Fistulas of the Gastrointestinal Tract Experience with Eighty-One Cases Socrates Athanassiades, MD, Athens, Greece Phillp Notis, MD, Athens, Greece Constantine Tountas, MD, Athens, Greece
Fistulas of the gastrointestinal tract, frequently a postoperative complication, occasionally present difficult problems in management, especially when they are of high output or associated with severe intraperitoneal infection. Management of gastrointestinal fistulas requires adequate replacement of fluid and electrolyte losses, sufficient caloric intake, and control of coexisting infection. It is also essential to choose correctly between medicai and surgical treatment and to decide the proper time for surgical intervention. Surgical skill to properly evaluate the findings and perform the necessary procedure is an important prerequisite for a successful result. Although results of medical and surgical treatment have improved, especially after the introduction of intravenous hyperalimentation, the mortality rate for gastrointestinal fistula in the presence of intraperitoneal infection remains high. The high incidence of coexisting severe sepsis in most of the cases referred to our hospital is responsible for the high mortality (23.4 per cent) in our series. Clinical Data Eighty-one cases of gastric or intestinal fistulas were treated in the Second Surgical Clinic of the University of Athens at Areteion Hospital during a six year period (1968 to 1974).
The ratio of males to females was 1:l. The age of the patients ranged from sixteen to ninety years, with an average of fifty years, and ten patients were oldi than seventy years. The fistula was external in sixty-five cases and internal in eleven; external and internal fistulas were coexistent in five cases. Fifteen patients had multiple fistulas, thus increasing the total number of fistulas to 106. Fistulization was spontaneous in fourteen cases, with the fistula opening internally in thirteen cases and externallv in one. Sixtv-seven cases of external From the Second Surgical Clinic, University of Athens, Areteion Hospital. Athens, Grbece. Reprint requests should be addressed to Socrates Athanassiadek. MD. Second Surgical Clinic, University of Athens, Areteion Hospital, Athens, Greece.
26
fistula followed surgical intervention performed primarily in the gastrointestinal tract or other intra-abdominal organs. The operative procedures preceding fistulization are listed in Table I. Table II indicates the location of fistulas in the gastrointestinal tract, showing that most presented in the small bowel, mainly the ileum and duodenum. Forty of seventy cases of external fistula had high output. Thirty-five cases were associated with severe intraperitoneal infection that either preceded (twenty-one cases) or followed (fourteen cases) the appearance of the fistula. Fifty-two patients were treated medically and twentynine patients underwent operation. Eight patients had recurrence of fistula in the immediate postoperative period after reparative surgery. Intraperitoneal infection was present in five of these patients, and three had had radiotherapy for intra-abdominal neoplastic disease. Of the eight patients with recurring fistula, two died, two underwent successful reoperation, and four were treated medically, with cure in two and significant improvement on discharge from hospital in the other two. Table III shows mortality according to the type of treatment, presence or absence of intraperitoneal infection, and location of fistula in the gastrointestinal tract. Total parenteral hyperalimentation, employed in our clinic since 1970, was administered in thirty patients, generally for an average duration of forty days among the surviving patients, but as long as 112 days in one case. Mean duration of hospitalization was 42.5 days, extending longer in patients undergoing operation (55 days) than in patients treated conservatively (35 days).
