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Timbol ABG, Co VCO, Djajakusuma AV, Banez VP. Duodenocolic fistula diagnosed by endoscopy: a rare complication of colon cancer. BMJ Case Rep 2017; 2017:bcr2016218050. [PMID: 28174187 PMCID: PMC5307291 DOI: 10.1136/bcr-2016-218050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2017] [Indexed: 01/21/2023] Open
Abstract
Duodenocolic fistula (DCF) is a rare complication of colon cancer with only 70 cases reported since its first description in 1862. Owing to its rarity, current knowledge on DCF still relies on single case reports. We present 2 cases of DCF from a hepatic flexure adenocarcinoma demonstrated initially by endoscopy. 2 adult male patients were admitted due to a 2-3-month history of right-upper quadrant pain, vomiting, diarrhoea and a palpable right upper quadrant mass. In both cases, a circumferential, friable mass was noted on upper endoscopy at the second portion of the duodenum, leading to the ascending colon. A similar-looking lesion was also noted on colonoscopy. Biopsies in both cases confirmed colonic adenocarcinoma. Owing to the advanced nature of the disease, en bloc resection was not achieved. Instead, tube jejunostomy and loop ileostomy were created. Both patients were discharged tolerating feeding with improvement in symptoms.
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Affiliation(s)
- Aeden Bernice G Timbol
- Section of Gastroenterology, Department of Medicine, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Vanessa Charlene O Co
- Section of Gastroenterology, Department of Medicine, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Angela V Djajakusuma
- Section of Gastroenterology, Department of Medicine, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Virgilio P Banez
- Section of Gastroenterology, Department of Medicine, Philippine General Hospital, University of the Philippines, Manila, Philippines
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2
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Gong J, Wei Y, Gu L, Li Y, Guo Z, Sun J, Ding C, Zhu W, Li N, Li J. Outcome of Surgery for Coloduodenal Fistula in Crohn's Disease. J Gastrointest Surg 2016; 20:976-84. [PMID: 26718702 DOI: 10.1007/s11605-015-3065-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 12/21/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study was conducted to report the short- and long-term outcomes of surgery for coloduodenal fistula in Crohn's disease and explore the effect of preoperative optimization on surgical outcome. METHODS This is a retrospective review of 34 patients with coloduodenal fistula complicating Crohn's disease between Jan 2008 and May 2015. Demographic information, preoperative management, and intraoperative and postoperative outcome data were collected. RESULTS Primary duodenal repair was carried out in 33 patients (13 with duodenal defect >3 cm), and bypass surgery was performed in one patient with duodenal stenosis. Patients undergoing preoperative optimization (n = 25) had decreased postoperative major (24.0 vs. 87.5 %, P = 0.005) and intra-abdominal septic (20.0 vs. 75.0 %, P = 0.008) complications compared to patients with emergent/semi-emergent surgery (n = 8). No duodenal stenosis occurred on a median follow-up of 22.5 months. Patients with duodenum-ileocolic anastomosis fistula had longer postoperative stay (14.0 vs. 10.0 days, P = 0.032) and increased possibility of refistulization of the duodenum on follow-up (30.0 vs. 0 %, P = 0.031) compared with those with spontaneous duodenum-colonic fistula. CONCLUSION Primary duodenal repair can be safely performed in coloduodenal fistula in Crohn's disease provided there was no duodenal stenosis, even for large duodenal defects. Preoperative optimization is associated with reduced postoperative complications. Patients with duodenum-ileocolic anastomosis fistula are more likely to have duodenum fistula recurrence compared to those with spontaneous duodenum-colonic fistula.
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Affiliation(s)
- Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, People's Republic of China, 210002
| | - Yao Wei
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, People's Republic of China, 210002
| | - Lili Gu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, People's Republic of China, 210002
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, People's Republic of China, 210002
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, People's Republic of China, 210002
| | - Jing Sun
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, People's Republic of China, 210002
| | - Chao Ding
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, People's Republic of China, 210002
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, People's Republic of China, 210002.
