Enterocutaneous fistula as a long-term complication of jejunostomy tube placement in a dog with hyperadrenocorticism

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While generally well-tolerated, complications such as enterocutaneous fistula formation can occur. Hyperadrenocorticism (HAC) is associated with impaired wound healing and increased susceptibility to infections, potentially predisposing affected patients to delayed complications following enteral feeding tube placement and removal. Case Presentation An 11-year-old, 2.9 kg Maltese dog presented with persistent gastrointestinal signs and focal cellulitis with purulent discharge. The dog had previously undergone intestinal anastomosis and JT placement for foreign body removal, with an uneventful recovery. Four months postoperatively, ultrasonography and fistulography confirmed an enterocutaneous fistula extending from the subcutaneous tissue to the intestinal lumen. Concurrently, HAC was diagnosed based on a post-stimulation cortisol level exceeding 20 µg/dL following an adrenocorticotropic hormone (ACTH) test. Given HAC’s pathophysiological effects —including glucocorticoid-induced dermal atrophy, diminished tissue elasticity, and increased infection susceptibility— HAC was suspected to have contributed to fistula formation. Surgical treatment comprised jejunal resection and anastomosis, as well as excision and debridement of the fistular tract. The patient exhibited no recurrence over a three-year follow-up period with sustained medical management of HAC using trilostane therapy. Conclusions This case highlights enterocutaneous fistula as a delayed and previously unreported complication of JT placement in a dog with HAC. Given the adverse effects of HAC on wound healing, clinicians should recognize the potential for such complications and implement vigilant postprocedural monitoring and appropriate endocrine management in patients undergoing enteral tube placement. enterocutaneous fistula hyperadrenocorticism jejunostomy tube enteral feeding veterinary surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Jejunostomy tube (JT) feeding, as other types of enteral feeding, has been recommended for early nutritional support in critically ill patients, since it is helpful to maintain the integrity of the gastrointestinal mucosal barrier, preserving the intestinal immune function and preventing bacterial translocation 1 . One of the greatest benefits of JT feeding is its ability to provide adequate enteral nutrition to patients experiencing persistent appetite loss or requiring rapid nutritional support following gastrointestinal surgery 2 , or vomiting which preclude the enteral feeding via esophagus or stomach 1 . In both humans and small animals, JT placement is known to be relatively safe with overall complication rate of 1.5~21% in human patients 3 , and 15-43.2% in veterinary patients 2,4,5,6 . Despite the relatively high complication rate in small animals compared to humans, the majority of cases were not life-threatening, with non-fatal complication rate of 15-36.7%, such as tube dislodgement, occlusion, focal cellulitis, peristomal infection and mild vomiting/ diarrhea. while serious life-threatening complications, including intestinal contents leakage into the tissue or abdomen due to severe cellulitis, fasciitis, and inadvertent jejunopexy were rarely occurred in veterinary patients representing 0-6.5% 2,4,5,6 . This case report describes an enterocutaneous fistula that occurred 4 months after JT placement in a dog accompanied by hyperadrenocorticism (HAC). To the best of authors knowledge, enterocutaneous fistula is the first reported complication associated with JT placement, especially as a long-term complication, in a dog. Case Presentation A 11-year-old 2.9 kg spayed female Maltese dog presented to Konkuk Veterinary Medical Teaching Hospital (KUVMTH) with a five-day history of persistent regurgitation, anorexia, lethargy. On physical examination, the patient appeared depressed, but no abnormalities were detected with the vital signs. Complete blood count (CBC) showed a leukocytosis with neutrophilia (white blood cell count of 27,950/L, reference range of 5,050-16,760; segmented neutrophils of 24,330/㎕, reference range of 2,950-11,640; monocytes of 1,560/㎕, reference range of 160-1,120). The biochemistry results demonstrated elevations in amylase and lipase to 5,932 U/L and 7,382 U/L, respectively (reference ranges: 500–1,500 U/L and 200–1,800 U/L). Only alkaline phosphatase (ALKP) was mildly elevated at 285 U/L (reference range: 23–212 U/L), while all other chemistry values, including liver enzyme levels, were within the expected limits. Serum canine pancreatic lipase (cPL) exceeded 1,000.00 ng/mL (reference range: 200–400 ng/mL), and D-dimer levels were elevated at 2,087.87 ng/mL (reference range: 50–250 ng/mL). Abdominal ultrasonography identified pronounced acoustic shadowing consistent with a suspected foreign body from the gastric antrum to the proximal portion of the descending duodenum, with concurrent dilation of the intestinal segment. Additionally, ultrasonography revealed a thickened and hypoechoic pancreas, warranting differential diagnoses, including acute pancreatitis. A laparotomy was performed to remove the intestinal foreign body, followed by excision of necrotic intestinal tissue and primary anastomosis. The procedure was carried out under general anesthesia, which was induced with midazolam (3 mg/kg, IV) and propofol (4 mg/kg, IV), and maintained with isoflurane in 100% oxygen. Following the anastomosis, a 6 French silicone jejunostomy feeding tube (MILA International Inc., Erlanger, KY) was placed using the interlocking box technique for enteral feeding. A Stab incision was made on the right abdominal wall with a No. 15 scalpel blade, and a segment of proximal jejunum was isolated. An antimesenteric border incision was made, and the distal end of the feeding tube was inserted through the incision, advancing 15 cm aboral. The tube was secured with a purse-string suture. Jejunopexy was then performed using the interlocking box technique, which involved creating two complete suture boxes extending from the jejunum to the abdominal wall, enclosing the JT in a routine fashion (Fig. 1). Postoperatively, a liquid diet was administered through JT after surgery, beginning at 3ml/hr and gradually increasing to 5ml/hr. The dog recovered uneventfully, and the JT was removed five days post-surgery. Both the surgical site and the tube removal site were healed without complications. Four months later, the dog was represented with focal cellulitis of mid-caudal abdomen, characterized by erythema, swelling, and purulent discharge. The referring veterinarian identified dehiscence at the lesion site and performed sugar dressings and a two-week of antibiotic therapy. Despite these interventions, serosanguineous to purulent discharge was consistently produced from the lesion, prompting re-evaluation at KUVMTH. Upon presentation, the dog was quiet, alert, and responsive, appearing clinically healthy aside from the cutaneous lesion. Physical examination revealed a body temperature of 38.4℃, systolic blood pressure of 150 mmHg measured by Doppler, no signs of dehydration and pink mucous membranes with a capillary refill time within 2 seconds. Cardiac auscultation was unremarkable, with no murmurs detected, and a heart rate of 132 beat/min with intermittent panting. Gross examination revealed thinning of the skin and dehiscence on the mid-abdomen, presenting as a circular fistula with a diameter of 1 cm, and a small amount of serosanguineous discharge (Fig. 2). CBC showed mildly decreased RBC (4.84 × 10 12 /L, reference range of 5.65 × 10 12 /L to 8.87 × 10 12 /L), HCT (32.2%, reference range of 37.3% to 61.7%), HGB (11 g/dL, reference range of 13.1 g/dL to 20.5 g/dL). Neutrophil and total white blood cell count were within the reference range. Results of Serum biochemistry was unremarkable, except for a marked increase in alkaline phosphatase (ALKP, 685 U/L; reference range: 23–212 U/L), which had risen significantly compared to values recorded four months prior. The smear cytology of the lesion revealed numerous neutrophil and rod type bacteria were detected. An adrenocorticotropic hormone (ACTH) stimulation test was performed, yielding a basal cortisol concentration of 2.4 ㎍/dL (reference range 0.5 ㎍/dL to 10 ㎍/dL) and a post-stimulation cortisol concentration exceeding 30 ㎍/dL (reference range 6 ㎍/dL to 18 ㎍/dL), suggesting a tentative diagnosis of hyperadrenocorticism (HAC). Ultrasonography identified that sizes of both adrenal glands were within reference intervals, measuring 3.1 mm and 3.9 mm respectively. Ultrasound examination of the abdominal skin defect confirmed its connection through the subcutaneous tissue and abdominal wall to the spindle-shaped hypoechoic area measuring 28.1 mm, containing hyperechoic material with acoustic shadowing. A connection between the subabdominal hypoechoic area and the adjacent jejunal segment was confirmed, revealing the absence of normal intestinal wall structure and an abnormally thickened muscularis layer on the ventral aspect. Fistulography was performed to identify the origin and patency of fistula. For the fistulography, 24G over-the-needle catheter was inserted into the fistula, and iohexol (Omnipaque™, Amersham Health, Cork, Ireland) was injected slowly under cinefluoroscopy. The fluoroscopy demonstrated contrast passage from the catheter into the subcutaneous and subabdominal regions, confirming communication with the fistula subsequent filling of the intestinal lumen adjacent to abdominal wall (figure 3). These findings led to a definitive diagnosis of an enterocutaneous fistula. Although computed tomography (CT) was recommended to evaluate the extent of adhesion between the intestine and abdominal wall, the procedure was not performed due to the owner's financial constraints. To debride the necrotic tissue and excise the enterocutaneous fistula, a laparotomy was performed through a ventral midline incision over the fistula site. For this procedure, general anesthesia was administered using midazolam (3 mg/kg, IV) and propofol (4 mg/kg, IV) for induction, with maintenance achieved using isoflurane in 100% oxygen. Within the abdominal cavity, the jejunopexy site from the previous surgery was observed to be completely adhered to the abdominal wall (figure 4A), ensuring no leakage of intestinal contents into the abdominal cavity. The lesion was carefully assessed, and the jejunum and abdominal wall were meticulously dissected from their pexy using a combination of blunt and sharp dissection. The fistula orifices connecting the abdominal wall and the jejunum were identified (figure 4B). The fistula, along with chronically degenerated tissues, encompassed approximately half the intestinal diameter (Figure 4C), making primary healing without stricture unlikely. Consequently, intestinal resection of