Results and Comments Although there is a variety of causes for the development of fistulas of the gastrointestinal tract, the great majority of external fistulas follow operative procedures performed in the gastrointestinal tract or other intra-abdominal organs [I-3]. Thus, 98.5 per cent of the external fistulas in our series were postoperative. Of these, 80 per cent followed operations in the gastrointestinal tract (primarily the stomach and duodenum) and 20 per cent fol-
The Amerkan Journal of Surgery
Athanassiades,
TABLE
I
Surgical Procedures Preceding Appearance of Fistula
the
Total (5) or partial (11) gastrectomy for cancer or gastroduodenal ulcer Suture of perforated gastric or duodenal ulcer Pyloroplasty Duodenotomy for removal of stone impacted at the ampulla Suture of traumatic rupture of duodenum Lysis of adhesions (3) with enterectomy (2) for small bowel obstruction Cesarian section with subsequent peritonitis and drainage Hysterectomy for fibroids Removal of ovarian cancer Excision of tube for ruptured ectopic pregnancy Enterectomy for strangulated inguinal hernia Drainage of abscess of right iliac fossa after appendectomy Total colectomy for ulcerative colitis Right colectomy for Crohn’s disease Cholecystectomy for acute cholecystitis Closure of transverse colon colostomy Repair of incarcerated umbilical hernia (injury to transverse colon) Anterior resection for cancer (3) or diverticulitis (2) Removal of left kidney for pyonephrosis (injury to descending colon) Total
IIIC
Treatment
and Mortality
16
Esophagus and jejunum Stomach Stomach and jejunum Duodenum Gallbladder and duodenum Jejunum (2 internal) Ileum Cecum Hepatic flexure Transverse colon Descending colon Sigmoid colon (1 internal) Rectum (5 internal) Total
4 2 1 2 5 5 1 2 1 1
* Fifteen
6 1 2 2 9
Medical Surgical Total
1 67
Treatment Medical Surgical Total
15 14 29
Deaths 6 9 (8) 15 (14)
(internal)
had more than one fistula.
Number of Patients
Treatment
5
~-
TABLE IIIB
52 29 81
130, July 1975
in Eighty-One Fistula
Deaths
Mortality (per cent)
14 (9)* 11 (10) 25 (19)
27 (17.3) 38 (34.5) 30.9 (23.4)
Treatment and Mortality or without lntraperitoneal
in Patients with Infection
With Infection
Treatment Medical Surgical Total
Number of PaMortality Gents Deaths (per cent) 21 14 35
5 25 7 (6) 50 (42.8) 12 (11) 34 (31.4)
Without Infection Number of Patients
Deaths
32 14 46
9 (4) 4 13 (8)
Mortality (per cent) 28 (12.5) 28.6 28.3 (17.4)
to Location of Fistula
Mortality (per cent) 40 64.3 (57) 51.7 (48)
Small Bowel Number of Patients 13 13 26
Deaths 2 2 4
Large Bowel Mortality (per cent) 15.4 15.4 15.4
Number of Patients
Deaths
Mortality (per cent)
22 4 26
6 (1) 0 6 (1)
27.3 (4.5) 0 23 (3.8)
* The numbers in parentheses represent the mortality after deducting six deaths related not to the fistula ing severe post-traumatic pancreatitis in one patient and disseminated neoplastic disease in five patients.
