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10.1245/s10434-006-9117-6
Annals of Surgical Oncology 13:1622-1626 (2006)
© 2006 Society of Surgical Oncology
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Original Article

Perineal Small Bowel Fistula After Pelvic Exenteration for Cancer: Technical Guidelines for Perineal Fistula

Olivier Turrini, MD1, Jérome Guiramand, MD1, Vincent Moutardier, MD, PhD4, Frédéric Viret, MD2, Djamel Mokart, MD3, Anne Madroszyk, MD2, Bernard Lelong, MD1, Thierry Bège, MD1, Jean-Louis Blache, MD3, Gilles Houvenaeghel, MD1 and Jean-Robert Delpero, MD1

1 Department of Surgical Oncology, Institut Paoli-Calmettes and Universitéde la Méditerranée, 232 Bd de Sainte Marguerite, 13009, Marseille, France
2 Department of Medical Oncology, Institut Paoli-Calmettes and Universitéde la Méditerranée, Marseille, France
3 Department of Intensive Care, Institut Paoli-Calmettes and Universitéde la Méditerranée, Marseille, France
4 Department of Digestive and General surgery, Hôpital Nord and Universitéde la Méditerranée, Marseille, France

Correspondence: Address correspondence and reprint requests to: Olivier Turrini, MD; E-mail: oturrini{at}yahoo.fr


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background: To determine guidelines for the management of perineal small bowel fistula (PSF) after total or posterior pelvic exenteration.

Methods: During 15 years, 315 curative pelvic exenterations were performed. PSF occurred in 15 patients (3.5%). We retrieved the precise modality of radiotherapy (fields and doses) and management of all patients (type of surgery, number of surgery and mortality). Delay of occurrence was divided in early (within 30 days or before hospital discharge) and delayed.

Results: All patients underwent surgery. Mortality rate was 13%. Fourteen patients (93%) had history of radiotherapy. No PSF was noted after anterior pelvic exenteration. Higher frequency of PSF was noted after total pelvic exenteration versus posterior pelvic exenteration (P = 0.04). Early PSF occurred in four patients (27%) with higher frequency of small bowel intraoperative injury. Late PSF occurred in 11 patients (73%) divided in small bowel injury in contact with pelvic staples (n = 4) and disease recurrence (n = 6, local recurrence or carcinomatosis). One patient had delayed PSF by ulceration of small bowel in contact with pelvic drain.

Conclusion: PSF was a life-threatening complication of pelvic exenteration. Radiotherapy leads to weaken small bowel with difficulty of cicatrisation. During pelvic exenteration: (a) extreme careful dissection and interposition of great omentum could avoid small bowel injury, (b) control of pelvic vessels and closure of rectum remnant should not used staplers. Intra-operative management of PSF used successful simple repair in case of early PSF or segmentary resection indeed enlarged to right colon in case of delayed PSF. Postoperative courses had to use intravenous hyperalimentation and digestive tract discharge.

Key Words: Pelvectomy • Perineal fistula • Radiotherapy • Small bowel


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Exenteration has a major role in the treatment of advanced or recurrent pelvic cancer. En bloc removal of the pelvic viscera in case of central tumor improves survival for persistent cancer of the cervix after radiation therapy, and advanced or recurrent vaginal, vulvar or rectal cancer.1–5 The results of our series of pelvic exenterations are identical to other series published around the world.6,7 Enhancement of local control by optimization of resection margins is the main role of radiation therapy. Thus, the majority of patients undergoing pelvic exenteration had received full-dose radiotherapy, increasing their risk for postoperative complication. However, the mortality rate after pelvic exenteration has decreased significantly during the last decade.8–10 PSF represents a rare but life-threatening complication of pelvic exenteration. Because the high outflow of corrosive digestive fluid leads to severe and intolerable inflammation of perineal tissues, medical management is often ineffective. Precise identification of the mechanism of PSF and appropriate repair of irradiated tissues is essential to avoid recurrence of PSF. We retrospectively reviewed the medical charts of patients who have had pelvic exenteration for cancer in our institution during 15 years to characterize the factors leading to PSF and to delineate the optimal management.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The charts of patients who were treated with pelvic exenteration at Institut Paoli-Calmettes between January 1990 and December 2004 were reviewed. Three hundred and fifteen curative pelvic exenterations (155 posterior pelvic exenterations, 115 total pelvic exenterations and 45 anterior pelvic exenterations) were performed. The primary cancers were cervical cancer (n = 125), ovarian cancer (n = 90), colorectal cancer (n = 78) and sarcoma (n = 22). The terminal digestive tract was not restored in 91 patients and the anal canal or rectum remnants were always closed by stapler. In the case of cystectomy, a urinary tract was achieved by ureteral reimplantation through ileal (Bricker’s procedure) or right colon (Miami procedure) pouch.11 A myocutaneous flap was used in 62 patients: (a) to fill the pelvic cavity in the case of a large defect after pelvic or pelviperineal exenteration or (b) for vaginal reconstruction.12,13 A vascular stapler was usually used to divide an immovable high volume tumor from major pelvic vessels (hypogastric vessels).

