Scientific Research and Essays Vol. 6(21), pp. 4634-4638, 30 September, 2011 Available online at http://www.academicjournals.org/SRE DOI: 10.5897/SRE11.996 ISSN 1992-2248 ©2011 Academic Journals Full Length Research Paper Gastrojejunocolic fistula after gastroenterostomy with Billroth II reconstruction for duodenal ulcer: Report of a case Yin-Lu Ding*, Yong Zhou and Jian-Liang Zhang Department of General Surgery, The Second Hospital of Shandong University, Beiyuan Road, Jinan , 250033, Shandong Province, China. Accepted 24 August, 2011 Gastrojejunocolic fistula is a late, rare and severe complication of gastroenterostomy with Billroth II reconstruction for peptic ulcer and is associated with inadequate gastric resection and incomplete vagotomy. The fistula is thought to be due to perforation of a marginal ulcer into the transverse colon. In the past, attempted primary repair had high mortality and staged operations were normally performed. We herein report the case of a 60 year-old man with gastrojejunocolic fistula who was admitted to our hospital with a symptom triad of faecal vomiting/breath, chronic diarrhea and weight loss. His history included a distal gastric resection and Billroth II reconstruction for a duodenal ulcer 15 years previously. The laboratory data on admission revealed hypoproteinemia and hypoalbuminemia. Both barium-enema and colonoscopy examination showed the existence of the gastrojejunocolic fistula. After improving his state of malnutrition, a one-stage repair was performed. The postoperative course was uneventful and the patient was discharged on the 22th postoperative day. In this case, improved nutritional support allowed successful one-stage surgical repair to be performed. Key words: Gastrojejunocolic fistula, gastrectomy, stomal ulcer. INTRODUCTION Gastrojejunocolic fistula (GJF) is associated with patients with GJF, operative mortality following surgical previous gastroenterostomy with Billroth II reconstruction repair has been as high as 40%. Staged repair of GJF for peptic ulcer. It is thought to be the late, rare and with preliminary proximal colostomy, then later a second severe complication of a stomal ulcer which develops as operation (resection of involved colon and jejunum and a result of inadequate gastric resection or incomplete partial gastrectomy with or without vagotomy) has been vagotomy for peptic ulcer disease. GJF occurs in about favored to minimize mortality (Pfeiffer, 1941; Sorensen, 14% of cases of gastrojejunal ulcer and in about 0.5% of 1969). One-stage repair, a partial resection of the cases in which gastroenterostomy is performed (Walters remnant stomach, transverse colon, and jejunum which et al., 1939). Most patients with GJF present with a were involved in the fistula has also been possible with symptom triad of faecal vomiting/breath, chronic diarrhea the assistance of intensive preoperative and and weight loss (Alhan et al., 1990; Lowdon, 1953). The postoperative support. We report the management of a diagnostic investigation of choice to date has been case with GJF, seen at the Second Hospital of Shandong barium enema which has a sensitivity of 95% for this University, in December 2004. The application of barium condition (Lowdon, 1953; Thoeny et al., 1960). Given the enema and colonoscopy to the diagnosis of this improvement in endoscopic imaging and instruments, uncommon disease and the surgical strategy however, colonoscopy may now have a role in the implemented are described. diagnosis of GJF. Due to the poor nutritional status of CASE REPORT *Corresponding author. E-mail: [email protected]. Tel: +86- A 60 year-old Chinese man presented at our hospital for 531-85875563. Fax: +86-531-85875563. assessment of faecal vomiting/breath, chronic diarrhea, Ding et al. 4635 Figure 1. A lip-like fistula found by colonoscopy. passing as many as 15 ~ 20 pale stools per day and gastrectomy, posterior vagectomy, partial transverse severe weight loss on December 24, 2004. These colon and jejunum resection. symptoms had been present for 10 months. Over this Roux-en-Y reconstruction of bowel continuity was time his weight had fallen from 76 to 54 kg. His past applied by gastroenterostomy, jejunojejunostomy and medical history included a gastroenterostomy with Billroth colocolostomy. Postoperatively, the patient received II reconstruction for duodenal ulcer (DU) 15 years ago. A intensive care for 6 days and was able to resume a full complete blood count revealed a haemoglobin level of 92 diet on day 10 and TPN discontinued. Recovery was g/L (normal range, 110 to 160 g/L), a total protein level of uneventful; the patient remained well at follow-up. 46 g/L (normal range, 60 to 83 g/L), and an albumin level of 23 g/L (normal range, 35 to 53 g/L), a sodium level of 127 mmol/L (normal range, 136 to 142 mmol/L). There DISCUSSION were no other findings of note. Chest and abdominal X- rays were unremarkable. A lip-like fistula with a diameter The first gastroenterostomy was done in 1881 and until of about 2 cm was found in the middle of transverse recently was a