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International Journal of Surgery 10 (2012) 129e133

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International Journal of Surgery

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Review Gastrocolic fistulae; From Haller till nowadays

Michael Stamatakos a,*, Ioannis Karaiskos b, Ioannis Pateras b, Ioannis Alexiou c, Charikleia Stefanaki d, Konstantinos Kontzoglou c

a Generasl Surgeon, N. Athinaion M.D., Hospital, Athens, Greece b 1st Department of Surgery, Medical School, University of Athens, Laikon General Hospital, Athens, Greece c 2nd Department of Propaedeutic Surgery, Medical School, University of Athens, Laikon General Hospital, Athens, Greece d Medic. Athens, Greece

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Article history: Gastrocolic Fistula is, in the majority of cases the pathological communication between and Received 5 April 2011 transverse colon, because cases involved with the , and skin have been also Received in revised form documented, even though are rare. It occurs mostly in adults, but they can be present to infants, as well, as 14 February 2012 a result of congenital abnormalities or iatrogenic procedures (i.e. migration of PEG tube that placed before). Accepted 15 February 2012 In the Western Countries, the most common cause is the adenocarcinoma of the colon, while in Japan, Available online 20 February 2012 adenocarcinoma of the stomach is the most frequent cause. It seldom appears, as a complication of a benign peptic ulcer, in Crohn’s disease and as a result of significant intake of steroids or NSAIDs. Keywords: fi Gastrocolic fistula The typical symptoms of a gastrocolic stula are abdominal , -, and Colocutaneous fistula . NSAIDs Radiology has been used for the detection of the fistulae all these years but the golden standard Crohn’s disease remained the enema. Barium meal and CT findings play a smaller role in the diagnosis. Pharmaceutical treatment Although the management of gastrocolic fistulae has historically been surgical, medical treatment has Surgical treatment recently been recommended as the first line when a malignancy can be excluded. Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction the skin without other organ included), 2) internal (i.e. gastrocolic or cologastric, depending on which organ it originates, ileosigmoid, This condition was described in 1755 as a complication of gastric between a loop of ileum and the sigmoid part of the , carcinoma by Albrecht von Haller,1 while Douglas Firth described duodenojejunal fistulae, formed between loops of duodenum and the first case in English bibliography in 1920, as a complication of jejunum, respectively) 3) complicated (i.e. gastrojejunocolic, gastric ulcer disease.2 The fistulous tract is usually located between between the greater curvature of the stomach, more often, and the the greater curvature of the stomach and the distal half of the adjacent jejunum, gastropancreaticocolic fistulae, between transverse colon. There are two theories regarding to the mecha- stomach and large intestine due to adherence with the pancreatic e nism of its formation. At first, the neoplasm grows contiguously tissue).4 6 through the gastrocolic omentum from the originating organ to the Another classification divides them into primary (when they other and, secondly, the primary tumor develops an ulceration, occur spontaneously) and secondary (when they formed after followed by either a peritoneal reaction or exudation, which leads operative gastric resection),7 or after migration of a PEG feeding to an adherent formation of the adjacent structures and finally to tube. The fistulae that formed are also called iatrogenic.8 (Table 1). perforation of the other organ lumen.3 3. Etiology 2. Classification As already mentioned, gastric cancer is the most frequent cause fi Fistulae are classified according to accompanied organs that of gastrocolic stulae in Japan and Eastern Countries, while trans- involve: 1) external (i.e. colocutaneous fistula, between colon and verse colon adenocarcinomas are the most common cause in the Western World,3 with a reported incidence of 0.3e0.4% in operated cases.6,9 fi * Corresponding author. Tel.: þ30 6944133068; fax: þ30 2107485444. Gastrocolic stulae occur in approximately one in seven indi- E-mail address: [email protected] (M. Stamatakos). viduals with marginal or recurrent ulceration, they are more

1743-9191/$ e see front matter Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2012.02.011 REVIEW

