DOI: 10.5897/SRE11.996

Gastrojejunocolic fistula is a late, rare and severe complication of gastroenterostomy with Billroth II reconstruction for peptic ulcer and is associated with inadequate gastric resection and incomplete vagotomy. The fistula is thought to be due to perforation of a marginal ulcer into the transverse colon. In the past, attempted primary repair had high mortality and staged operations were normally performed. We herein report the case of a 60 year-old man with gastrojejunocolic fistula who was admitted to our hospital with a symptom triad of faecal vomiting/breath, chronic diarrhea and weight loss. His history included a distal gastric resection and Billroth II reconstruction for a duodenal ulcer 15 years previously. The laboratory data on admission revealed hypoproteinemia and hypoalbuminemia. Both barium-enema and colonoscopy examination showed the existence of the gastrojejunocolic fistula. After improving his state of malnutrition, a one-stage repair was performed. The postoperative course was uneventful and the patient was discharged on the 22th postoperative day. In this case, improved nutritional support allowed successful one-stage surgical repair to be performed.


INTRODUCTION
Gastrojejunocolic fistula (GJF) is associated with previous gastroenterostomy with Billroth II reconstruction for peptic ulcer.It is thought to be the late, rare and severe complication of a stomal ulcer which develops as a result of inadequate gastric resection or incomplete vagotomy for peptic ulcer disease.GJF occurs in about 14% of cases of gastrojejunal ulcer and in about 0.5% of cases in which gastroenterostomy is performed (Walters et al., 1939).Most patients with GJF present with a symptom triad of faecal vomiting/breath, chronic diarrhea and weight loss (Alhan et al., 1990;Lowdon, 1953).The diagnostic investigation of choice to date has been barium enema which has a sensitivity of 95% for this condition (Lowdon, 1953;Thoeny et al., 1960).Given the improvement in endoscopic imaging and instruments, however, colonoscopy may now have a role in the diagnosis of GJF.Due to the poor nutritional status of *Corresponding author.patients with GJF, operative mortality following surgical repair has been as high as 40%.Staged repair of GJF with preliminary proximal colostomy, then later a second operation (resection of involved colon and jejunum and partial gastrectomy with or without vagotomy) has been favored to minimize mortality (Pfeiffer, 1941;Sorensen, 1969).One-stage repair, a partial resection of the remnant stomach, transverse colon, and jejunum which were involved in the fistula has also been possible with the assistance of intensive preoperative and postoperative support.We report the management of a case with GJF, seen at the Second Hospital of Shandong University, in December 2004.The application of barium enema and colonoscopy to the diagnosis of this uncommon disease and the surgical strategy implemented are described.

CASE REPORT
A 60 year-old Chinese man presented at our hospital for assessment of faecal vomiting/breath, chronic diarrhea, passing as many as 15 ~ 20 pale stools per day and severe weight loss on December 24, 2004.These symptoms had been present for 10 months.Over this time his weight had fallen from 76 to 54 kg.His past medical history included a gastroenterostomy with Billroth II reconstruction for duodenal ulcer (DU) 15 years ago.A complete blood count revealed a haemoglobin level of 92 g/L (normal range, 110 to 160 g/L), a total protein level of 46 g/L (normal range, 60 to 83 g/L), and an albumin level of 23 g/L (normal range, 35 to 53 g/L), a sodium level of 127 mmol/L (normal range, 136 to 142 mmol/L).There were no other findings of note.Chest and abdominal Xrays were unremarkable.A lip-like fistula with a diameter of about 2 cm was found in the middle of transverse colon by colonoscopy examination (Figure 1).The cavity of residual stomach, afferent and efferent loop of jejunum could be seen through the fistula (Figure 2); the jejunum mucosa could also be seen through the fistula (Figure 3).A barium enema examination was done which showed the residual stomach, jejunum and transverse colon simultaneously (Figure 4).Total parental nutrition (TPN) was given for 3 weeks until the patient's albumin level improved to 38 g/L and after correction of his anemia; the patient underwent laparotomy on January 15, 2005.Intraoperatively, a 'polya gastrectomy' with a gastric remnant of more than 50% and a GJF was seen.A radical en bloc resection was performed involving a subtotal gastrectomy, posterior vagectomy, partial transverse colon and jejunum resection.
Roux-en-Y reconstruction of bowel continuity was applied by gastroenterostomy, jejunojejunostomy and colocolostomy.Postoperatively, the patient received intensive care for 6 days and was able to resume a full diet on day 10 and TPN discontinued.Recovery was uneventful; the patient remained well at follow-up.