Fifteen patients (3.6%) developed PSF defined by enteric fluid exteriorized through a perineal wound, anus remnant, coloanal anastomosis or vaginal remnant regardless of outflow level. Primary medical treatment always combined aspirated gastric tubes, parenteral hyperalimentation and continuous intravenous octreotide (300 µg per day). Postoperative intravenous hyperalimentation and gastric tubes were always used until normal digestive transit and the absence of suspect perineal fluid exteriorization were noted. Postoperative antibiotherapy was not routinely used.

The delay (in days) between pelvic exenteration and diagnosis of PSF was noted. Early PSF was defined as occurring within 30 days or before hospital discharge. Late PSF was defined as occurring after 30 days, or after hospital discharge. The total dose of abdominal radiotherapy (grays), the origin of the fistula, the surgical delay from the diagnosis of PSF (in days), the number and type(s) of surgery(ies), the surgical procedure used to avoid repeated fistula, and the cause of death were noted.

Data were tabulated into Microsoft Excel (Seattle, WA) spreadsheets. Statistical analysis was completed using a commercially available software SPSS (Chicago, IL). Statistical significance was determined by the log rank test.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
PSF occurred at an average of 220 days (range 6–660) after pelvic exenteration (Table 1Go). Medical treatment was always ineffective and all patients underwent surgical management with a mean delay of 3 days (range 1–5) after diagnosis of PSF. Fourteen patients (93%) have had an abdominal or pelvic radiotherapy with an average delivered dose of 44.5 Gy. No patients developed PSF after anterior pelvic exenteration. PSF after total pelvic exenteration or posterior pelvic exenteration occurred in 8% (nine patients) and 4% (six patients) (P = 0.04), respectively. Patients having myocutaneous flap reconstruction (n = 62) or not (n = 253) developed PSF in 1.6% (one patient) and 5.5% (14 patients) (P = 0.04), respectively. Early PSF and late PSF were noted in four cases (27%) and 11 cases (73%), respectively. Six patients (40%) needed more than one surgical procedure (average 2, range 1–5). Two patients (13%) died of causes directly related to PSF.


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  		TABLE 1. Details of patients with PSF (perineal small bowel fistula)
 
Patients with Early PSF (n = 4)
Two patients had PSF due to unrecognized intra operative small bowel injury (days 6, 12). Surgical management consisted of successful simple repair of small bowel.

One patient had not had any radiotherapy and acquired PSF by ulceration of the small bowel in contact with staples used for vascular control of hypogastric vessels (day 21); surgical management consisted of one successful simple repair of the small bowel.

One patient acquired PSF by ulceration of the small bowel in contact with staples used for closure of the rectum remnant (day 25); surgical management consisted of short resection with end-to-end anastomosis. This patient had four other recurrences of PSF always due to leakage of anastomosis, and finally a terminal ileostomy was performed with fatal outcome (day 42) due to massive pelvic hemorrhage following leakage of a previously stapled hypogastric artery in a septic pelvic cavity.