130 M. Stamatakos et al. / International Journal of Surgery 10 (2012) 129e133

Table 1 in the right popliteal fossa should be reported, involving a case of Classification of gastrocolic fistulae. a low anterior dissection, operated 4 years ago, that was published 28 1. According to involved organs in 2008 by Dordea et al. External In children, gastrocolic fistulae are very rare, especially in Internal newborns and infants. Since 1970, only 3 cases have been reported Complicated in the literature, by Cook.29 The patients of the cases mentioned 2. According to their formation Primary (spontaneous) above died a few days after surgical correction of the fistula. Gas- Secondary (iatrogenic) trocolic fistulae result from perforation of the stomach into the 3. According to daily amount colon or of the opposite, mostly among premature and immature < Low out-put ( 500 ml) small-for-dates infants.30 This occurs because of stress ulcer, gastric High out-put (>500 ml) tissue ischemia or trauma, due to complications of necrotizing enterocolitis, Hirschsprung’s disease and meconium ileus, respec- tively. Also, gastrocolic fistulae in children can occur after migration common in women between 50 and 60 years of age, with reported or placement of PEG feeding tubes.29,30 predominance of 2/1 in Western World, while in Eastern Countries more common in men of same age with a 5:2 predominance.10 4. Symptomatology Except for a malignancy of the stomach or the colon, which is the most common cause in adults, they are also observed in peptic Typically, an adult patient with gastrocolic fistula presents with ulceration, Crohn’s disease, chronic pancreatitis, pancreatic abscess, malnutrition, visceral abdominal pain, nausea, vomiting (most carcinoid tumors of the colon, infiltrating tumors of the pancreas, times feculent), weight loss, diarrhea and complains of fecal hali- duodenum and biliary tract and diverticular disease, as e e tosis and eructation. Also, symptoms like gastrointestinal bleeding, well.3 6,9,11 13 Other rare causes, worth of mentioning are the resulting to anemia, dehydration and steatorrhea were record- increasing frequency of aspirin, NSAIDs, steroids and ACTH-intake, e e ed.1 3,7 10 Hematemesis, melena or hematochezia were reported in tuberculosis, trauma, Hodgkin’s lymphoma, gastric lymphoma, less than a third of the patients.5 The diarrhea is described as cold syphilis, gastric from Cytomegalovirus in patients who e and acidic, due to the rapid passage of gastric content and secre- suffer from HIV and migration of PEG feeding tubes.3,6,8,14 16 tions into the colon. Furthermore, bacterial colonization of the Coronary artery bypass procedure involving the right gastro- stomach and gastric acid irritate the colon and exacerbate the epiploic artery, has also been reported as a cause of a gastrocolic diarrhea.6 As a consequence, the skin around anus and around the fistula.7 Additionally, a rare case has been mentioned by James and orifice in a colocutaneous fistula becomes irritated and eroded. Key in 1948 after bilateral for a stomal ulcer, which led to Even though, diarrhea is usually described as an outstanding the formation of a gastrojejunocolic fistula as a result of further symptom, its presence is variable. It may be intermittent or absent penetration.17 At this point, two cases, who sustained bariatric altogether and may be present. As Mathewson surgery, who developed a gastrocolic fistula, will be reported. The reported, when diarrhea was present, the gastrocolic opening was first one refers to a slippage of a gastric band, which adjusted large or there was some obstruction to the normal flow of gastric laparoscopically, inside the transverse colon, as found with the contents through the pylorus. On the other hand, in enterocolic or assistance of the . The patient underwent laparoscopic gastrojejunocolic fistulae where a small intestine segment was band removal and closure of both stomach and colon walls, thus involved, diarrhea was invariably present. As a conclusion, diarrhea treating the fistula.18 Slippage is the most common band-related was the result of a low threshold of irritability of the upper complication.19 Gastric perforation and bleeding, gastro-gastric for colonic patients.31 fistula, pouch dilatation, esophageal dilatation and dysmotility, Because of its extreme rarity in children only symptoms have food intolerance, and intragastric band migration (erosion) are not been well documented. Stools appear watery and milky, vom- other possible band-related complications.20,21 The other one refers iting of colonic material immediately after eating is also present, to a gastrocolic fistula formed after a re-sleeve to a 54- children are always hungry and they loose weight rapidly.30 year-old female patient, which treated with the placement of an (Table 2). for 19 days and laparoscopically repair of the fistula.22 5. Physical findings Finally, a gastrocolic fistula was presented in a 60-year-old female from China due to a metastatic marginal ulcer from cervical The most often findings in these patients are tenderness and carcinoma.23 distension. The abdominal examination is positive for approxi- Concluding with the causes of the internal gastrocolic fistulae, mately the 50% of those patients.6 Borborygmi and spasm can also some causes of the colocutaneous fistulae should be reported. They be present and palpable masses were reported in 64% of patients are commonly associated with diverticular diseases or inflamma- tory bowel disease and usually involve the lower abdominal wall. fi Throughout the references, formation of colocutaneous stula is Table 2 reported often after abdominal trauma due to delayed rupture of Symptomatology of gastrocolic fistulae. descending colon more often.24 Other rare cases that are docu- Water and electrolytes loss mented refer to a complication after therapeutic percutaneous Malnutrition mesenteric embolization to massive lower gastrointestinal Metabolic disorders-Vitamin insufficiency bleeding,25 to patients who also suffer from co-morbid diseases and Sepsis surgical treatment is not recommended and a late complication of Respiratory failure 26 Hepatic failure total hip replacement in rheumatoid arthritis. At this stage, Renal failure a unique case should be mentioned, which occurred to a 60-year- Multiple Organ Failure Syndrome old female Chinese who suffered a colocutaneous fistula for around Skin and abdominal wall lesions 30 years after removal of left renal stones and developed to Hemopoietic system disorders Septic emboli a squamous cell carcinoma.27 Herein, another colocutaneous fistula REVIEW

