Surg Today (2003) 33:623625
DOI 10.1007/s00595-003-2547-x
Sigmoidoduodenal Fistula as a Rare Complication of Colonic
Carcinoma: Report of a Case
John Melissas, George Schoretsanitis, Markos Daskalakis, and Demetrios D. Tsiftsis
Department of Surgical Oncology, Heraklion University Hospital, Heraklion, Crete, Greece
Abstract
We report a very unusual case of malignant sigmoi-
doduodenal communication. To the best of our knowl-
edge, this is the first documentation of this entity in the
English language literature. A 76-year-old man pre-
sented with weakness, severe weight loss, foul-smelling
eructations, anemia, constipation, and episodes of diar-
rhea. A sigmoidoduodenal fistula was found by barium
enema, and a diagnosis of ulcerative colonic adenocarci-
noma was made from the colonoscopy findings. Thus,
we performed sigmoid colectomy with resection of the
fistula and the involved anterior wall of the third duode-
nal part, followed by primary closure of the duodenal
defect. Histological examination confirmed a Dukes B
(Stage II T4N0M0) colonic adenocarcinoma, and the
excision margins of the resected duodenal specimen
were clear. We gave adjuvant chemotherapy with 5-
fluorouracil and leucovorin. The patient is still alive and
disease-free, 2 years postoperatively.
Key words Duodenal neoplasm Sigmoid Sigmoid
neoplasm Fistula
Introduction
Duodenocolonic neoplastic fistulas can occur as a rare
complication of colonic carcinoma.1 They are usually
caused by neoplasms of the hepatic flexure or the as-
cending colon eroding the adjacent second part of the
duodenum.2,3 Less than 100 cases have been reported in
the English and Japanese literature;1 however, to our
knowledge, fistulization between the third part of the
duodenum and the sigmoid colon due to malignancy has
Reprint requests to: J. Melissas, 16 Sifaki Street, Heraklion
71409, Crete, Greece
Received: April 3, 2002 / Accepted: November 19, 2002
never been reported in the English language literature.
Although we found a similar case in a Medline search,
this was reported in a Italian Indexed Journal.4
Case Report
A 76-year-old man was admitted to our hospital with
weakness, fatigue, weight loss of 52 kg over the previous
year, dyspepsia, foul-smelling eructations, and severe
constipation with occasional episodes of diarrhea. He
had a history of diabetes mellitus, controlled by diet,
and had suffered from chronic renal failure for 2 years.
He had also undergone hernia repair 15 years earlier.
On clinical examination, he was anemic and dehy-
drated. He had a clear chest and a soft undistended
abdomen with increased bowel sounds. No abnor-
malities were found on rectal examination. Laboratory
analysis showed iron deficiency anemia with hematocrit
29%, hemoglobin 9.8 g/dl, increased urea and creati-
nine, and low albumin levels. Carcinoembryonic anti-
gen (CEA) was 37 ng/ml (normal range 0.25 ng/ml for
nonsmokers). Stools were positive for occult blood.
Abdominal ultrasound revealed gallstones.
Barium enema showed an irregular stricture causing
complete obstruction of the sigmoid colon, which com-
municated with the distal duodenum (Fig. 1). At
colonoscopy, we found an ulcerated tumor obstructing
the entire sigmoid lumen. Biopsies were taken and a
diagnosis of colonic adenocarcinoma was confirmed.
Computed tomography scan with oral contrast showed
cholelithiasis, pyelonephritic changes of both kidneys,
edema of the third and fourth part of the duodenum,
and a fistula between this area and the sigmoid colon
(Figs. 2 and 3).
The patient was operated on after 7 days preparation
with parenteral nutrition, blood transfusion, and hemo-
dialysis, as well as bowel preparation and antibiotics. At
laparotomy, the sigmoid colon was found to be adhered
624
to the third part of the duodenum, which contained the
fistula. We performed a typical sigmoid colectomy after
ligating the inferior mesenteric artery close to the aorta
and excising all of the lymphatic channels accompany-
ing the main arterial supply, with 15-cm margins proxi-
mal to, and 10-cm margins distal to the tumor. An
end-to-end anastomosis was done using a circular sta-
pler. The fistula was resected and the involved anterior
duodenal wall was excised at the longitudinal axis (Fig.