Volume
5 4 3 16 5 6 29 9 4 12 2 3 8 106*
Treatment and Mortality Cases of Gastrointestinal
__.
Esophagus, Stomach, and Duodenum Number of Patients
patients
TABLE IIIA
1
according
Number of Fistulas
Location
lowed operations in other intra-abdominal organs (primarily the female reproductive organs). Fistulization was spontaneous in 17 per cent of the patients, opening internally in 93 per cent and externally in 7 per cent. The cause of spontaneous fistulization was inflammation in 53 per cent and radiotherapy for neoplastic disease, still active in many cases, in 47 per cent. The most common internal spontaneous fistulizations encountered were cholecystoduodenal (in five patients) and rectovaginal (in five patients). Cholecystoduodenal fistu-
TABLE
Location of Fistulas in the Gastrointestinal Tract
TABLE II
Number of Patients
Surgical Procedure
Notis, and Tountas
itself
but to coexist-
27
GastrointestinalFistulas
las were always inflammatory in origin, whereas rectovaginal fistulas followed either inflammation (two patients) or radiotherapy for cancer (three patients). The four other spontaneous fistulizations were sigmoidovesical due to cancer of the sigmoid colon in one patient, pancreaticojejunal after acute pancreatitis in two patients, and cecocutaneous after radiation therapy in one patient. Most of the large bowel fistulas were treated medically, whereas fifty per cent of the gastric, duodenal, and small bowel fistulas required operation, usually because of failure of medical treatment. The most common causes of lack of success with medical treatment were: intestinal obstruction distal to the fistula due to adhesions or disseminated neoplasms; active disease of the bowel wall, either inflammatory or neoplastic; an opening of the bowel wall larger than 1 cm; or eversion of bowel mucosa with indurated and fixed margins as well as epithelialization of the fistulous tract. When none of these causes is noted, most of the fistulas heal spontaneously within six to eight weeks; in fact, the average time of hospitalization for medically treated patients in our series was thirty-five days. When discharge from the fistula continues beyond the eighth week, unless the discharge is minimal, there will be no spontaneous healing and surgical treatment is required. However, surgical intervention should be decided on earlier when spontaneous healing is not anticipated because of an obvious or strongly suspected cause, such as distal obstruction or presence of a foreign body, or when fluid losses are copious, with no sign of decreasing within a short time, as may happen with large fistulas located high in the small bowel [2,4]. In these patients surgical treatment is undertaken as soon as fluid and electrolyte deficits are corrected and the general condition of the patient is improved by vigorous medical treatment. The treatment of fistulas associated with severe intraperitoneal infection (usually localized abscesses and occasionally generalized peritonitis), the clinical situation nresented in most natients referred to us. is more difficult and comalicated. In these patients surgical correction of the fistula itself is delayed until infection is controlled [2]; when undertaken, operation should be limited to procedures that treat the infection, such as drainage of abscess, or indirectly influence the fistula, such as proximal colostomy. Surgical correction of the fistula itself in the presence of infection, besides presenting other complications, entails a high incidence of failure and was considered the
28
cause of recurrence in five of eight cases in our series. Intravenous hyperalimentation has been of considerable value in medically treating patients with fistulas [5] as well as in preparing them for operation. Comparative results, before and after the introduction of total parenteral hyperalimentation, are not available from the literature, and conclusions cannot be drawn from our series, as it is difficult to find two comparable groups: we are, however, convinced that many of these very ill patients would have died without this treatment. Mortality due to fistulas was high (Table III), especially in the surgically treated group, which included the more severe cases. Also, mortality due to fistulas associated with severe intraperitoneal infection was twice as high in both medically and surgically treated patients as that in patients without infection. Moreover, mortality was disappointingly higher in those patients with esophagojejunal (after total gastrectomy), gastric, and duodenal fistulas than in those patients with small bowel fistulas, being three times higher in medically treated patients and four times higher in surgically treated patients. However, mortality in patients with large bowel fistulas was low (3.8 per cent) if deaths due to dissemination of the original neoplastic disease are excluded. Summary
Eighty-one cases of gastrointestinal fistulas are reported. Sixty-seven of these fistulas occurred postoperatively, all of them external, and fourteen occurred spontaneously, all but one internal. Fifty-two patients were treated conservatively and twenty-nine underwent operation, with an overall mortality rate of 23.4 per cent. It is noted that the presence of severe intraperitoneal infection and a high location of the fistula were associated with an unfavorable prognosis, with mortality rates of 31.4 per cent and 48 per cent, respectively. References
1. Halversen RC, Hogle HH, Richards RC: Gastric and small bowel fistulas. Ah J Surg 118: 986. 1969. 2. Nassos TP, Braasch JW: External small bowel fistulas. Current treatment and results. Surg C/in North Am 51: 687. 1971. 3. Welch CE, Edmunds LH: Gastrointestinal fistulas. Surg C/in NorthAm42: 1311, 1962. 4. Chapman R, Foran R, Dunphy JE: Management of intestinal fistulas. Am J Surg 108: 157, 1964. 5. Dudrick BJ. Wilmore DN, Vars HM. et al: Can intravenous feeding as the sole means of nutrition support growth inthe child and restore weight loss in an adult? An affirmative answer. Ann Surg 169: 974, 1969.
