INTESTINAL FISTULAS FORMATION FOLLOWING PELVIC EXENTERATION - A REVIEW OF THE UNIVERSITY-OF-TEXAS M-D-ANDERSON-CANCER-CENTER EXPERIENCE, 1957-1990

Intestinal fistulae are an uncommon but serious complication of pelvic exenteration. To characterize factors leading to fistula formation and to define optimal management of this complication, we reviewed 533 cases of patients who underwent pelvic exenteration at the University of Texas M. D. Anderson Cancer Center between 1957 and 1990. Forty-two of those patients developed an intestinal fistula following total (n = 29), anterior (n = 12), or posterior (n = 1) exenteration which was not tumor related. Prior to routine pelvic floor reconstruction, the fistula rate was 16%. With the advent of omental pedicle grafts and gracilis flaps, the rate decreased to 4.5%. The fistulae described included those from the small bowel to the pelvic cavity (n = 15) or the neovagina (n = 8), and from the large bowel to the neovagina (n = 8). Complex fistulae were noted in 11 patients. Early fistulae, those that developed during initial hospitalization, occurred in 25 patients and were mainly related to infectious complications. Twenty-three patients underwent attempted surgical repair of fistulae. Eleven died during their hospitalization of sepsis, recurrent wound complications, or fistula. Late fistulae, those that developed after discharge, occurred in 17 patients and were mainly related to delayed healing. Early and late fistulae did not differ in location. Only two patients with late fistula formation died from complications of therapy. Significant long-term morbidity, however, included short bowel syndrome. Based on our review, we conclude the following: (1) Pelvic floor reconstruction, careful attention to surgical technique and aggressive treatment of infections reduces the risk of early fistula formation; (2) in cases associated with significant infection, treatment should be surgical; and (3) in stable patients, conservative management with hyperalimentation and bowel should be considered. (C) 1995 Academic Press, Inc.