| | - Ning Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, People's Republic of China, 210002
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, People's Republic of China, 210002
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Shapey IM, Mahmood K, Solkar MH. Malignant sigmoidoduodenal fistula. Int J Surg Case Rep 2014; 5:995-7. [PMID: 25460456 PMCID: PMC4275860 DOI: 10.1016/j.ijscr.2014.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 09/01/2014] [Accepted: 09/07/2014] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Duodenocolic fistula is a rare complication of malignant colonic disease especially when involving and originating from the sigmoid colon. We aim to discuss the unusual clinical presentation of this case as well as the investigation and management of duodenocolic fistulas. PRESENTATION OF CASE A 91 year old lady presented as an emergency to a general surgical service at a District General Hospital with diarrhoea, vomiting and weight loss. Computed Tomography (CT) reported a large ovarian cyst elevating the sigmoid colon into immediate proximity of the duodenum. Adenocarcinoma was confirmed on histology obtained by colonoscopy. A classic apple core lesion with fistulating tract from the sigmoid colon to the duodenum was synchronously demonstrated on barium enema. DISCUSSION Sigmoido-duodenal fistulae represent a complex manifestation of gastrointestinal pathologies. CONCLUSION Management options must be considered in the context of patient wishes, their co-morbidities, and predicted post-operative outcome. In most cases this is likely to represent a non-operative approach, however surgical resection may benefit selected cases on occasion.
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Affiliation(s)
- I M Shapey
- Tameside General Hospital, Fountain Street, Ashton-under-Lyne OL6 9RW, United Kingdom.
| | - K Mahmood
- Tameside General Hospital, Fountain Street, Ashton-under-Lyne OL6 9RW, United Kingdom
| | - M H Solkar
- Tameside General Hospital, Fountain Street, Ashton-under-Lyne OL6 9RW, United Kingdom
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4
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Zuiki T, Meguro Y, Kumano H, Koinuma K, Miyakura Y, Horie H, Lefor AT, Sata N, Yasuda Y. Successful management of a colo-duodenal fistula in a patient with Crohn's disease using a double lumen gastro-jejunostomy tube. Case Rep Gastroenterol 2014; 8:162-8. [PMID: 24932163 PMCID: PMC4049022 DOI: 10.1159/000363374] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 41-year-old woman was admitted with upper abdominal pain, vomiting and fever. Abdominal CT scan showed a colo-duodenal fistula with inflammatory thickening of the transverse colon. The patient's general health was poor because of hypoalbuminemia and coagulopathy. Endoscopy showed a fistula at the lower duodenal angle and the stomach was filled with refluxed stool. Ileostomy and percutaneous endoscopic gastrostomy were performed at that time and a double lumen gastro-jejunostomy inserted through the gastrostomy to allow both gastric drainage and distal enteral feeding. Nutrition support was gradually converted from parenteral to enteral feeding. Colonoscopy showed stenosis of the transverse colon with a colo-colonic fistula near the stenosis. Two months later, right hemi-colectomy and closure of the colo-duodenal fistula were performed. The resected specimen showed stenosis and a fistula in the transverse colon due to Crohn's disease. The colo-colonic fistula was present and the colo-duodenal fistula had almost closed due to fibrosis. The postoperative course was uneventful and the patient was discharged after administration of infliximab. Use of a double lumen gastro-jejunostomy tube was effective in improving the patient's general condition. This therapeutic strategy allowed the safe conduct of major resection in a high-risk patient.
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Affiliation(s)
- Toru Zuiki
- Department of Surgery, Jichi Medical University, Shimotsuke City, Japan
| | - Yoshiyuki Meguro
- Department of Surgery, Jichi Medical University, Shimotsuke City, Japan
| | - Hidetoshi Kumano
- Department of Surgery, Jichi Medical University, Shimotsuke City, Japan
| | - Koji Koinuma
- Department of Surgery, Jichi Medical University, Shimotsuke City, Japan
| | - Yasuyuki Miyakura
- Department of Surgery, Jichi Medical University, Shimotsuke City, Japan
| | - Hisanaga Horie
- Department of Surgery, Jichi Medical University, Shimotsuke City, Japan
| | - Alan T Lefor
- Department of Surgery, Jichi Medical University, Shimotsuke City, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Shimotsuke City, Japan
| | - Yoshikazu Yasuda
- Department of Surgery, Jichi Medical University, Shimotsuke City, Japan
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5
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McCabe RP, Chow CJ, Rothenberger DA. Duodenal-pleural fistula in Crohn's disease: successful long-term medical management. Inflamm Bowel Dis 2013; 19:E38-9. [PMID: 22517779 PMCID: PMC3652677 DOI: 10.1002/ibd.22946] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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6
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Sawaguchi M, Jin M, Matsuhashi T, Ohba R, Hatakeyama N, Koizumi S, Onochi K, Tawaraya S, Watanabe N, Uchinami H, Yamamoto Y, Ohnishi H, Mashima H. Duodenocolic fistula caused by a peptic stomal ulcer following distal gastrectomy. Intern Med 2013; 52:1579-83. [PMID: 23857089 DOI: 10.2169/internalmedicine.52.0496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein describe the case of a 51-year-old man with a duodenocolic fistula (DCF) caused by a stomal ulcer. The patient complained of watery diarrhea, dysgeusia and malnutrition. His medical history included distal gastrectomy with Billroth I reconstruction for duodenal ulcer perforation. A combination study using endoscopy and contrast imaging confirmed the presence of DCF. Laparotomic fistulectomy was performed, which resulted in the patient's recovery from diarrhea and malnutrition. The histological findings suggested that the fistula had originated from a stomal ulcer. In patients with chronic watery diarrhea of obscure origin following gastrectomy, DCF is a possible cause of the diarrhea.
