Journal of Surgical Oncology 21:33-36 (1982)

Ma1ignant Duodenocolic Fistulas:

A Case Report and Review of the Literature
ALFRED E. CHANG, MD, AND JONATHAN E. RHOADS, MD, FACS
From the Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia

A case of primary malignant duodenocolic fistula is presented. Colonic

carcinoma is the most common etiology of this entity. Clinical features
include diarrhea, weight loss, anemia, and feculent vomiting. Review of
the literature indicates that the treatment of choice is a right
hemicolectomy with a pancreaticoduodenectomy or segmental duodenec-
tomy if the disease is localized. Forty-six percent of patients undergoing
this procedure have been reported to be alive more than 2.5 years later. If
the disease is disseminated, the best palliative procedure appears to be a
right hemicolectomy with a partial duodenectomy. The early morbidity
and mortality associated with this latter procedure have been attributed
most often to dehiscence of the duodenal closure.

KEY WORDS:duodenocolic fistula, colonic carcinoma

INTRODUCTION blood. Laboratory evaluation was remarkable for a

Malignant duodenocolic fistulas are rare. Carcinoma hemoglobin of 7.3 gm% with a normal white cell count.
of the colon usually arising from the hepatic flexure or Electrolytes and liver function studies were normal.
proximal transverse colon is the most common etiology. Serum protein evaluation revealed a depressed albumin
The incidence of duodenocolic fistula has been estimated of 2.7 gm% and a total protein of 5.9 gm%.
to occur in about 1 in 900 colorectal carcinomas [I]. A The patient was placed on intravenous hyperalimenta-
total of 63 primary malignant duodenocolic fistulas have tion the day of admission. Barium enema examination
been reported in the world literature [2-181. This report revealed a fistulous tract between the hepatic flexure and
of a new case illustrates the clinical features and the second portion of the duodenum (Fig. 1). This was
problems associated with malignant duodenocolic confirmed by an upper gastrointestinal study. Gastro-
fistulas which differ markedly from uncomplicated duodenoscopy was remarkable for an ulcerated lesion in
colonic cancer. The experience of different surgical the duodenum. Biopsy of the lesion was consistent with
approaches to this problem is reviewed. chronic inflammatory tissue but showed no tumor. After
2 weeks of hyperalimentation the patient underwent a
CASE REPORT laparotomy.
A 77-year-old white male was admitted to the Hospital At surgery, a tumor measuring 7 x 6 cm2 was found in
of the University of Pennsylvania with a 6-week history the hepatic flexure of the transverse colon and was
of diarrhea. The diarrhea was described as clay colored adherent to the anterior wall of the duodenum (Fig. 2A).
without melena and was associated with crampy lower In addition, a mass in the lateral aspect of the right lobe
abdominal pain. The patient also experienced an of the liver was found and a needle biopsy done. A
18-pound weight loss during these 6 weeks. He denied frozen section examination proved it to be metastatic
any nausea, vomiting, fever, or chills. He had undergone adenocarcinoma. It was felt that the patient would bene-
a cholecystectomy and common bile duct exploration fit from a palliative resection of the primary tumor. A
several years earlier. right hemicolectomy was performed wjth excision of the
On physical examination the patient was noted to be in
no acute distress with normal vital signs. Abdominal Accepted for publication February 9, 1982.
Address reprint requests to Alfred E. Chang, MD, Department ot'Sur-
examination revealed no evidence of tenderness or gery, Hospital of the University of Pennsylvania, Philadelphia, PA
masses. Rectal examination was positive for occult 19104.
0022-4790/82/2101-0033$01.50 0 1982 Alan R. Liss, Inc.
34 Chang and Rhoads
anterior duodenal wall. The duodenal wall defect was
closed transversely in two layers, and the suture line
reinforced with omentum. A T-tube was placed in the
common bile duct with the distal arm extending through
the ampulla into the duodenum. The specimen revealed
a moderately differentiated colloid adenocarcinoma of
the colon invading the duodenum with a fistulous tract
within the tumor (Fig. 2B). The specimen margins were
clear of tumor; 5 of 21 regional lymph nodes had
evidence of metastases. During the postoperative period
the patient was maintained on hyperalimentation.
Gastric emptying was delayed due to scarring or edema
at the duodenotomy site as demonstrated by follow-up
barium studies. This resolved with the administration of
metoclopramide. Adequate oral intake was achieved
(approximately 1400 cal per day) and the metoclopra-
mide discontinued by the third postoperative week. He
was subsequently discharged to have 5-fluorouracil
chemotherapy as an outpatient. Recent follow-up
examination revealed him to be alive and doing well
eighteen months since surgery.
DISCUSSION
The first documented case of a primary malignant
duodenocolic fistula was recorded by Haldane in 1862
[14]. Since that time 63 such cases have been recorded in
Fig. I . Barium enema with arrow indicating fistulous tract to the the literature. These cases consisted of 54 colonic
duodenum with filling of the proximal small bowel.
carcinomas, 1 colonic lymphosarcoma, 2 gallbladder
carcinomas, 1 duodenal carcinoma, and 5 carcinomas of
undetermined origin. In 1947, Calmenson and Black
reviewed 1400 cases of right colonic cancer at the Mayo
Clinic and found only 2 complicated by a duodenocolic
fistula [3]. More recently Welch and Warshaw reported