M. Stamatakos et al. / International Journal of Surgery 10 (2012) 129e133 131 with gastrocolic fistula.6 is absent and the is normal without occult blood in the stool. Physical examination and medical history, contribute to differential diagnosis between peptic ulcer and to cancer. Faulty anastomosis must be included in differential diagnosis especially in patients who had been operated for must not be excluded.6

6. Laboratory findings

The laboratory findings are consistent with those of malnutri- tion and acute or chronic loss of electrolytes. The total serum protein levels are decreased and hypoalbuminemia occurs due to vomiting. Anorexia and malabsorption, resulting from avitamin- oses B and D, are also present.6 Hypochromic anemia occurs, secondary to malignancy, in most patients, while white blood cell count, erythrocyte sedimentation rate and C reactive protein ranging between normal values.6 One study reports a peptic ulcer disease patient with reported fasting serum gastrin levels greater than 1000 pg/ml (1044 pg/ml), which indicated Zollinger-Ellison syndrome (gastrinoma). Such a gastrinoma was not present and surgical correction of the fistula resulted in normalization of the serum gastrin.32 Fig. 1. A gastrocolic fistula (barium meal). 7. Complications-pathophysiology

6,33 Clinical disorders associated to a gastrocolic fistula are of a broad colon. On the other hand, the barium meal may miss the diag- spectrum. Gastrointestinal loss of water and electrolyte, leads to nosis in 30 up to 70% of cases, because the barium column exerts less 11,14,34 metabolic disorders, vitamin insufficiency and severe malnutrition. pressure than the barium enema does. (Figs. 1 and 2). fi Respiratory, hepatic and renal insufficiency and disorders from the Gastroscopy and colonoscopy are not rst line examinations for fi hemopoietic system (anemia, leucopenia, thrombocytopenia) are the gastrocolic stula diagnosis, since the communication can be usually the results of combined existence of malnutrition and easily missed between the gastric folds or the colonic haustrae, fi fi 11 sepsis. unless the stulous ori ce is big enough and can be visualized. In colocutaneous fistulae, the skin lesion than can be caused by Both of them must be taken preoperatively to rule out underlying the irritation of the septic content around the orifice of the fistula, malignant disease as a cause by obtaining cytological and biopsy 11,14 may be severe enough and an eczema is possible to be formed materials, while the role of CT scan to the diagnosis is doubtable rendering its healing difficult. (Table 3.) but it is of great importance in preoperative planning by delineating the fistula, assessing its extent and identifying the subsequent etiology.3,9 8. Radiologic diagnosis Finally, the colocutaneous fistulae are best detected by a fistu- logram contrast medium is instillated through the orifice at the skin In most cases, the diagnosis can be made on the basis of the and plain films are taken to identify the extent and pathway of the careful history and physical examination, whether the fistula is due fistula.35 to complications of cancer or peptic ulceration disease. The differ- ential diagnosis of faulty gastroileal or gastrocolic anastomosis in previously operated peptic ulcer patients must be excluded but it is easily ensured by roentgenologic examination.6 The most reliable diagnostic method by far is the barium enema, which confirms the diagnosis in 90e100% of all cases.11 By means of the enema, the barium is administered slowly, the fistula may be clearly demonstrated by increasing the intraluminal pressure within the bowel and the stomach may be seen to be filled rapidly from the

Table 3 Complications of gastrocolic fistulae.

