Gupta Vikas, Kurdia Kailash C, Kumar Pavan, Yadav Thakur D, Gulati Ajay, Sinha Saroj K, Vaiphei Kim, Kochhar Rakesh
Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
Updates Surg. 2018 Dec;70(4):449-458. doi: 10.1007/s13304-018-0570-0. Epub 2018 Jul 27.
Duodenal involvement in colonic malignancy is a rare event and poses challenge to surgeons as it may entail major resection in a malnourished patient. Nine patients with malignant colo-duodenal fistula were reviewed retrospectively. Depending on the pattern of duodenal involvement, it was classified as-type I involving lateral duodenal wall less than half circumference; type II involving more than half circumference away from papilla; type III involving more than half circumference close to papilla. Type I was managed with sleeve resection, type II with segmental and type III with pancreaticoduodenectomy. Median age was 47 years, with male to female ratio of 2:1. Eight patients had anemia and seven had hypoproteinemia. Tumor was located in right colon in eight patients and distal transverse colon in one. Diagnosis of fistula was established by CT abdomen in seven (78%), foregut endoscopy in three and intraoperatively in two patients. Two patients had metastatic disease. Elective resection was done in seven while two required emergence surgery. Five patients underwent sleeve resection of the duodenum, two underwent segmental resection and two required pancreaticoduodenectomy. All patients had negative resection margin. One patient died. Median survival was 14 months in eight survivors. Duodenal resection in malignant colo-duodenal fistula should be tailored based on the extent and pattern of duodenal involvement. Negative margin can be achieved even with sleeve resection. En bloc pancreaticoduodenectomy is sometimes required due to extensive involvement. Resection with negative margin can achieve good survival.
十二指肠受累于结肠恶性肿瘤是一种罕见事件，给外科医生带来挑战，因为这可能需要对营养不良的患者进行大范围切除。对9例恶性结肠 - 十二指肠瘘患者进行了回顾性研究。根据十二指肠受累的模式，将其分为：I型，累及十二指肠外侧壁小于半周；II型，累及距乳头超过半周；III型，累及距乳头半周以内。I型采用袖状切除术，II型采用节段性切除术，III型采用胰十二指肠切除术。中位年龄为47岁，男女比例为2:1。8例患者有贫血，7例有低蛋白血症。肿瘤位于右半结肠8例，横结肠远端1例。7例（78%）通过腹部CT确诊瘘管，3例通过上消化道内镜确诊，2例术中确诊。2例患者有转移性疾病。7例行择期切除，2例需要急诊手术。5例患者接受十二指肠袖状切除术，2例接受节段性切除术，2例需要胰十二指肠切除术。所有患者切缘阴性。1例患者死亡。8例幸存者的中位生存期为14个月。恶性结肠 - 十二指肠瘘的十二指肠切除术应根据十二指肠受累的范围和模式进行个体化。即使采用袖状切除术也可实现切缘阴性。由于广泛受累，有时需要行整块胰十二指肠切除术。切缘阴性的切除术可实现良好的生存期。