B
Fig. 2. (A) Photograph of the resected specimen which showr probe
through the fistulous tract. (B) Photomicrograph depicting moderately
differentiated colloid adenocarcinoma invading the duodenum
(hematoxylin and eosin stain).
 Duodenocolic Fistula 35

the experience at the Massachusetts General Hospital TABLE 1. Clinical Features Associated With Malignant
and found 5 cases of malignant duodenocolic fistula, Duodenocolic Fistulas*
and estimated its occurrence to be 1 in 900 colorectal Finding Incidence ( 7 0 )
tumors [l]. A review of the medical records of the
Diarrhea 51 (80)
Hospital of the University of Pennsylvania during the Weight loss 46 (72)
last 17 years did not reveal additional cases of this Pain 37 (58)
uncommon entity. Benign processes leading to duodeno- Anemia 33 (51)
colic fistulas are also rare. These include duodenal ulcer, Vomiting 27 (42)
diverticulitis, regional enteritis, ulcerative colitis, tuber- Palpable abdominal mass 24 (38)
Undigested food in feces 11 (17)
culous lymphadenitis, ruptured appendicitis, pancreati- Feculent emesis I 1 (17)
tis, and foreign body penetration [20].
The mean age of the patients reported in the literature *Collected from 64 reported catet
is 54.7 years with a range of 27 to 85. The male: female
ratio is 3.8:l which is much higher than that found in
cancer of the right colon in general, as previous review- closing these large defects [lo]. The longest period of
ers have already indicated [ 5 ] . Symptoms associated with survival reported in patients undergoing this operation
the entity are listed in Table I. The clinical presentation is was 16 months. Recurrence of tumor was seen in most of
similar to a gastrocolic or gastrojejunocolic fistula. the patients.
Diarrhea is the most prominent symptom and can be sig- Complete resection of the involved duodenum was
nificant enough t o result in electrolyte imbalances, first performed by Linton in 1944 [6]. His radical
hypoproteinemia, and hypovitaminoses. The diarrhea approach to the problem of malignant duodenocolic
has been attributed to any or all of the following causes: fistulas involved combining the Whipple technique of
(a) the presence of hydrochloric acid in the colon causing pancreaticoduodenectomy with a right hemicolectomy.
hyperperistalsis and irritation of the colonic mucosa; (b) He performed this in two stages. In the first procedure
regurgitation of colonic contents into the small bowel the fistula was isolated from the stomach by a gastro-
leading to fecal contamination of the small bowel with jejunostomy and an ileotransverse colostomy. The pa-
bacterial enteritis; (c) irritation of the colonic mucosa by tient was then able to be nutritionally repleted. A second
unconjugated bile acids being shunted through the fis- procedure included the pancreaticoduodenectomy and
tula [21]. Weight loss is present in 72% of these patients. right hemicolectomy. In 1955 the first one-stage right
Physical findings include a palpable abdominal mass hemicolectomy and pancreaticoduodenectomy for a
38% of the time. malignant duodenocolic fistula was reported by Janes
The diagnosis is most often made by barium enema. and Mills [7]. Gallagher applied the term extended right
Upper gastrointestinal studies have not been as accurate hemicolectomy for this surgical approach to malignant
in documenting the fistulous tract [5]. Characteris- duodenocolic fistulas [ 1 11. Thirteen cases have been
tically, retrograde obstruction to the flow of barium is reported after having this operation (Table 11). There
usually present at the hepatic flexure with sudden filling were no postoperative deaths. Six of the patients (46%)
of the small bowel. Occasionally an irregular mucosal survived at least 2.5 years after surgery with the longest
pattern may be seen to help make a diagnosis of a survivor reported alive 26 years after operation. Lymph
neoplasm. node status of the resected specimens was reported on
A variety of surgical procedures have been reported in three of the six patients surviving more than 2.5 years,
dealing with this problem. Resection of the tumor seems and all were negative for metastases.
to provide the best palliation as well as chance for a cure. Two cases involved segmental duodenectomy without
If feasible, the procedure should include a right any pancreatic resection. I t would appear that right
hemicolectomy, ileotransverse colostomy, and excision hemicolectomy with pancreaticoduodenectomy or seg-
of the fistulous tract and involved duodenum. The pro- mental duodenectomy is the preferred procedure for
cedure most frequently employed in the literature has cure if disseminated disease is not present. The patient
been a right hemicolectomy and partial duodenectomy described in this report presented with a liver metastasis
with simple closure of the duodenal wall defect. at the time of surgery. Attempt for a curative resection
Eighteen such cases have been reported with a post- was abandoned, and the patient accordingly had a
operative mortality rate of 28% (five patients) within the palliative procedure which involved a right hemi-
first 30 days of operation. The high mortality rate colectomy and partial duodenectomy.
reported has been mainly attributed to the difficulty in When tumor is unresectable due to massive retro-
closure of the duodenal defect with subsequent leakage peritoneal involvement, gastrojejunostomy in conjunc-
and peritonitis. Ellis et a1 have described techniques in tion with ileotransverse colostomy may be employed.
36 Chang and Rhoads

