V85 - Stapled Divided Bypass for Palliation of Complex Enteric Fistula

CME Eligible

Purpose/Background: Enteric fistulae are an uncommon but highly morbid complication of advanced intraabdominal malignancy. They are associated with prior surgery, radiation therapy, inflammatory bowel disease, and advanced neoplasia. Fistulae to the genitourinary system can cause feculent leakage via the urethra or vagina, with a high risk of further complications such as infection. Fistulae cause a profound impairment in quality of life for patients. Conventional surgical management typically involves resection of the fistula tract, necessitating extensive dissection in a difficult surgical field, which carries a high risk of morbidity and recurrence. We describe a novel palliative surgical approach, which we refer to as the stapled and divided bypass, which avoids extensive dissection by preserving the fistula, while still providing symptomatic relief and improving quality of life.

Methods/Interventions: Using an open surgical approach, the segment of bowel containing the fistula is identified. This loop of bowel is divided proximal and distal to the fistulized segment using a linear stapler. A new stapled side-to-side functional end-to-end anastomosis is then created between the proximal and distal ends, thereby bypassing the segment containing the fistula. The excluded segment is left in situ, preserving its mesenteric blood supply and maintaining its drainage through the existing fistula tract. No attempt is made to excise or close the fistula itself.

Results/Outcomes: A 60-year-old male with history of Crohn's Disease and recurrent rectal cancer status post total proctocolectomy and end ileostomy presented with an enterovesical fistula in the setting of prior pelvic radiation and multiple colonic and partial bladder resections. The patient reported continuous feculent and bilious drainage from the urethra. A stapled and divided bypass was performed without complication. The postoperative course was uneventful, with a length of stay of four days and no wound complications or persistent pain. Following discharge, the patient experienced complete cessation of feculent urethral drainage. Follow-up CT imaging demonstrated decompression of the bowel segment involved the fistula tract.

Conclusion/Discussion: The stapled and divided bypass represents a safe, efficient, and less technically demanding alternative for palliative management of enteric fistulae in patients with advanced malignancy. This technique minimizes operative trauma by avoiding dissection in hostile, irradiated, inflamed, and previously operated fields while providing effective symptom relief and preserving quality of life. Further study in a larger cohort is warranted to evaluate long-term outcomes and compare efficacy with conventional resection-based approaches.