The American Journal of Surgery
Fistulas of the gastrointestinal tract, frequently a postoperative complication, occasionally present difficult problems in management, especially when they are of high output or associated with severe intraperitoneal infection. Management of gastrointestinal fistulas requires adequate replacement of fluid and electrolyte losses, sufficient caloric intake, and control of coexisting infection. It is also essential to choose correctly between medicai and surgical treatment and to decide the proper time for surgical intervention. Surgical skill to properly evaluate the findings and perform the necessary procedure is an important prerequisite for a successful result. Although results of medical and surgical treatment have improved, especially after the introduction of intravenous hyperalimentation, the mortality rate for gastrointestinal fistula in the presence of intraperitoneal infection remains high. The high incidence of coexisting severe sepsis in most of the cases referred to our hospital is responsible for the high mortality (23.4 per cent) in our series. Clinical Data Eighty-one cases of gastric or intestinal fistulas were treated in the Second Surgical Clinic of the University of Athens at Areteion Hospital during a six year period (1968 to 1974).
The ratio of males to females was 1:l. The age of the patients ranged from sixteen to ninety years, with an average of fifty years, and ten patients were oldi than seventy years. The fistula was external in sixty-five cases and internal in eleven; external and internal fistulas were coexistent in five cases. Fifteen patients had multiple fistulas, thus increasing the total number of fistulas to 106. Fistulization was spontaneous in fourteen cases, with the fistula opening internally in thirteen cases and externallv in one. Sixtv-seven cases of external From the Second Surgical Clinic, University of Athens, Areteion Hospital. Athens, Grbece. Reprint requests should be addressed to Socrates Athanassiadek. MD. Second Surgical Clinic, University of Athens, Areteion Hospital, Athens, Greece.
26
fistula followed surgical intervention performed primarily in the gastrointestinal tract or other intra-abdominal organs. The operative procedures preceding fistulization are listed in Table I. Table II indicates the location of fistulas in the gastrointestinal tract, showing that most presented in the small bowel, mainly the ileum and duodenum. Forty of seventy cases of external fistula had high output. Thirty-five cases were associated with severe intraperitoneal infection that either preceded (twenty-one cases) or followed (fourteen cases) the appearance of the fistula. Fifty-two patients were treated medically and twentynine patients underwent operation. Eight patients had recurrence of fistula in the immediate postoperative period after reparative surgery. Intraperitoneal infection was present in five of these patients, and three had had radiotherapy for intra-abdominal neoplastic disease. Of the eight patients with recurring fistula, two died, two underwent successful reoperation, and four were treated medically, with cure in two and significant improvement on discharge from hospital in the other two. Table III shows mortality according to the type of treatment, presence or absence of intraperitoneal infection, and location of fistula in the gastrointestinal tract. Total parenteral hyperalimentation, employed in our clinic since 1970, was administered in thirty patients, generally for an average duration of forty days among the surviving patients, but as long as 112 days in one case. Mean duration of hospitalization was 42.5 days, extending longer in patients undergoing operation (55 days) than in patients treated conservatively (35 days).
