Duodenocolic fistula: case report and review of the literature.
ES Xenos, JD Halverson
Lincoln County Memorial Hospital, Troy, MO 63379, USA., USA
E S Xenos
Lincoln County Memorial Hospital, Troy, MO 63379, USA.
Duodenocolic fistula is a rare complication of malignant and inflammatory bowel disease. It presents as diarrhoea and faeculent vomiting. The diagnosis is established with upper and lower gastrointestinal tract contrast studies. A case is reported and the optimal operative procedure is discussed.
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Xenos E S, Halverson J D. Duodenocolic fistula: case report and review of the literature. J Postgrad Med 1999;45:87-9
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Xenos E S, Halverson J D. Duodenocolic fistula: case report and review of the literature. J Postgrad Med [serial online] 1999 [cited 2020 Nov 29 ];45:87-9
Available from: https://www.jpgmonline.com/text.asp?1999/45/3/87/341
Carcinomas of the hepatic flexure infrequently erode into the adjacent second portion of the duodenum forming a duodenocolic fistula. The passage of duodenal contents into the colon shortens the intestinal transit time. Hydrochloric acid and bile salts have an irritating effect on the colonic mucosa resulting in diarrhoea. Other characteristic symptoms include faeculent vomiting and foul smelling eructations. We report a patient who was diagnosed with a duodenocolic fistula secondary to a hepatic flexure carcinoma.
A 53-year-old white male with history of gastro-oesophageal reflux, chronic obstructive pulmonary disease and biliary colic secondary to cholelithiasis underwent uneventful laparoscopic cholecystectomy. He presented to the emergency room five days after the procedure complaining of diarrhoea and faeculent vomiting for the past three days. No other systemic symptoms were present. Physical examination revealed a soft non-distended abdomen without palpable masses. Rectal examination was positive for occult blood. Laboratory values were within normal limits with the exception of the haematocrit, which was 35%. Upper gastro intestinal series with Gastrografin revealed a duodenocolic fistula. Computed tomography of the abdomen confirmed involvement of the duodenum from a mass at the hepatic flexure without evidence of metastatic disease. On barium enema, a large non-obstructing lesion was present occupying the distal ascending colon, the hepatic flexure and the proximal transverse colon. Colonic biopsy revealed a poorly differentiated adenocarcinoma. The patient was placed on parenteral nutrition and on hospital day six was taken to the operating room after receiving mechanical and antibiotic bowel preparation. On exploration he had a tumour involving the hepatic flexure and the second portion of the duodenum without extension into the pancreas. The mass was adherent to the under surface of the liver without actual invasion. We performed an extended right hemicolectomy and resected the involved duodenal wall en bloc [Figure:1]. The duodenal defect was reconstructed with a jejunal serosal patch, and gastrointestinal continuity was re-established with an ileocolic anastomosis. The patient experienced an uneventful postoperative course. Pathologic examination of the specimen revealed moderately to poorly differentiated adenocarcinoma extending through the full thickness of the colonic wall into the pericolic adipose tissue. The colonic and duodenal resection margins were free of tumour. Twenty-seven pericolic lymph nodes were negative for tumour.
Colonic malignancy and Crohn's disease are the most frequent causes of duodenocolic fistula,,. Less common causes include perforated duodenal diverticulum, perforated duodenal ulcer, and inadvertent injury to the duodenum and colon during gastric surgery. Less than a hundred cases of malignant duodenocolic fistula have been reported in the English and Japanese literature,. Several operations have been proposed for management of this problem. The complexity of the pancreatoduodenal area makes the operative approach challenging. When palliation is the goal and a curative resection is not considered possible because of extended retroperitoneal involvement, procedures that exclude the tumour and the fistula have been described. One example involves anastomosis of the terminal ileum to the transverse colon and gastrojejunostomy. The symptoms of the fistula are relieved but complications from the presence of the tumour can still arise. Survival in these cases is usually less than a year.
Resection of the tumour and the fistula en bloc provides the only hope for cure. Colectomy with partial duodenectomy and primary closure of the duodenal defect would be appropriate in cases with minimal duodenal involvement, which is unusual. An attractive alternative is repair of the duodenal wall defect using an intestinal loop as a serosal patch. There is controversy in the literature as to whether or not this procedure is really curative since the dissection of the regional lymph nodes is limited. At the least however, it provides excellent palliation, especially in cases with resectable local disease but with distant metastatic spread. Colectomy with pancreatoduodenectomy (Whipple procedure) achieves en bloc resection of the tumour and the fistula as well as adequate regional lymph node dissection. In the review of Izumi et al the highest one year survival was achieved with this approach. Due to the scarcity of this clinical entity there are no prospective randomised trials comparing the different procedures. In view of the diminishing mortality of the pancreaticoduodenectomy when performed by expert surgeons in the most recent years it would seem reasonable to combine the colectomy and a Whipple resection in patients with extensive duodenal and /or pancreatic involvement in whom care appears possible. Colectomy and resection of the tumour with serosal patch reconstruction is an alternative approach for tumours that involve the lateral duodenal wall (as was the case with our patient). However, there are insufficient survival data comparing the different approaches. Therefore, the apparent stage of the disease, likelihood of cure and medical status of the patient must be considered on a case by case basis.
Malignant duodenocolic fistula is a rare complication of colon cancer. Faeculent vomiting and diarrhoea are typically present at the diagnosis is relatively easily established by radiological means. The extent of the resection depends on the intent to cure or palliate, as well as the individual patient risk factors. Surgical management ranges from bypass of the tumour and the fistula to colectomy with partial duodenal resection to a Whipple procedure.
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