of that ulcer was to have been anticipated. Th e only surprising aspect is the failure of the roentgenologist to find

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Tepper,

Masse&-FistuIa

a penetrating posterior waII ulcer of this type. Another approach to the handIing of gastrojejunocoIic fistuIa has recentIy been presented by Pfeiffer.5 He advocates estabIishment of a Ioop coIostomy proxima1 to the fistuIous opening in the coIon. In his series, coIostomy was foIIowed by so much genera1 nutritional improvement and so much improvement in the IocaI condition that most of the patients were abIe to withstand adequate resection at the time of cIosure of the fistuIa. Whether operation is performed in one stage or two, whether cIosure of the fistuIa or estabhshment of a coIostomy is done in the first stage, the final procedure shouId incIude gastric resection. The previous existence of jejuna1 uIcer and fistuIa is evidence that anything short of this procedure is IikeIy to be a therapeutic faiIure. SUMMARY I. GastrojejunocoIic fistuIa is becoming more frequent as a consequence of gastroenterostomy for peptic uIcer. 2. The symptoms and diagnosis are discussed brieff y.

3. This condition may be prevented by more carefu1 selection of operative procedure for peptic ulcer and better medica foIIow-up. Gastroenterostomy shouId be avoided in maIes with duodenal uIcer. 4. Treatment of the f%tuIa requires excision and gastric resection. The operation may advantageousIy be divided into two stages. 5. A case report is presented. REFERENCES I. ALLEN, ARTHUR. An aseptic technic applicable to gastrojejunocolic fistula. Surgery, I: 338, 1937. z. BORNSTEIN, M. and WEINSHEL, L. R. Gastrojejunocolic fkula. Internat. Abstr. Surg., 72: 459465, 1941. 3. GRAY, H. K., WALTERS, W. and PRIESTLEY, J. T. Report of surgery of the stomach and duodenum for ,940. Proc. Staff Meet., Mayo Clin., 16: 721, 1941. 4. LAHEY, F. H. Diagnosis and management of gastrojejunal uker and gastrojejunocolic fistula. Surg. Clin. Nortb America, 20: 767, 1940. 5. PFEIFFER, D. B. SurgicaI treatment of gastrojejunocoIic fistula. Surg., Gynec. @ Obst., 72: 282-289, 1941. 6. VERBRUGGE, JEAN. Gastrojejunocolic fistulas. Arch. Surg., I: 790, 1925. 7. WALTERS, W. and CLAGETT, 0. T. GastrojejunocoIic ulcer and fistuIa. Am. J. Surg., 46: 94-102, 1939.3