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 an d to define optimal management of this complication, we reviewed 533 c ases of patients who underwent pelvic exenteration at the University o f 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 n ot tumor related. Prior to routine pelvic floor reconstruction, the fi stula rate was 16%. With the advent of omental pedicle grafts and grac ilis flaps, the rate decreased to 4.5%. The fistulae described include d those from the small bowel to the pelvic cavity (n = 15) or the neov agina (n = 8), and from the large bowel to the neovagina (n = 8). Comp lex fistulae were noted in 11 patients. Early fistulae, those that dev eloped during initial hospitalization, occurred in 25 patients and wer e mainly related to infectious complications. Twenty-three patients un derwent attempted surgical repair of fistulae. Eleven died during thei r 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 fi stulae did not differ in location. Only two patients with late fistula formation died from complications of therapy. Significant long-term m orbidity, however, included short bowel syndrome. Based on our review, we conclude the following: (1) Pelvic floor reconstruction, careful a ttention to surgical technique and aggressive treatment of infections reduces the risk of early fistula formation; (2) in cases associated w ith significant infection, treatment should be surgical; and (3) in st able patients, conservative management with hyperalimentation and bowe l should be considered. (C) 1995 Academic Press, Inc.