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Affiliation(s)
- Masayuki Sawaguchi
- Department of Gastroenterology, Akita University Graduate School of Medicine, Japan
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7
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Parray FQ, Wani ML, Bijli AH, Thakur N, Irshad I, Nayeem-ul-Hassan. Crohn's disease: a surgeon's perspective. Saudi J Gastroenterol 2011; 17:6-15. [PMID: 21196646 PMCID: PMC3099084 DOI: 10.4103/1319-3767.74430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Crohn's disease (CD) is known for wide anatomic distribution, different presentations, life-threatening complications, and multiple modalities of management. Its multiple implications are still unaddressed. Since all the patients do not show a good response to medical modalities of treatment, a significant percentage of these patients are referred to the surgeon for the palliation of complications or for the ultimate curative treatment. Since most surgeons come across such patients only rarely, it is sometimes difficult for them to choose the appropriate procedure at the time of need. Moreover, the various surgical modalities available for the different presentations and complications of the disease have not been adequately discussed. The aim of this review is to offer insight and a detailed account of the management of CD from a surgical perspective. This review offers an overview of the various surgical options available, their utility in context, and an approach to various scenarios of complicated CD.
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Affiliation(s)
- Fazl Q. Parray
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
| | - Mohd Lateef Wani
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India,Address for correspondence: Dr. Mohd Lateef Wani, Senior Resident (General Surgery), F-12, B Block, Married Doctors Hostel, Skims Soura Srinager, Srinager, India. E-mail:
| | - Akram H. Bijli
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
| | - Natasha Thakur
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
| | - Ifat Irshad
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
| | - Nayeem-ul-Hassan
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
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8
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Bedioui H, Mouelhi L, Jouini M, Nouira K, Najjar T, BenSafta Z. Maladie de Crohn colique compliquée d’une fistule cologastrique et sigmoïdovésicale : diagnostic et prise en charge thérapeutique. Presse Med 2009; 38:e11-4. [DOI: 10.1016/j.lpm.2008.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 07/26/2008] [Accepted: 07/31/2008] [Indexed: 10/20/2022] Open
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9
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Ha JPY, Leung LH, Tang CN, Li MKW. Silent duodenocolic fistula secondary to biliary stent migration. SURGICAL PRACTICE 2007. [DOI: 10.1111/j.1744-1633.2007.00362.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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El-Hajj II, Abdul-Baki H, El-Zahabi LM, Barada KA. Primary coloduodenal fistula in Crohn's disease. Dig Dis Sci 2007; 52:59-63. [PMID: 17180466 DOI: 10.1007/s10620-006-9227-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2005] [Accepted: 01/04/2006] [Indexed: 01/30/2023]
Abstract
The posterior surface of the proximal transverse colon and the anterior surface of the descending duodenum are intimately related, predisposing to fistulization in this area. We herein describe a rare case of benign duodenocolic fistula secondary to Crohn's disease. We emphasize the clinical presentation with fecaloid vomiting, as well as the establishment of the diagnosis by endoscopy, which are both extremely rare. The presence of a colonic stricture supports the hypothesis that the disease started in the colon rather than in the duodenum, and mandates surgical rather than medical therapy. Our case illustrates the possibility of coloduodenal fistula in patients with long-standing Crohn's disease, which should be considered in patients presenting with fecaloid vomiting, abdominal pain, and weight loss.