Patients with Delayed PSF (n = 11)
Four patients acquired PSF by ulceration of the small bowel in contact with staples used for vascular control of hypogastric vessels (days 210, 300, 660) or closure of the rectum remnant (day 65). The surgical procedure was successful small bowel resection in three cases combined with epiploplasty to avoid contact of the small bowel with staples. One patient needed one identical supplementary procedure.

Six patients acquired PSF due to pelvic recurrence (n = 4) or peritoneal carcinomatosis (n = 2). The PSF mechanism was occlusion with perforation of the distended small bowel (n = 4) or involvement of the terminal ileal loop (n = 2). The surgical procedure was segmentary resection of the small bowel with end-to-end anastomosis without resection of recurrence or carcinomatosis. Among these, one patient had repeated PSF, requiring three reinterventions, and finally terminal jejunostomy and death caused by multi organ failure. Three patients required one reintervention for repeated PSF. All patients with involvement of the terminal ileal loop had recurrence of PSF treated by successful resection of the terminal small bowel enlarged to the right colon with ileocolic anastomosis. Two tentative exclusions of the pelvic cavity by placement of a resorbable mesh failed with repeated PSF.

One patient had ulceration of the small bowel in contact with a suction pelvic drain (day 82) left in place due to unsolved urinary fistula. The surgical procedure was successful simple repair.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
PSF after pelvic exenteration was a rare (3.5%) but concerning complication because it is: (a) associated with a high mortality rate (13%) and (b) frequently indicative of disease recurrence (40%). PSF induced an intolerable perineal cellulitis due to the failure to adapt a satisfying device to collect a high outflow of digestive fluid from the perinea. Thus, medical treatment was always ineffective. Recurrence of PSF indicated a concerning cycle (Fig. 1Go) because death always occurred if more than two surgical procedures were needed.


Figure 1
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  		FIG. 1. Vicious circle of repeat PSF (perineal small bowel fistula).

 
In 1976 Berman et al.14 published the first series of PSF reports. For 17 years (1956–1973) various therapeutic modalities led to a concerning mortality rate of 80%. Thus, a specific program was established and divided into three phases: (a) preoperative management associating hyperalimentation, routine antibiotherapy and reduced surgical delay; (b) perioperative management with isolation without excision of the damaged segment, mucocutaneous fistulae for the defunctionalized segment and cutaneous ileostomy when a tumor is present; (c) postoperative management with systematic gastric tube, hyperalimentation and antibiotics. In this way, four patients were managed without mortality. Pre- and postoperative management were similar. However, perioperative isolation of the damaged segment was not performed and should not be proposed because improvement of pelvic surgery, perioperative anaesthetic management and intensive care permitted a safe resection in the absence of local recurrence.

In our experience three questions needed precise answers: (a) Why did PSF occur? (b) What was the best intraoperative management? (c) How can recurrences be avoided? Furthermore, PSF almost always occurred in patients who have had abdominal or pelvic radiotherapy. Thus, the small bowel had radiation-induced modifications of the wall structure and vasa vasorum leading to cicatrisation difficulty and then exposure to repair failure.

Technical Aspect During Pelvic Exenteration
Each surgeon had to be concerned with PSF or intra-abdominal digestive fistula when performing a pelvic exenteration. Generally, total or posterior pelvic exenteration needed abdominal and pelvic dissection of already operated fields. Thus, perforative or preperforative injuries were possible. We recommended extremely careful small bowel dissection and verification of all digestive tubes before closing the abdomen in order to recognize and carefully repair all injuries. In case of electric damage due to electric dissector, reviving the small bowel wall was recommended in order to perform a suture on a well-vascularized structure.

In our study, PSF always occurred after total or posterior pelvic exenteration, and total pelvic exenteration led to a higher incidence of PSF than posterior pelvic exenteration (P = 0.04). Thus, anterior pelvic cavity exenteration was safer. Pelvic cavity exenteration leaves behind two pitfalls for an irradiated small bowel: natural bone spines and recesses and salient staples possibly used for control of pelvic vessels or closure of the rectum remnant. In our study, natural bone spines or recesses were not directly incriminated but we can hypothesize that they had a minor role in patients with repeated PSF after careful end-to-end anastomosis. Staples used for vascular control or closures of the rectum remnant were aggressive for a fragile small bowel. Thus, we recommended possibly using a simple ligature to control pelvic vessels. A vascular stapler had to be used only in the case of a high volume tumor with mobilization difficulty. Similarly, staples should be used for closure of the rectum remnant if combined with enclosure of the stapling wire by continuous suturing.