4). There were no enlarged regional duodenal lymph
nodes. The duodenum was repaired with interrupted
Fig. 1. Barium enema showed a malignant fistula between the
distal duodenum and the sigmoid colon
Fig. 2 and 3. Computed tomography scans showed the sigmoidoduodenal communication
J. Melissas et al.: Sigmoidoduodenal Fistula
absorbable sutures at the transverse axis and the gall-
bladder was removed.
The patient had an uneventful recovery. He was
placed on total parenteral nutrition of 2100 kcal/day,
which was discontinued on day 11. An upper gas-
trointestinal barium examination, done on postopera-
tive day (POD) 7, confirmed the absence of any leaks or
stenosis of the duodenum. Histological examination of
the resected specimen showed adenocarcinoma of the
sigmoid colon, with infiltration of the entire thickness of
the bowel wall. The excised mesenteric lymph nodes
were free of disease (Dukes B or Stage II T4N0M0).
Neoplastic infiltration was seen in the duodenal speci-
men, but the excision margins were clear. Adjuvant
chemotherapy was given according to the Mayo regi-
men (D1D5: 5-fluorouracil 425 ng/m2 i.v. and leucovorin
20 mg i.v. daily) every 28 days for six cycles. The patient
was disease-free when last seen 2 years after the opera-
Fig. 4. The resected specimen, showing the colonic end of the
fistula
J. Melissas et al.: Sigmoidoduodenal Fistula
tion. His CEA levels also returned to within normal
values postoperatively and have remained low.
Discussion
Duodenal fistulas are either of benign or malignant
origin.1 Crohns disease is the most frequent benign
cause,5,6 while less common benign causes include perfo-
rated duodenal diverticulum, perforated duodenal ul-
cer, acute cholecystitis, tubercular lymphadenitis, and
intraoperative damage of the duodenum during gastric
operations.1
Malignant duodenocolonic fistula is a rare complica-
tion of colonic neoplasms, which affects men more of-
ten3 than women (3.8 : 1), even though the distribution
of large bowel cancer is relatively equal between the
two sexes.7 Carcinomas of the ascending colon and the
hepatic flexure may infrequently erode into the adja-
cent second part of the duodenum.2,3 Other malignan-
cies such as cancer of the pancreas8 or intraoperative
metastasis from esophageal carcinoma9 have been re-
ported as rare causes of duodenocolonic fistula forma-
tion. However, to the best of our knowledge, neoplastic
communication between the third part of the duode-
num and the sigmoid colon has never been reported in
the English language literature.
The clinical presentation of a duodenocolonic fistula
varies according to the underlying disease.1,3,5 Colicky
abdominal pain, malabsorption with diarrhea, weight
loss, constipation, gastrointestinal hemorrhage, fecal
vomiting, and intraabdominal abscess formation have
all been reported in patients suffering from this unusual
condition. Double-contrast barium enema is the investi-
gation of choice for synchronous demonstration of the
duodenocolonic fistula and the underlying pathology of
the large bowel.3 Upper gastrointestinal series do not
usually show the duodenum fistula simply because
increased intraluminar colonic pressure proximal to
the tumor diverts the bowel contents towards the
duodenum.10
Surgical management is challenging due to the com-
plexity of the pancreaticoduodenal area. Resection of
the tumor and the fistula en bloc provides the only hope
of cure.1 When the malignant fistula is small, simple
excision with primary closure of the duodenal defect,7 as
we performed in our patient, may be appropriate, or
alternatively, an intestinal jejunal loop can be used as a
serosal patch.1 Although this approach has been criti-
cized about whether it really is curative, since the dissec-
625
tion of the regional lymph nodes of the duodenal area is
limited, it is generally accepted that it at least provides
excellent palliation.11,12
Colectomy with pancreaticoduodenectomy for a
duodenocolonic fistula between the second part of the
duodenum and the right colon can allow resection of the
colonic malignancy and the fistula en bloc with the adja-
cent regional lymph nodes. In experienced hands, this
operation can be safely performed with a high associ-
ated survival rate.10 However, in the presence of distal
metastasis or in a severely ill patient, ileotransverse
anastomosis and gastrojejunostomy with pyloric exclu-
sion offers good palliation, but may only achieve sur-
vival of less than 1 year.1 Therefore, the apparent stage
of disease, the likelihood of metastasis, the patients
medical condition, and the site of the fistula must all be
taken into consideration on a case-by-case basis, when
deciding the most appropriate method of treatment.
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