DISCUSSION
The first gastroenterostomy was done in 1881 and until recently was a frequently drainage procedure after vagotomy.In the era of Helicobactor pylori eradication for peptic ulcer disease, there has been a great reduction in the use of gastric surgery.However, awareness of the potential complications of such surgery is still important as they can appear late with divastating effect.Gastrojejunocolic fistula, which was first described in 1903 (Forrest et al., 2000) is thought to be the late complication of inadequate surgery resulting from simple gastroenterostomy, inadequate gastric resection or incomplete vagotomy (Subramaniasivam et al., 1997).This results in stomal ulcer, which if untreated leads to the development of a fistula into surrounding organs.In our case, an insufficient resection of the stomach might  be the cause of this disease.Besides inadequate gastric resection, or incomplete vagotomy, the stomal ulcer could also be ascribed to malignant gastrinoma (Alhan et al., 1995).The operations which most frequently cause GJF were a Billroth II reconstruction or a gastrojejunostomy without a gastrectomy, whereas Billroth I reconstruction accounted for only 6.8% of GJF (Ohta et al., 2002).Type of ante-or retro-colic gastro-jejunostomy may also have different effect on the incidence of GJF.In a group of I4 cases, all patients had had retro-colic gastro-jejunostomy which the colon lay directly upon the gastrojejunal anastomosis (Samuel, 1945).It is important that when retro-colic gastro-jejunostomy is employed, the anastomosis should be made through an opening in the mesocolon placed near the base of the mesocolon and as far as possible from the colon.Most patients with GJF present with a symptom triad of faecal vomiting/breath, chronic diarrhea and weight loss (Alhan et al., 1990;Lowdon, 1953).Diarrhea and weight loss are recognized in 80%.Faecal vomiting/breath are marked features for diagnosis and often cause severe embarrassment for patients.However, diarrhea may be the only complaint (Forrest et al., 2000).The usual diagnostic test for GJF is barium enema with diagnostic rate of 95% (Thoeny et al., 1960).The diagnositic value of colonoscopy is superior to the gastroscopy with diagnostic rate of 85.7 and 44.4% respectively.Diarrhea, weight loss and faecal vomiting/breath were recognized in our case, both barium-enema and colonoscopy examination showed the existence of GJF.The surgical options and treatments of GJF have changed over the years.The historical approach was 2 to 3-staged operations even involving a preliminary diversion colostomy in order to ameliorate the nutritional status of the patient and to decrease mortality (Lowdon, 1953;Pfeiffer, 1941).
In the late 1930s, the 3-staged procedures included: 1) colostomy, 2) resection of the fistula and, 3) colostomy closure (Cody et al., 1975).Then 2-staged operation was defined.This operation which is known as Lahey's procedure was very popular because it was done with lower morbidity and mortality (Marshall et al., 1957).Advances in TPN over the last 30 years, however, allow the patient's condition to be optimised before definitive surgery (Sorensen, 1969).This has been the trend in the recent years, and both operative morbidity and mortality have been subsequently minimized with one-stage surgical repair (Alhan et al., 1995).Today, one-stage resection can be applied and the mortality rates are getting lower.In conclusion, GJF, although uncommon is seen occasionally in current medical practice as a result of pastgastric surgery.To prevent the occurrence of GJF, adequate gastric resection or complete vagotomy for peptic ulcer is necessary.Pri-operative examination and in-operative exploration to exclude gastrinoma is of equal importance.Attention should be paid to those that underwent gastroenterostomy for DU when diarrhea, faecal vomtiting/breath and weight loss appeared.Colonoscopy and barium enema are two methods with

Figure 1 .
Figure 1.A lip-like fistula found by colonoscopy.

Figure 3 .
Figure 3. Jejunum mucosa could also be seen through the fistula by colonoscopy.