frequently drainage procedure after colon by colonoscopy examination (Figure 1). The cavity vagotomy. In the era of Helicobactor pylori eradication for of residual stomach, afferent and efferent loop of jejunum peptic ulcer disease, there has been a great reduction in could be seen through the fistula (Figure 2); the jejunum the use of gastric surgery. However, awareness of the mucosa could also be seen through the fistula (Figure 3). potential complications of such surgery is still important A barium enema examination was done which showed as they can appear late with divastating effect. the residual stomach, jejunum and transverse colon Gastrojejunocolic fistula, which was first described in simultaneously (Figure 4). Total parental nutrition (TPN) 1903 (Forrest et al., 2000) is thought to be the late was given for 3 weeks until the patient’s albumin level complication of inadequate surgery resulting from simple improved to 38 g/L and after correction of his anemia; the gastroenterostomy, inadequate gastric resection or patient underwent laparotomy on January 15, 2005. Intra- incomplete vagotomy (Subramaniasivam et al., 1997). operatively, a ‘polya gastrectomy’ with a gastric remnant This results in stomal ulcer, which if untreated leads to of more than 50% and a GJF was seen. A radical en bloc the development of a fistula into surrounding organs. In resection was performed involving a subtotal our case, an insufficient resection of the stomach might 4636 Sci. Res. Essays Figure 2. The cavity of residual stomach (G), afferent (J1) and efferent (J2) loop of jejunum seen through fistula by colonoscopy. Figure 3. Jejunum mucosa could also be seen through the fistula by colonoscopy. be the cause of this disease. Besides inadequate gastric also be ascribed to malignant gastrinoma (Alhan et al., resection, or incomplete vagotomy, the stomal ulcer could 1995). The operations which most frequently cause GJF Ding et al. 4637 Figure 4. Barium enema showed the residual stomach (G), jejunum (J) and transverse colon (C) simultaneously. were a Billroth II reconstruction or a gastrojejunostomy approach was 2 to 3-staged operations even involving a without a gastrectomy, whereas Billroth I reconstruction preliminary diversion colostomy in order to ameliorate the accounted for only 6.8% of GJF (Ohta et al., 2002). Type nutritional status of the patient and to decrease mortality of ante- or retro-colic gastro-jejunostomy may also have (Lowdon, 1953; Pfeiffer, 1941). different effect on the incidence of GJF. In a group of I4 In the late 1930s, the 3-staged procedures included: 1) cases, all patients had had retro-colic gastro-jejunostomy colostomy, 2) resection of the fistula and, 3) colostomy which the colon lay directly upon the gastrojejunal closure (Cody et al., 1975). Then 2-staged operation was anastomosis (Samuel, 1945). It is important that when defined. This operation which is known as Lahey’s retro-colic gastro-jejunostomy is employed, the procedure was very popular because it was done with anastomosis should be made through an opening in the lower morbidity and mortality (Marshall et al., 1957). mesocolon placed near the base of the mesocolon and Advances in TPN over the last 30 years, however, allow as far as possible from the colon. Most patients with GJF the patient’s condition to be optimised before definitive present with a symptom triad of faecal vomiting/breath, surgery (Sorensen, 1969). This has been the trend in the chronic diarrhea and weight loss (Alhan et al., 1990; recent years, and both operative morbidity and mortality Lowdon, 1953). Diarrhea and weight loss are recognized have been subsequently minimized with one-stage in 80%. Faecal vomiting/breath are marked features for surgical repair (Alhan et al., 1995). Today, one-stage diagnosis and often cause severe embarrassment for resection can be applied and the mortality rates are patients. However, diarrhea may be the only complaint getting lower. In conclusion, GJF, although uncommon is (Forrest et al., 2000). The usual diagnostic test for GJF is seen occasionally in current medical practice as a result barium enema with diagnostic rate of 95% (Thoeny et al., of pastgastric surgery. To prevent the occurrence of GJF, 1960). The diagnositic value of colonoscopy is superior to adequate gastric resection or complete vagotomy for the gastroscopy with diagnostic rate of 85.7 and 44.4% peptic ulcer is necessary. Pri-operative examination and respectively. Diarrhea, weight loss and faecal in-operative exploration to exclude gastrinoma is of equal vomiting/breath were recognized in our case, both importance. Attention should be paid to those that barium-enema and colonoscopy examination showed the underwent gastroenterostomy for DU when diarrhea, existence of GJF. The surgical options and treatments of faecal vomtiting/breath and weight loss appeared. GJF have changed over the years. The historical Colonoscopy and barium enema are two methods with 4638 Sci. Res. Essays higher diagnostic rate. One-staged en bloc resection is Samuel F, Marshall (1945).