the affected jejunal segment followed by end-to-end anastomosis was performed. An omental patch was applied after the lavage with sufficient saline and a leakage test. Tissue samples from the affected abdominal wall were collected for bacterial culture, and the fistula tissues were resected and debrided. Histopathological analysis was not performed due to owner’s financial constraints. The abdominal cavity was routinely closed, and the dog recovered uneventfully from anesthesia. Postoperative management included administration of cefotaxime 30mg/kg q 8 hours and metronidazole 15 mg/kg bid for four days, with omeprazole 1mg/kg bid, trilostane 1mg/kg bid for managing HAC. Analgesia was provided with fentanyl citrate 2 μg/kg loading followed by 12 μg/kg/hr for 12 hours. Bacterial culture of the fistula tissue identified Proteus mirabilis and Escherichia coli ., both of which were susceptible to cefotaxime, validating the continued use of the antibiotic for five days. Patient’s appetite was normal, and no postoperative gastrointestinal symptoms and clinical signs occurred. At the four-week follow-up after initiating trilostane therapy, post-cortisol levels remained within the reference range, and clinical signs of HAC such as panting, hypertension and skin thinning, had improved. No recurrence of the fistula was noted three years post-surgery. Discussion The definition of an enterocutaneous fistula is an abnormal opening structure between the intestinal lumen and skin and is a rare complication of the JT placement 7 . The pathophysiology of enterocutaneous fistula formation is thought to involve unfavorable epithelization at the tube removal site 8 . Common clinical signs of enterocutaneous fistulas include fluid leakage, abscess formation, hemorrhage, sepsis, malnutrition, and electrolyte imbalances; in severe cases, they can lead to death, often associated with sepsis and multiple organ dysfunction 8 . The external loss of intestinal fluids, which are rich in electrolytes, minerals, and protein, exacerbates complications such as electrolyte imbalance and malnutrition 9 . In human medicine, the mortality rate associated with enterocutaneous fistulas varies depending on the volume of fluid loss, the treatment of sepsis and the timing of surgical intervention 10 . The reported mortality rate has improved significantly from 65% to approximately 20% by early detection and appropriate treatment 10 . The most common cause of enterocutaneous fistula in humans mainly include inflammatory bowel disease, malignant tumor, radiotherapy, and intestinal diverticulum 11 . In human medicine, risk factors of enterocutaneous fistula formation include Crohn’s disease, ulcerative colitis, previous radiotherapy, intra-abdominal malignancy, diverticular disease and desmoid disease 10 . Active inflammation associated with conditions such as Crohn’s disease, granulation tissue, or sepsis can lead to fistula formation, impaired healing, or recurrence. Crohn’s disease is the leading primary small intestinal disease associated with enterocutaneous fistula formation in humans 12 . The transmural inflammation occurs with Crohn’s disease arouses to adherence of the intestine to nearby structures. Micro perforation then leads to abscess formation and subsequent perforation into the nearby structure. However, fistula formation involving the anterior abdominal wall is less common, likely due to the anatomical positioning of the intestines, which minimizes direct contact with the anterior abdominal wall. Fistulas develop in 20% to 40% of patients with Crohn’s disease 13 . Reports of enterocutaneous fistulas in veterinary medicine are rare and have been documented in cases of pelvic trauma 14 , chronic bite wound 7 , intraperitoneal gauze foreign body 15 , and colonic foreign body perforation 16 . In human medicine, enterocutaneous fistula has also been reported as a complication of tube placement, such as in percutaneous endoscopic gastrostomy (PEG) tubes, and there are even rare reports of bronchocutaneous fistula formation following chest tube insertion 17,18 . Enterocutaneous fistula after JT placement have been reported in 3 out of 2022 cases (0.14%) in human medicine 19 , but there are no known reports in veterinary medicine. In this case, HAC was strongly implicated as a contributing factor in the development of the enterocutaneous fistula following JT tube removal. HAC is characterized by elevated glucocorticoid concentrations, which are associated with clinical signs such as skin thinning, decreased elasticity, and increased susceptibility to infections—all of which were evident in this case 20 . Glucocorticoids exert antiproliferative effects on fibroblasts and inhibit collagen synthesis, resulting in impaired wound healing, increased skin fragility, and delayed tissue repair 21 . These effects substantially increase the risk of wound dehiscence and may lead to the breakdown of previously healed scar tissue during the healing process. Furthermore, HAC is known for its insidious onset and gradual progression over months or years 22 . Given these characteristics, patients with HAC, whether suspected or confirmed, are at increased risk for complications such as fistula formation. The chronic effects of HAC, particularly impaired wound healing and tissue fragility, underscore the importance of vigilant monitoring and proactive management to mitigate the risk of severe sequelae in these patients. In this patient, HAC likely contributed to delayed