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Affiliation(s)
- Ihab I El-Hajj
- Department of Internal Medicine, American University of Beirut Medical Center (AUBMC), 110 32090, Beirut, Lebanon
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11
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van Hogezand RA, Witte AM, Veenendaal RA, Wagtmans MJ, Lamers CB. Proximal Crohn's disease: review of the clinicopathologic features and therapy. Inflamm Bowel Dis 2001; 7:328-37. [PMID: 11720325 DOI: 10.1097/00054725-200111000-00010] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Crohn's disease in the proximal region of the digestive tract is uncommon. Better diagnostically procedures and more careful histologic examination has led to a higher detection of proximal Crohn's disease. The diagnosis is based on symptoms, endoscopy with serial sections, or double contrast radiography. The most common histologic finding for this diagnosis are granulomas in the mucosa in Helicobacter pylori-negative patients, but the granulomas are not always frequently detected. Endoscopic lesions in the proximal regions look like the lesions that could be found in the distal regions. Notching in the duodenal folds could be a strong indication for Crohn's desease. Radiological lesions are not always characteristic, but should be used in combination with endoscopy. Stenosis is an important complication, but fistula formation and pseudodiverticular formation is possible. There is no uniform medical therapy, but the regular anti-inflammatory management for Crohn's disease is most often used. Sometimes surgery is needed.
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Affiliation(s)
- R A van Hogezand
- Department of Gastroenterology-Hepatology, Leiden University Medical Center, The Netherlands.
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12
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Abstract
Historically, Crohn's disease of the esophagus, stomach, and duodenum has been reported only rarely. With more frequent use of upper endoscopy, however, upper gastrointestinal involvement has been found to be more common than previously suspected. The surgeon with an interest in Crohn's disease needs to be familiar with all areas that are potentially affected in this perplexing and sometimes devastating disease. This article examines the literature on foregut Crohn's and discusses the incidence, clinical manifestations, diagnosis, medical management, surgical indications, and operative techniques.
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Affiliation(s)
- H L Reynolds
- Department of Surgery, University Hospitals of Cleveland, Ohio, USA
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13
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Hurst RD, Molinari M, Chung TP, Rubin M, Michelassi F. Prospective study of the features, indications, and surgical treatment in 513 consecutive patients affected by Crohn's disease. Surgery 1997; 122:661-7; discussion 667-8. [PMID: 9347840 DOI: 10.1016/s0039-6060(97)90071-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of this prospective study was to elucidate the features, indications, and surgical treatment in patients affected by complications of Crohn's disease. METHODS Between January 1985 and July 1996, 513 consecutive patients (248 male, 265 female; mean age, 38 years) were operated on for 542 occurrences of Crohn's disease. Data were collected prospectively. RESULTS Indications for abdominal surgery were often multiple but included failure of medical management (n = 220), obstruction (n = 94), intestinal fistula (n = 68), mass (n = 56), abdominal abscess (n = 33), hemorrhage (n = 7), and peritonitis (n = 9). Four hundred sixty-four abdominal procedures were performed, necessitating 425 intestinal resections and 97 stricture plasties. The use of stricture plasty was more common in the second half of the study (16.0% versus 7.3%, second half versus first half; p < 0.01). Perioperative complications occurred in 75 of the 464 abdominal operations (16%). There were no deaths. One hundred thirty patients (25%) required operation for perineal complications of Crohn's disease. The presence of Crohn's disease in the rectal mucosa was associated with a higher risk for permanent stomas in patients requiring operation for treatment of perianal Crohn's disease (67% versus 11%; p < 0.001). CONCLUSIONS Patterns of surgical treatment in Crohn's disease are changing, with more emphasis on nonresectional options. The presence of rectal involvement significantly increases the need for a permanent stoma in patients with perianal Crohn's disease.