The great omentum should be used to exclude the small bowel from the pelvis to prevent contact with the pelvic cavity or pelvic staples. The omentum can be separated from the transverse colon mesentery and transferred on either of its vascular pedicles with low morbidity.15 However in many reoperative cases great omentum has already been resected or it may not have adequate bulk to fill a large cavity.

A myocutaneous flap was also used and keeping the small bowel out of the pelvic cavity significantly decreased the risk of PSF (P = 0.04). However, this procedure should not be used routinely in all pelvic exenterations but can be considered in cases of large pelviperineal resection.12,16,17

Exclusion of the pelvic cavity by a prosthetic device used for breast reconstruction was successfully used for small bowel protection before radiotherapy and should be proposed in patients with high risk of PSF (pelviperineal dissection, high dose of preoperative radiotherapy, use of pelvic staples).18

Technical Aspect During Laparotomy for PSF
Progress in surgery, especially in peri- and postoperative intensive care, permitted complex surgical procedures and isolation without excision of the damaged segment should not be proposed.

Immediate postoperative PSF was frequently the consequence of small bowel intraoperative injury. Simple careful repairs were the best option and segmentary resection was unnecessary.

The mechanism of delayed PSF incriminated small bowel injury by pelvic staples or disease recurrence. Trauma by staples was always successfully treated by segmentary resection of the small bowel combined when possible with epiploplasty. Total exclusion of the pelvic cavity by interposing prosthetic resorbable mesh was ineffective because intestinal weight, bowel movements or proper fistula recurrence led to removal of the device.

PSF indicating disease recurrence (40%) was the worst situation. Involvement of the terminal ileal loop by a pelvic recurrence always led to PSF recurrence when segmentary resection of the small bowel was achieved. Thus, we recommended performing primary large resection of the terminal small bowel enlarged to the right colon because ileocolic anastomosis did not have contact with the pelvic cavity and no anastomotic fistula was noted after this procedure. Resection of pelvic recurrence was not performed during the same surgery due to: (a) the brutal occurrence of PSF and necessity of emergency surgery did not permit characterization of the recurrence and detection of eventual msetastasis; (b) treatment of local recurrence may require preoperative radiotherapy; (c) complex pelvic dissection was hazardous in a potentially septic context. Thus, we recommended: (a) treatment of the PSF, (b) restoration to a good clinical status, (c) characterization of the pelvic recurrence (locally and generally), (d) assessment of the situation to determine the best management (preoperative radiotherapy or radiochemotherapy if possible, type of surgery...). Moreover, treatment of disease recurrences revealed by PSF was obviously delayed, with decreased survival.

The presence of peritoneal carcinomatosis was the concerning situation because anastomosis after segmentary resection always leads to failure. Association of radiation-induced modifications of the small bowel, carcinomatosis and poor clinical status certainly decreased the cicatrisation capacity. We did not indicate a better management than iterative surgery, including terminal jejuno or ileostomy. The objective was to rapidly restore an acceptable digestive tract in order to permit the treatment of the carcinomatosis.

PSF due to ulceration of the small bowel by a pelvic drain was treated by successful simple repair. However this demonstrated that all details are important during and after pelvic exenteration, especially on an irradiated small bowel.

Attentive postoperative management must combine intravenous hyperalimentation and digestive tract discharge to permit a correct cicatrisation and to avoid septic problems, as in other complex digestive surgeries.


   CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
PSF was a concerning complication and the best approach consisted of prevention by observing simple technical patterns during exenteration. PSF surgery must: (a) identify occurrence factors in order to use the best device to avoid repeated PSF; (b) perform careful repair with various techniques, from simple repair in cases of early PSF with good tissues to large resection in cases of repeated PSF or in the presence of recurrence. Postoperative management was essential to avoid difficulty of cicatrisation and sepsis.

Received for publication May 26, 2006. Accepted for publication June 5, 2006.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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