wound healing at the JT removal site, culminating in the formation of an enterocutaneous fistula four months later. At the initial presentation, the patient did not exhibit any clinical signs suggestive of HAC, so diagnostic test was not performed. However, when the fistula developed, clinical signs such as polydipsia, polyuria and panting were observed, prompting an ACTH stimulation test that strongly indicated HAC. Therefore, HAC was presumed to have caused delayed wound healing and persistent active inflammation at the JT removal site, ultimately leading to fistula formation. An abscess developed in the abdominal wall, progressed to a subcutaneous abscess, and resulted into skin perforation. Potential risk factors, such as intestinal inversion or ischemic necrosis due to the purse string suture around the tube were evaluated after the jejunopexy separation, but no evidence of inversion or excessive tissue ischemia was identified. Fortunately, the interlocking box technique used for jejunopexy effectively prevented enteral fluid leakage into the abdominal cavity. Leakage of enteral fluids or food into the body cavity could have led to fatal peritonitis. The technique ensured a secure fixation of the jejunum to the abdominal wall, preventing any gaps and leakage 23 . Tan et al . reported that most fistulas in human patients resolved spontaneously with conservative treatment within 6 weeks to 2 months, but 15% of cases fail to close even after 2 months and require surgical intervention 8 . In these non-closing cases where conservative management fails, traditional intra-abdominal techniques or less invasive options such as fibrin glue application, skin grafts, flaps and T-tube intubation are utilized 8 . However, less invasive extraperitoneal methods are difficult to apply when the fistula size is more than 1.5 cm 8 . In this case, surgical reconstruction was deemed necessary due to the chronic nature and larger diameter of the fistula, as well as the underlying HAC. After discussing potential complications with the owner, surgical intervention was chosen over conservative management to close the fistula and prevent further infection or inflammation. The surgery, along with appropriate management of HAC, resulted in successful resolution of enterocutaneous fistula. Conclusion To the authors’ knowledge, this is the first reported case of an enterocutaneous fistula following JT placement associated with HAC. This case highlights the importance of considering the potential for enterocutaneous fistula formation as a long-term sequela in patients with underlying conditions that impair wound healing, such as HAC. In such cases, incomplete closure of the jejunal stoma may lead to serious complication following enteral tube placement. Although rare, clinicians should be aware of this risk when employing JT in patients with compromised wound healing. Abbreviations IV, intravenous; KUVMTH, Konkuk Veterinary Medical Teaching Hospital; CBC, Complete blood count; ALKP, alkaline phosphatase; cPL, Serum canine pancreatic lipase; ACTH, An adrenocorticotropic hormone; HAC, hyperadrenocorticism; CT, computed tomography; PEG, percutaneous endoscopic gastrostomy Declarations Ethics Approval and Consent to Participate Ethical approval was not required for this case report, as it complied with local regulations and institutional guidelines. All necessary consents for medical treatment and inclusion of patient data were obtained from the animal owner or legal guardian. The study did not involve experimental procedures or interventions beyond standard veterinary care, and the patient's well-being and privacy were protected through informed consent procedures. Written informed consent was obtained from the owner for the participation of their animal in this study. Consent for Publication Written informed consent was obtained from the owner of the dog in this case for the publication of this case report and accompanying images. Availability of Data and Material All clinical data presented in this case report are included in the article. Further inquiries can be directed to the corresponding author. Competing Interests The authors declare that this study was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest. Funding Not applicable Author Contributions JM and HC conducted the clinical examination, assisted with the surgery, and performed postoperative follow-ups. HH was the primary surgeon for this case. JM and HC analyzed the case and drafted the manuscript. HH supervised the study, contributed to manuscript revisions, and approved the final version. All authors (JM, HC, HH) have read and approved the final version of the manuscript. Acknowledgments Not applicable. References Tsuruta K, Mann FA, Backus RC. Evaluation of jejunostomy tube feeding after abdominal surgery in dogs. J Vet Emerg Crit Care . 2016;00(0):1-7. doi:10.1111/vec.12494 Crowe DT, Devey JJ. Clinical experience with jejunostomy feeding tubes in 47 small animal patients. J Vet Emerg Crit Care . 1991;7(1):7-19. Tapia J, Murguia R, Garcia G, Espinoza de los Monteros P, Oñate E. Jejunostomy: techniques, indications, and complications. World J Surg . 1999;23(6):596-602. doi:10.1007/PL00012345 Allen SW, King JM, Reimann KA, Mason JC. Complications associated with use of jejunostomy tubes in dogs and cats: 40 cases (1989-1994). J Am Vet Med Assoc . 1996;209(10):1611-1615. Tsuruta K, Mann FA, Backus RC. Evaluation of jejunostomy tube feeding after abdominal surgery in dogs. J Vet Emerg Crit Care . 