Results and Comments Although there is a variety of causes for the development of fistulas of the gastrointestinal tract, the great majority of external fistulas follow operative procedures performed in the gastrointestinal tract or other intra-abdominal organs [I-3]. Thus, 98.5 per cent of the external fistulas in our series were postoperative. Of these, 80 per cent followed operations in the gastrointestinal tract (primarily the stomach and duodenum) and 20 per cent fol-
The Amerkan Journal of Surgery
Athanassiades,
TABLE
I
Surgical Procedures Preceding Appearance of Fistula
the
Total (5) or partial (11) gastrectomy for cancer or gastroduodenal ulcer Suture of perforated gastric or duodenal ulcer Pyloroplasty Duodenotomy for removal of stone impacted at the ampulla Suture of traumatic rupture of duodenum Lysis of adhesions (3) with enterectomy (2) for small bowel obstruction Cesarian section with subsequent peritonitis and drainage Hysterectomy for fibroids Removal of ovarian cancer Excision of tube for ruptured ectopic pregnancy Enterectomy for strangulated inguinal hernia Drainage of abscess of right iliac fossa after appendectomy Total colectomy for ulcerative colitis Right colectomy for Crohn’s disease Cholecystectomy for acute cholecystitis Closure of transverse colon colostomy Repair of incarcerated umbilical hernia (injury to transverse colon) Anterior resection for cancer (3) or diverticulitis (2) Removal of left kidney for pyonephrosis (injury to descending colon) Total
IIIC
Treatment
and Mortality
16
Esophagus and jejunum Stomach Stomach and jejunum Duodenum Gallbladder and duodenum Jejunum (2 internal) Ileum Cecum Hepatic flexure Transverse colon Descending colon Sigmoid colon (1 internal) Rectum (5 internal) Total
4 2 1 2 5 5 1 2 1 1
* Fifteen
6 1 2 2 9
Medical Surgical Total
1 67
Treatment Medical Surgical Total
15 14 29
Deaths 6 9 (8) 15 (14)
(internal)
had more than one fistula.
Number of Patients
Treatment
5
~-
TABLE IIIB
52 29 81
130, July 1975
in Eighty-One Fistula
Deaths
Mortality (per cent)
14 (9)* 11 (10) 25 (19)
27 (17.3) 38 (34.5) 30.9 (23.4)
Treatment and Mortality or without lntraperitoneal
in Patients with Infection
With Infection
Treatment Medical Surgical Total
Number of PaMortality Gents Deaths (per cent) 21 14 35
5 25 7 (6) 50 (42.8) 12 (11) 34 (31.4)
Without Infection Number of Patients
Deaths
32 14 46
9 (4) 4 13 (8)
Mortality (per cent) 28 (12.5) 28.6 28.3 (17.4)
to Location of Fistula
Mortality (per cent) 40 64.3 (57) 51.7 (48)
Small Bowel Number of Patients 13 13 26
Deaths 2 2 4
Large Bowel Mortality (per cent) 15.4 15.4 15.4
Number of Patients
Deaths
Mortality (per cent)
22 4 26
6 (1) 0 6 (1)
27.3 (4.5) 0 23 (3.8)
* The numbers in parentheses represent the mortality after deducting six deaths related not to the fistula ing severe post-traumatic pancreatitis in one patient and disseminated neoplastic disease in five patients.
Volume
5 4 3 16 5 6 29 9 4 12 2 3 8 106*
Treatment and Mortality Cases of Gastrointestinal
__.
Esophagus, Stomach, and Duodenum Number of Patients
patients
TABLE IIIA
1
according
Number of Fistulas
Location
lowed operations in other intra-abdominal organs (primarily the female reproductive organs). Fistulization was spontaneous in 17 per cent of the patients, opening internally in 93 per cent and externally in 7 per cent. The cause of spontaneous fistulization was inflammation in 53 per cent and radiotherapy for neoplastic disease, still active in many cases, in 47 per cent. The most common internal spontaneous fistulizations encountered were cholecystoduodenal (in five patients) and rectovaginal (in five patients). Cholecystoduodenal fistu-
TABLE
Location of Fistulas in the Gastrointestinal Tract
TABLE II
Number of Patients
Surgical Procedure
Notis, and Tountas
itself
but to coexist-
27
GastrointestinalFistulas
