Thoracocolonic fistula

THORACOCOLONIC H.

R.

REICHMAN,

FISTULA* M.D.

Salt Lake City, Utah

T

HIS case is considered to be of interest for two reasons: (I) in a Iimited review of the literature no comparabIe case couId

fail of 1945 when because of a chronic productive cough and Ioss of weight she was again hospitaked. On November I Ith a thoracotomy was done for

FIG. I. Photograph showing numerous openings of listula; primary opening in chest at site of thorncotomy \Vound.

be found; (2) it iIIustrates the severe systemic effects which can foIIow proctoIogic infections. CASE

REPORT

A thirty

year oId white femaIe was hospitaIized in June, 1942, for an exacerbation of poIyarthritis, the severity of which was such that sIight jarring of the bed caused her to cry out with pain. Roentgenographic examination of the gastrointestina1 tract discIosed no pathoIogic changes. Estimation of the hemogIobin concentration

Frc. z. CoIon x-ray study with thoracic

showed marked anemia. I saw the patient for the first time then because of an extensive perinea1 fistuIa which had ruptured

in the vagina. The process was incised wideIy and drained June 3, 1942. Her genera1 condition improved rapidIy, her arthritic symptoms subsided compIcteIy and she was discharged from the hospital. In June, 1943, one year later, she returned to the hospital and her rectovagina1 fistuIa was repaired. flier recovery was uneventfu1. During the preceding year she had gained 35 pounds, and her onIy residua1 compIaint was a moderate degree of ankylosis of the cervica1 spine. This patient remained in good heaIth unti1 the * From the Proctologic

Service of the Latter

showing

communication

fistula.

drainage of an empyema secondary to a Iung abscess and bronchopIeura1 fistuIa. Her genera1 condition improved but the thoracic fistula faiIed to hea1. In the spring of 1946 IipiodoI injected into the thoracic fistuIa appeared to empty into the intrstine. During the past months there had been a recurrence of arthritic pains. She refused hospitaIization for study and treatment of her condition. Her symptoms increased and her genera1 heaIth decIined. She re-entered the hospita1 in February, 1948. There was a marked exacerbation of a11 sympwms with a weight Ioss to IOO pounds. After each mea1 pus and feces would run from the openings now muItipIe in her Ieft thorax and Iumbar region. (Fig. I.) She had deveIoped marked cIubbing of her fingers which disappeared subsequent to coIectomy. Roentgenographic examina-

Day Saints Hospital,

and the University

of Utah SchooI of hfedicine,

Salt Lake Cit,y, Utah.

‘94

American

Journal

oj’ Surger>-

Reichman-Thoracocolonic I io115 at I liis time showed the colon to be discasetl throughout with many poIypoid tumors and the thoracic fistuIa was seen to communicate with the apex of the spIenic flexure. (Fig. 2.) The stomach and duodenum appeared normaI. Urography folIowing the intravenous administration of the opaque medium showed the urinary tract to be normaI. The concentration of hemoglobin was 7.5 Cm. per 100 cc. of bIood with 2,600,000 erythrocytes and 7,400 Ieukocytes per cu. mm. of bIood. There were 6.7 Gm. of protein per IOO cc. of serum. At the first stage an iIeosigmoidostomy was done with side-to-side anastomosis of the termina1 iIeum to the dista1 sigmoid. The iIeum distal to the anastomosis was wrapped with poIythene; this in turn was wrapped with pIain ceIIophane and sutured to the mesentery. This was done with the hope of graduaIIy stenosing the Iumen of the iIeum and compIeteIy shunting the feca1 stream from the listula. The patient’s convaIescence was uneventfu1. After preparation three weeks Iater the patient’s abdomen was reopened through the same midline incision and a right coIectomy was done. A coIostomy was made in the upper angIe of the midline incision by bringing out the proxima1 end of the dista1 third of the transverse coIon. The splenic llexurc was noted to be very adherent as formerly. The anastomosis was in exceIIent condition. Thr fistuIous tracts in the Iumbar region and thorax faiIed to hea or regress as had been anticipated. Four weeks later the muItipIe sinus tracts in the Ieft thoracoIumbar region were incised and the necrotic tissue removed. This was done to

January,

Igp

FistuIa

195

provide more adequate drainage of t IIC purulrllt materia1 before the abdomen was reopcncd to remove the remaining portion of the coIon containing the fistuIa. Cultures of this tissue showed no unusua1 organisms as had a11 previous cuttures. Twenty-one days after this procedure the patient was again operated upon at which time the coIostomy was cIosed. The abdomen was opened through the side of the previous midline incision and the dista1 portion of the transverse, the spIenic flexurc and the descending and proxima1 two-thirds of the sigmoid coIon were removed. The Iumen of the sigmoid just above the anastomosis was cIosed with a doubIe row of chromic catgut reinforced lvith interrupted No. 40 cotton sutures. Two Iarge tracts which readiIy admitted the index finger wcrc indentified; one extended into the thorax and the other to the Iumbar region. The pancreas, spleen and Ieft kidney appeared undamaged by the infectious process. Recovery from this operation was uneventfu1. The patient was advised to have a skin graft to the denuded area of the thoracoIumbar region to shorten her ConvaIescence. She declined because of the numerous operative procedures to which she had been subjected. The wound heaIed without incident. Her entire convaIescence aIthough prolonged was most satisfactory. AI1 foods were we11 toIerated. She had norma bowe1 movements two to four times daiIy with good contro1. When Iast seen she had gained 40 pounds, was in good spirits and was symptom-free.