2016;00(0):1-7. doi:10.1111/vec.12494 Zullinger M, Hackett TB, McKenzie EC, et al. Postoperative complications associated with jejunostomy tube placement using the interlocking box technique compared with other jejunopexy methods in dogs and cats: 76 cases (1999-2003). J Am Vet Med Assoc . 2004;225(6):897-902. Inoue H, Miyazaki Y, Hori Y, et al. Enterocutaneous fistula as a result of chronic bite wound repair in a dog. J Vet Med Sci . 2002;64(6):569-571. Tan KC, Chua CL, Tan HK. Extraperitoneal approach for closure of epithelized enterocutaneous fistulas following late removal of jejunostomy tube. Surg Today . 2001;31(3):255-258. Dudrick SJ, Evans BC. Current management of enterocutaneous fistula. J Am Coll Surg . 1995;180(4):485-491. Levy E, Frileux P, Cugnenc PH, et al. An 11-year experience of enterocutaneous fistula. Br J Surg . 1989;76(6):563-566. Fischer JE. Current management of enterocutaneous fistulas. Surg Clin North Am . 2011;91(3):481-491. Lindberg E, Jarnerot G, Huitfeldt B. Smoking in Crohn’s disease: effect on localization and clinical course. Gut . 1992;33(6):779-782. Lloyd DA, Gabe SM, Windsor AC. Classification and pathophysiology of enterocutaneous fistulas. Br J Surg . 2006;93(9):1045-1055. Dixon RT, Balfour RJ, Johnson CA. Rectal perforation, rectocutaneous fistula formation, and enterocutaneous fistula formation after pelvic trauma in a dog. J Am Anim Hosp Assoc . 1994;30(1):58-62. Ashdown RR, Niles JD, Brown MP. Enterocutaneous fistula in a dog secondary to an intraperitoneal gauze foreign body. Aust Vet J . 1985;62(2):69-72. Pearson H. Enterocutaneous fistula formation in a dog as a result of colonic foreign body perforation. Vet Rec . 1983;113(15):355-356. Crosby J, Thomas P, Williams JG. Enterocutaneous fistula: a rare complication of PEG tube placement. Clin Nutr ESPEN . 2007;2(3):125-127. Sziklavari Z, Heiss MM. Bronchocutaneous fistula after chest-tube placement: a rare complication of tube thoracostomy. J Thorac Cardiovasc Surg . 2009;137(5):1296-1298. Myers JG, Page CP, Stewart RM, Schwesinger WH, Sirinek KR, Aust JB. Complications of needle catheter jejunostomy in 2,022 consecutive applications. Am J Surg . 1995;170(6):547-550. Greco DS. Hyperadrenocorticism in 10 dogs with skin lesions as the only presenting clinical signs. J Am Anim Hosp Assoc . 2001;37(2):107-113. Behrend EN. Canine hyperadrenocorticism. In: Feldman EC, Nelson RW, Reusch CE, et al., eds. Canine and Feline Endocrinology . 4th ed. Saunders; 2015:377-451. Nelson RW, Feldman EC, Reusch CE, Scott-Moncrieff JC. Hyperadrenocorticism (Cushing's syndrome). In: Mooney CT, Peterson ME, eds. BSAVA Manual of Canine and Feline Endocrinology . 4th ed. British Small Animal Veterinary Association; 2012:167-189. Devitt CM, Schultz P, Kirpensteijn J, Monnet E. Interlocking box jejunostomy: a new technique for enteral feeding. Vet Surg . 2001;30(5):497-503. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Oct, 2025 Read the published version in BMC Veterinary Research → Version 1 posted Editorial decision: Revision requested 02 Jun, 2025 Reviews received at journal 22 May, 2025 Reviewers agreed at journal 27 Apr, 2025 Reviews received at journal 22 Apr, 2025 Reviewers agreed at journal 16 Apr, 2025 Reviewers invited by journal 15 Apr, 2025 Editor assigned by journal 15 Apr, 2025 Editor invited by journal 15 Apr, 2025 Submission checks completed at journal 09 Apr, 2025 First submitted to journal 09 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6117162","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":443438278,"identity":"7c9d20e3-ac61-4a9e-93d5-84a11cf105f3","order_by":0,"name":"Je-Sung Moon","email":"","orcid":"","institution":"Konkuk Veterinary Medical Teaching Hospital, Konkuk University","correspondingAuthor":false,"prefix":"","firstName":"Je-Sung","middleName":"","lastName":"Moon","suffix":""},{"id":443438279,"identity":"69699384-1137-4bcd-9a51-44ce18cd1407","order_by":1,"name":"Hee-Jae Choi","email":"","orcid":"","institution":"Konkuk Veterinary Medical Teaching 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09:59:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":382558,"visible":true,"origin":"","legend":"\u003cp\u003eThe cutaneous dehiscence with a diameter of 1 cm, and small amount of serosanguineous discharge from the fistula\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6117162/v1/14846fe12a8b8b3f92940201.png"},{"id":82052166,"identity":"efaa8b15-1e9c-4c3c-bea2-286402224698","added_by":"auto","created_at":"2025-05-06 10:07:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":251750,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Over-the-needle catheter (red arrow) was placed for fistulography, (B) Iohexol being injected through cutaneous fistula tracts (white arrow), (C) iohexol was identified in jejunal lumen (yellow arrow)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6117162/v1/0b88667a11fb27667f08c57a.png"},{"id":82051135,"identity":"8f57b2e1-4e74-45c5-9806-e19416a64343","added_by":"auto","created_at":"2025-05-06 09:59:56","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":393260,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Previous jejunopexy site of jejunum fixed to the abdominal wall (white arrow), (B) fistula connected to the abdominal wall and jejunum (yellow arrow), (C) fistula and surrounding chronic degenerated tissues\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6117162/v1/4193511611be754c3186175d.png"},{"id":93419928,"identity":"498e12ce-7806-4bce-85f9-411d6cf4b33d","added_by":"auto","created_at":"2025-10-13 