TABLE 11. Results of Right Hemicolectomy and Pancreaticoduodenectomy for Malignant Duodenocolic Fistula*
Lymph node
Authors, date of report Postoperative follow-up status

Linton, 1944 [6] Case 1-died 10 mos. from Unknown

cardiac failure
Case 2-recurred 8 rnos. Negative
Calmenson and Black, 1947a [3] Died 1 yr. Unknown
Prohaska et al, 1956 [18] Died 2.5 yrs. Unknown
Gallagher, 1957 [ I I ] Case 1 -alive 3 yrs. Unknown
Case 2-died 2 rnos. from Unknown
cholangitis
lanes and Mills, 1959 [7] Alive 1 8 + yrs. Unknown
Hopkins, 1965 [I91 No follow-up Negative
Musicant and Thompson, 1969 [8] Alive 8 mos. Unknown
Couinand et al, 1971 [I61 Alive 16 mos. Negative
Vieta et al, 1974 [4] Alive 11 + yrs. Negative
Hirsch, 1975a [I31 Alive 26+ yrs. Negative
Welch and Warshaw, 1977 [I] Alive 14 yrs. Negative

*Modified from Vieta et al, 1974 [4].

Gegmental duodenectomy performed without partial resection of pancreas.

Thiswill exclude the stomach and colon from the fistula
and seems to give reasonable palliation of symptoms
[11,22].
Malignant duodenocolic fistulas are a rare manifesta-
,tion of colonic carcinoma. With the support of intra-
venous hyperalimentation severe protein malnutrition
and electrolyte disturbances can be corrected. If dis-
seminated disease is not present, the treatment of choice
appears to be an extended right hemicolectomy which
.would involve a right hemicolectomy with pancreatico-
duodenectomy or segmental duodenectomy. If distant
metastasis has occurred, right hemicolectomy with par-
tial duodenectomy may stop the diarrhea and weight loss
and provide a period of good palliation, as it has in this
case.
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