Typical symptoms Crampiform abdominal pain Nausea Feculent vomiting Weight loss Diarrhea Eructations Atypical symptoms Hematemesis Melena Hematochezia Steatorrhea Fig. 2. The same patient (arrows indicate the fistula). REVIEW

132 M. Stamatakos et al. / International Journal of Surgery 10 (2012) 129e133

9. Preoperative care-surgical therapy years several tactics and procedures took place. Even if it is a condition that needs operation a few cases of closure after The therapy for gastrocolic fistulae remains surgical. Patients medical treatment with PPIs have been mentioned. After all, we have to be prepared for two to three days for best results, especially must emphasize that it is a serious pathologic condition that can in cases where potassium normalization must be achieved. This lead to . preparation includes a high protein, high carbohydrate and low residue diet, parenteral fluids and electrolyte solutions with large Conflicts of interest doses of vitamins B and C and blood transfusions in case of anemia. None declared. Intravenous antibiotics, such as tetracyclines or aminoglycoside must also be administrated.6 Funding Supportive parenteral nutrition is preoperatively provided to all None declared. the patients to improve their general condition.30 Conservative management may be successful, including endoscopic injection of Ethical approval the fistulous tract with fibrin sealant, especially when the cause of None declared. the gastrocolic fistula is peptic ulceration disease.36,37 It is well documented that octretide, a long-acting somatostatin analog has been used successfully to prevent postoperative Author contribution complications, in fistulae that involve the pancreas. Parenteral administration seems to reduce significantly the output in both Michael Stamatakos: search of the literature, partial English internal and external fistulae but it does not participate to the editing, and correction closure of the fistulae. Its optimal dosage and duration of use Ioannis Karaiskos: editing 5 depends on the fistula itself. Ioannis Pateras: search of the literature Before the 1930s, simple excision of the fistulous tract was ChS: editorship of the manuscript performed, by en-bloc resection of the involved stomach and Ioannis Alexiou: search of the literature segment of the colon. Gastroenteric continuity was re-established Konstantinos Kontzoglou: final editing and corrections using a or Billroth II anastomosis and the colon was reapproximated with a closed end-to-end single layer anasto- 6,12 mosis. Because of the high frequency of complications, including References re-perforation and severe peritonitis, Pfeiffer and Kent, in 1939 recommended a preliminary , allowing an interim period 1. Haller A. Opuscula pathologica, 1755. In: Voorheeve N, editor. Die klinische und of recovery prior to resection. The continuity of the colon is radiologische diagnose der fistula gastrocolica. Deutsch Arch Klein Med 1912;vol. e 6,16,31,38 106. p. 294 308. establishing 3 or 4 months later. Although radical en-bloc 2. Firth D. A case of gastrocolic fistula. The Lancet 1920;195(5046):1061. resections seem to be the surgery of choice all these years, most 3. Forshaw M, Dastur J, Murali K, Parker M. Long-term survival from gastrocolic patients had a poor prognosis and only one survived for more than fistula secondary to adenocarcinoma of the transverse colon. World J Surg Oncol fi 3,10 2005;3(1):9. 9 years if the stula is of malignant origin. It must be well 4. Ruffolo C, Angriman I, Scarpa M, Bertin M, Pagano D, D’Amico DF, et al. understood that the surgical operation is unique for each patient, A gastrocolic fistula in Crohn’s disease. Dig Dis Sci 2005;50(5):933e4. with a common, specific aim$ to be radical resection with tumor- 5. Abeygunasekera S, Freiman J, Engelman J, Glenn D, Craig P. Gastro- pancreaticocolic fistula: complication of a benign ulcer. 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