16:08:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2332025,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6117162/v1/e6587ed1-136d-4632-a11f-2156a7d471e3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enterocutaneous fistula as a long-term complication of jejunostomy tube placement in a dog with hyperadrenocorticism","fulltext":[{"header":"Introduction","content":"\u003cp\u003eJejunostomy tube (JT) feeding, as other types of enteral feeding, has been recommended for early nutritional support in critically ill patients, since it is helpful to maintain the integrity of the gastrointestinal mucosal barrier, preserving the intestinal immune function and preventing bacterial translocation\u003csup\u003e1\u003c/sup\u003e. One of the greatest benefits of JT feeding is its ability to provide adequate enteral nutrition to patients experiencing persistent appetite loss or requiring rapid nutritional support following gastrointestinal surgery\u003csup\u003e2\u003c/sup\u003e, or vomiting which preclude the enteral feeding via esophagus or stomach\u003csup\u003e1\u003c/sup\u003e. In both humans and small animals, JT placement is known to be relatively safe with overall complication rate of 1.5~21% in human patients\u003csup\u003e3\u003c/sup\u003e, and 15-43.2% in veterinary patients\u003csup\u003e2,4,5,6\u003c/sup\u003e. Despite the relatively high complication rate in small animals compared to humans, the majority of cases were not life-threatening, with non-fatal complication rate of 15-36.7%, such as tube dislodgement, occlusion, focal cellulitis, peristomal infection and mild vomiting/ diarrhea. while serious life-threatening complications, including intestinal contents leakage into the tissue or abdomen due to severe cellulitis, fasciitis, and inadvertent jejunopexy were rarely occurred in veterinary patients representing 0-6.5%\u003csup\u003e2,4,5,6\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis case report describes an enterocutaneous fistula that occurred 4 months after JT placement in a dog accompanied by hyperadrenocorticism (HAC). To the best of authors knowledge, enterocutaneous fistula is the first reported complication associated with JT placement, especially as a long-term complication, in a dog.\u0026nbsp;\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 11-year-old 2.9 kg spayed female Maltese dog presented to Konkuk Veterinary Medical Teaching Hospital (KUVMTH) with a five-day history of persistent regurgitation, anorexia, lethargy. On physical examination, the patient appeared depressed, but no abnormalities were detected with the vital signs. Complete blood count (CBC) showed a leukocytosis with neutrophilia (white blood cell count of 27,950/L, reference range of 5,050-16,760; segmented neutrophils of 24,330/㎕, reference range of 2,950-11,640; monocytes of 1,560/㎕, reference range of 160-1,120). The biochemistry results demonstrated elevations in amylase and lipase to 5,932 U/L and 7,382 U/L, respectively (reference ranges: 500\u0026ndash;1,500 U/L and 200\u0026ndash;1,800 U/L). Only alkaline phosphatase (ALKP) was mildly elevated at 285 U/L (reference range: 23\u0026ndash;212 U/L), while all other chemistry values, including liver enzyme levels, were within the expected limits. Serum canine pancreatic lipase (cPL) exceeded 1,000.00 ng/mL (reference range: 200\u0026ndash;400 ng/mL), and D-dimer levels were elevated at 2,087.87 ng/mL (reference range: 50\u0026ndash;250 ng/mL). Abdominal ultrasonography identified pronounced acoustic shadowing consistent with a suspected foreign body from the gastric antrum to the proximal portion of the descending duodenum, with concurrent dilation of the intestinal segment. Additionally, ultrasonography revealed a thickened and hypoechoic pancreas, warranting differential diagnoses, including acute pancreatitis.\u003c/p\u003e\n\u003cp\u003eA laparotomy was performed to remove the intestinal foreign body, followed by excision of necrotic intestinal tissue and primary anastomosis. The procedure was carried out under general anesthesia, which was induced with midazolam (3\u0026thinsp;mg/kg, IV) and propofol (4\u0026thinsp;mg/kg, IV), and maintained with isoflurane in 100% oxygen. Following the anastomosis, a 6 French silicone jejunostomy feeding tube (MILA International Inc., Erlanger, KY) was placed using the interlocking box technique for enteral feeding. A Stab incision was made on the right abdominal wall with a No. 15 scalpel blade, and a segment of proximal jejunum was isolated. An antimesenteric border incision was made, and the distal end of the feeding tube was inserted through the incision, advancing 15 cm aboral. The tube was secured with a purse-string suture. Jejunopexy was then performed using the interlocking box technique, which involved creating two complete suture boxes extending from the jejunum to the abdominal wall, enclosing the JT in a routine fashion (Fig. 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePostoperatively, a liquid diet was administered through JT after surgery, beginning at 3ml/hr and gradually increasing to 5ml/hr. The dog recovered uneventfully, and the JT was removed five days post-surgery. Both the surgical site and the tube removal site were healed without complications. