Perineal small bowel fistula after pelvic exenteration for cancer: technical guidelines for perineal fistula.
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.


CONCLUSIONS
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. Intraoperative 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.
Turrini
Olivier
O
Department of Surgical Oncology, Institut Paoli-Calmettes and Université de la Méditerranée, 232 Bd de Sainte Marguerite, 13009, Marseille, France. oturrini@yahoo.fr
Guiramand
Jérome
J
Moutardier
Vincent
V
Viret
Frédéric
F
Mokart
Djamel
D
Madroszyk
Anne
A
Lelong
Bernard
B
Bège
Thierry
T
Blache
Jean-Louis
JL
Houvenaeghel
Gilles
G
Delpero
Jean-Robert
JR
D005260:Female; D006801:Humans; D015179:Colorectal Neoplasms / Q000532:radiotherapy / Q000601:surgery; D007412:Intestinal Fistula / Q000209:etiology; D007421:Intestine, Small / Q000601:surgery; D010051:Ovarian Neoplasms / Q000532:radiotherapy / Q000601:surgery; D010385:Pelvic Exenteration / Q000009:adverse effects; D010502:Perineum / Q000601:surgery; D011183:Postoperative Complications; D012509:Sarcoma / Q000532:radiotherapy / Q000601:surgery; D002583:Uterine Cervical Neoplasms / Q000532:radiotherapy / Q000601:surgery