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Affiliation(s)
- R D Hurst
- Department of Surgery, Pritzker School of Medicine, University of Chicago, IL 60637, USA
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14
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Poggioli G, Stocchi L, Laureti S, Selleri S, Marra C, Salone MC, Cavallari A. Duodenal involvement of Crohn's disease: three different clinicopathologic patterns. Dis Colon Rectum 1997; 40:179-83. [PMID: 9075753 DOI: 10.1007/bf02054984] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to assess clinical and pathologic features of duodenal Crohn's disease (CD) and address its management according to different patterns of disease. METHODS Twelve cases of duodenal involvement in CD are reported out of 336 patients treated between 1978 and 1993. They represent 3.6 percent of all cases. Three patients had a duodenal fistula, and nine had an intrinsic duodenal lesion. The duodenal fistula was in all cases a manifestation of recurrent CD involving an ileocolic anastomosis and the third portion of the duodenum. RESULTS Treatment consisted of resection of the fistula's source and primary closure of duodenal breach. Of nine patients with intrinsic CD, five had stenosis and the remaining four had peptic ulcer-like lesions. Duodenal stenosis was treated with strictureplasty in three cases and duodenojejunostomy in two. No patient with ulcer-like lesions underwent surgery. CONCLUSIONS Differences encountered in intrinsic duodenal lesions apparently reflect two different clinical patterns. Stenosis is not usually associated with multifocal disease and is often the first evidence of disease. Ulcer-like lesions are not specific; they do not evolve into stenosis as do ulcers in other sites of the disease, spontaneously disappear and relapse, and do not require surgery, except for complications. They are always associated with other locations of the disease.
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Affiliation(s)
- G Poggioli
- Clinica Chirurgica 2, Policlinico S. Orsola, Bologna, Italy
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15
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Intestinale Fisteln bei Morbus Crohn—Ein chirurgisches Therapiekonzept. Eur Surg 1995. [DOI: 10.1007/bf02602267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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Abstract
Surgery continues to play an important role in the overall treatment strategy for patients with Crohn's disease and ulcerative colitis. Innovative techniques have greatly facilitated the operative approach in patients with both disorders.
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Affiliation(s)
- K U Kahng
- Department of Surgery, Medical College of Pennsylvania, Philadelphia
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17
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Michelassi F, Stella M, Balestracci T, Giuliante F, Marogna P, Block GE. Incidence, diagnosis, and treatment of enteric and colorectal fistulae in patients with Crohn's disease. Ann Surg 1993; 218:660-6. [PMID: 8239781 PMCID: PMC1243038 DOI: 10.1097/00000658-199321850-00012] [Citation(s) in RCA: 108] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The authors review their experience, evaluating the incidence and examining the various modalities employed in the diagnosis and treatment of patients with Crohn's disease complicated by fistulae. SUMMARY BACKGROUND DATA Although common, internal and external fistulae in Crohn's disease may pose challenging problems to the surgeon. METHODS Of 639 patients who underwent surgical treatment at the University of Chicago between 1970 and 1988 for complications of Crohn's disease, 222 patients (34.7%) were found to have 290 intra-abdominal fistulae. RESULTS A fistula was diagnosed preoperatively in 154 patients (69.4%), intraoperatively in 60 (27%), and only after examination of the specimen in 8 (3.6%). The fistula represented the primary or single indication for surgical treatment in 14 patients (6.3%) and one of several indications in the remaining patients. Of 165 patients with an abdominal mass or abscess, 69 (41.8%) had a fistula. All patients underwent resection of the diseased intestinal segment; 160 (73.1%) with primary anastomosis and the remaining 62 with a temporary or permanent stoma. The fistula was directly responsible for a stoma in only 16 patients (7.2%) and was never responsible for a permanent stoma. Resection of the diseased bowel achieved en bloc removal of the fistula in 145 cases. Removal of 93 additional fistulae required resection of the diseased bowel segment along with closure of a fistulous opening on the stomach or duodenum (n = 14), bladder (n = 35), or rectosigmoid (n = 44). When the fistula drained through a vaginal cuff (n = 4), the opening was left to close by secondary intention; when the fistula opened through the abdominal wall (n = 46), the fistulous tract was debrided. In the remaining two entero-salpingeal fistulae, en bloc resection of the involved salpinx accomplished complete removal of the fistula. There was a dehiscence of one duodenal and one bladder repair; 14 patients (6%) experienced postoperative septic complications and one patient died. CONCLUSIONS Fistulae are diagnosed preoperatively in 69% of cases and can be suspected in as many as 42% of patients with an abdominal mass. Fistulae are the primary or single indication for surgical treatment and are directly responsible for a stoma only in a few patients. Treatment, based on resection of the diseased bowel and extirpation of the fistula, can be accomplished with minimal morbidity and mortality.
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Affiliation(s)
- F Michelassi
- Department of Surgery, University of Chicago, Illinois
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Affiliation(s)
- G E Block
- Department of Surgery, University of Chicago Medical Center, Illinois
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