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFour months later, the dog was represented with focal cellulitis of mid-caudal abdomen, characterized by erythema, swelling, and purulent discharge. The referring veterinarian identified dehiscence at the lesion site and performed sugar dressings and a two-week of antibiotic therapy. Despite these interventions, serosanguineous to purulent discharge was consistently produced from the lesion, prompting re-evaluation at KUVMTH.\u003c/p\u003e\n\u003cp\u003eUpon presentation, the dog was quiet, alert, and responsive, appearing clinically healthy aside from the cutaneous lesion. Physical examination revealed a body temperature of 38.4℃, systolic blood pressure of 150 mmHg measured by Doppler, no signs of dehydration and pink mucous membranes with a capillary refill time within 2 seconds. Cardiac auscultation was unremarkable, with no murmurs detected, and a heart rate of 132 beat/min with intermittent panting. Gross examination revealed thinning of the skin and dehiscence on the mid-abdomen, presenting as a circular fistula with a diameter of 1 cm, and a small amount of serosanguineous discharge (Fig. 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCBC showed mildly decreased RBC (4.84 \u0026times; 10\u003csup\u003e12\u003c/sup\u003e/L, reference range of 5.65 \u0026times; 10\u003csup\u003e12\u003c/sup\u003e/L to 8.87 \u0026times; 10\u003csup\u003e12\u003c/sup\u003e/L), HCT (32.2%, reference range of 37.3% to 61.7%), HGB (11 g/dL, reference range of 13.1 g/dL to 20.5 g/dL). Neutrophil and total white blood cell count were within the reference range. Results of Serum biochemistry was unremarkable, except for a marked increase in alkaline phosphatase (ALKP, 685 U/L; reference range: 23\u0026ndash;212 U/L), which had risen significantly compared to values recorded four months prior. The smear cytology of the lesion revealed numerous neutrophil and rod type bacteria were detected.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn adrenocorticotropic hormone (ACTH) stimulation test was performed, yielding a basal cortisol concentration of 2.4\u0026nbsp;㎍/dL (reference range 0.5\u0026nbsp;㎍/dL to 10\u0026nbsp;㎍/dL) and a post-stimulation cortisol concentration exceeding 30\u0026nbsp;㎍/dL (reference range 6\u0026nbsp;㎍/dL to 18\u0026nbsp;㎍/dL), suggesting a tentative diagnosis of hyperadrenocorticism (HAC). Ultrasonography identified that sizes of both adrenal glands were within reference intervals, measuring 3.1 mm and 3.9 mm respectively. Ultrasound examination of the abdominal skin defect confirmed its connection through the subcutaneous tissue and abdominal wall to the spindle-shaped hypoechoic area measuring 28.1 mm, containing hyperechoic material with acoustic shadowing. A connection between the subabdominal hypoechoic area and the adjacent jejunal segment was confirmed, revealing the absence of normal intestinal wall structure and an abnormally thickened muscularis layer on the ventral aspect. Fistulography was performed to identify the origin and patency of fistula. For the fistulography, 24G over-the-needle catheter was inserted into the fistula, and iohexol (Omnipaque\u0026trade;, Amersham Health, Cork, Ireland) was injected slowly under cinefluoroscopy. The fluoroscopy demonstrated contrast passage from the catheter into the subcutaneous and subabdominal regions, confirming communication with the fistula subsequent filling of the intestinal lumen adjacent to abdominal wall (figure 3). These findings led to a definitive diagnosis of an enterocutaneous fistula. Although computed tomography (CT) was recommended to evaluate the extent of adhesion between the intestine and abdominal wall, the procedure was not performed due to the owner\u0026apos;s financial constraints.\u003c/p\u003e\n\u003cp\u003eTo debride the necrotic tissue and excise the enterocutaneous fistula, a laparotomy was performed through a ventral midline incision over the fistula site. For this procedure, general anesthesia was administered using midazolam (3\u0026thinsp;mg/kg, IV) and propofol (4\u0026thinsp;mg/kg, IV) for induction, with maintenance achieved using isoflurane in 100% oxygen. Within the abdominal cavity, the jejunopexy site from the previous surgery was observed to be completely adhered to the abdominal wall (figure 4A), ensuring no leakage of intestinal contents into the abdominal cavity. The lesion was carefully assessed, and the jejunum and abdominal wall were meticulously dissected from their pexy using a combination of blunt and sharp dissection. The fistula orifices connecting the abdominal wall and the jejunum were identified (figure 4B). The fistula, along with chronically degenerated tissues, encompassed approximately half the intestinal diameter (Figure 4C), making primary healing without stricture unlikely. Consequently, intestinal resection of the affected jejunal segment followed by end-to-end anastomosis was performed. An omental patch was applied after the lavage with sufficient saline and a leakage test. Tissue samples from the affected abdominal wall were collected for bacterial culture, and the fistula tissues were resected and debrided. Histopathological analysis was not performed due to owner\u0026rsquo;s financial constraints. The abdominal cavity was routinely closed, and the dog recovered uneventfully from anesthesia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePostoperative management included administration of cefotaxime 30mg/kg q 8 hours and metronidazole 15 mg/kg bid for four days, with omeprazole 1mg/kg bid, trilostane 1mg/kg bid for managing HAC. Analgesia was provided with fentanyl citrate 2 \u0026mu;g/kg loading followed by 12 \u0026mu;g/kg/hr for 12 hours. Bacterial culture of the fistula tissue identified \u003cem\u003eProteus mirabilis\u003c/em\u003e and \u003cem\u003eEscherichia coli\u003c/em\u003e., both of which were susceptible to cefotaxime, validating the continued use of the antibiotic for five days.