las were always inflammatory in origin, whereas rectovaginal fistulas followed either inflammation (two patients) or radiotherapy for cancer (three patients). The four other spontaneous fistulizations were sigmoidovesical due to cancer of the sigmoid colon in one patient, pancreaticojejunal after acute pancreatitis in two patients, and cecocutaneous after radiation therapy in one patient. Most of the large bowel fistulas were treated medically, whereas fifty per cent of the gastric, duodenal, and small bowel fistulas required operation, usually because of failure of medical treatment. The most common causes of lack of success with medical treatment were: intestinal obstruction distal to the fistula due to adhesions or disseminated neoplasms; active disease of the bowel wall, either inflammatory or neoplastic; an opening of the bowel wall larger than 1 cm; or eversion of bowel mucosa with indurated and fixed margins as well as epithelialization of the fistulous tract. When none of these causes is noted, most of the fistulas heal spontaneously within six to eight weeks; in fact, the average time of hospitalization for medically treated patients in our series was thirty-five days. When discharge from the fistula continues beyond the eighth week, unless the discharge is minimal, there will be no spontaneous healing and surgical treatment is required. However, surgical intervention should be decided on earlier when spontaneous healing is not anticipated because of an obvious or strongly suspected cause, such as distal obstruction or presence of a foreign body, or when fluid losses are copious, with no sign of decreasing within a short time, as may happen with large fistulas located high in the small bowel [2,4]. In these patients surgical treatment is undertaken as soon as fluid and electrolyte deficits are corrected and the general condition of the patient is improved by vigorous medical treatment. The treatment of fistulas associated with severe intraperitoneal infection (usually localized abscesses and occasionally generalized peritonitis), the clinical situation nresented in most natients referred to us. is more difficult and comalicated. In these patients surgical correction of the fistula itself is delayed until infection is controlled [2]; when undertaken, operation should be limited to procedures that treat the infection, such as drainage of abscess, or indirectly influence the fistula, such as proximal colostomy. Surgical correction of the fistula itself in the presence of infection, besides presenting other complications, entails a high incidence of failure and was considered the
28
cause of recurrence in five of eight cases in our series. Intravenous hyperalimentation has been of considerable value in medically treating patients with fistulas [5] as well as in preparing them for operation. Comparative results, before and after the introduction of total parenteral hyperalimentation, are not available from the literature, and conclusions cannot be drawn from our series, as it is difficult to find two comparable groups: we are, however, convinced that many of these very ill patients would have died without this treatment. Mortality due to fistulas was high (Table III), especially in the surgically treated group, which included the more severe cases. Also, mortality due to fistulas associated with severe intraperitoneal infection was twice as high in both medically and surgically treated patients as that in patients without infection. Moreover, mortality was disappointingly higher in those patients with esophagojejunal (after total gastrectomy), gastric, and duodenal fistulas than in those patients with small bowel fistulas, being three times higher in medically treated patients and four times higher in surgically treated patients. However, mortality in patients with large bowel fistulas was low (3.8 per cent) if deaths due to dissemination of the original neoplastic disease are excluded. Summary
Eighty-one cases of gastrointestinal fistulas are reported. Sixty-seven of these fistulas occurred postoperatively, all of them external, and fourteen occurred spontaneously, all but one internal. Fifty-two patients were treated conservatively and twenty-nine underwent operation, with an overall mortality rate of 23.4 per cent. It is noted that the presence of severe intraperitoneal infection and a high location of the fistula were associated with an unfavorable prognosis, with mortality rates of 31.4 per cent and 48 per cent, respectively. References
1. Halversen RC, Hogle HH, Richards RC: Gastric and small bowel fistulas. Ah J Surg 118: 986. 1969. 2. Nassos TP, Braasch JW: External small bowel fistulas. Current treatment and results. Surg C/in North Am 51: 687. 1971. 3. Welch CE, Edmunds LH: Gastrointestinal fistulas. Surg C/in NorthAm42: 1311, 1962. 4. Chapman R, Foran R, Dunphy JE: Management of intestinal fistulas. Am J Surg 108: 157, 1964. 5. Dudrick BJ. Wilmore DN, Vars HM. et al: Can intravenous feeding as the sole means of nutrition support growth inthe child and restore weight loss in an adult? An affirmative answer. Ann Surg 169: 974, 1969.
The American Journal of Surgery