\u0026nbsp;Patient\u0026rsquo;s appetite was normal, and no postoperative gastrointestinal symptoms and clinical signs occurred.\u003c/p\u003e\n\u003cp\u003eAt the four-week follow-up after initiating trilostane therapy, post-cortisol levels remained within the reference range, and clinical signs of HAC such as panting, hypertension and skin thinning, had improved. No recurrence of the fistula was noted three years post-surgery.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe definition of an enterocutaneous fistula is an abnormal opening structure between the intestinal lumen and skin and is a rare complication of the JT placement\u003csup\u003e7\u003c/sup\u003e. The pathophysiology of enterocutaneous fistula formation is thought to involve unfavorable epithelization at the tube removal site\u003csup\u003e8\u003c/sup\u003e. Common clinical signs of enterocutaneous fistulas include fluid leakage, abscess formation, hemorrhage, sepsis, malnutrition, and electrolyte imbalances; in severe cases, they can lead to death, often associated with sepsis and multiple organ dysfunction\u003csup\u003e8\u003c/sup\u003e. The external loss of intestinal fluids, which are rich in electrolytes, minerals, and protein, exacerbates complications such as electrolyte imbalance and malnutrition\u003csup\u003e9\u003c/sup\u003e. In human medicine, the mortality rate associated with enterocutaneous fistulas varies depending on the volume of fluid loss, the treatment of sepsis and the timing of surgical intervention\u003csup\u003e10\u003c/sup\u003e. The reported mortality rate has improved significantly from 65% to approximately 20% by early detection and appropriate treatment\u003csup\u003e10\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe most common cause of enterocutaneous fistula in humans mainly include inflammatory bowel disease, malignant tumor, radiotherapy, and intestinal diverticulum\u003csup\u003e11\u003c/sup\u003e. In human medicine, risk factors of enterocutaneous fistula formation include Crohn\u0026rsquo;s disease, ulcerative colitis, previous radiotherapy, intra-abdominal malignancy, diverticular disease and desmoid disease\u003csup\u003e10\u003c/sup\u003e. Active inflammation associated with conditions such as Crohn\u0026rsquo;s disease, granulation tissue, or sepsis can lead to fistula formation, impaired healing, or recurrence. Crohn\u0026rsquo;s disease is the leading primary small intestinal disease associated with enterocutaneous fistula formation in humans\u003csup\u003e12\u003c/sup\u003e. The transmural inflammation occurs with Crohn\u0026rsquo;s disease arouses to adherence of the intestine to nearby structures. Micro perforation then leads to abscess formation and subsequent perforation into the nearby structure. However, fistula formation involving the anterior abdominal wall is less common, likely due to the anatomical positioning of the intestines, which minimizes direct contact with the anterior abdominal wall. Fistulas develop in 20% to 40% of patients with Crohn\u0026rsquo;s disease\u003csup\u003e13\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eReports of enterocutaneous fistulas in veterinary medicine are rare and have been documented in cases of pelvic trauma\u003csup\u003e14\u003c/sup\u003e, chronic bite wound\u003csup\u003e7\u003c/sup\u003e, intraperitoneal gauze foreign body\u003csup\u003e15\u003c/sup\u003e, and colonic foreign body perforation\u003csup\u003e16\u003c/sup\u003e. In human medicine, enterocutaneous fistula has also been reported as a complication of tube placement, such as in percutaneous endoscopic gastrostomy (PEG) tubes, and there are even rare reports of bronchocutaneous fistula formation following chest tube insertion\u003csup\u003e17,18\u003c/sup\u003e. Enterocutaneous fistula after JT placement have been reported in 3 out of 2022 cases (0.14%) in human medicine\u003csup\u003e19\u003c/sup\u003e, but there are no known reports in veterinary medicine.\u003c/p\u003e\n\u003cp\u003eIn this case, HAC was strongly implicated as a contributing factor in the development of the enterocutaneous fistula following JT tube removal. HAC is characterized by elevated glucocorticoid concentrations, which are associated with clinical signs such as skin thinning, decreased elasticity, and increased susceptibility to infections\u0026mdash;all of which were evident in this case\u003csup\u003e20\u003c/sup\u003e. Glucocorticoids exert antiproliferative effects on fibroblasts and inhibit collagen synthesis, resulting in impaired wound healing, increased skin fragility, and delayed tissue repair\u003csup\u003e21\u003c/sup\u003e. These effects substantially increase the risk of wound dehiscence and may lead to the breakdown of previously healed scar tissue during the healing process. Furthermore, HAC is known for its insidious onset and gradual progression over months or years\u003csup\u003e22\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven these characteristics, patients with HAC, whether suspected or confirmed, are at increased risk for complications such as fistula formation. The chronic effects of HAC, particularly impaired wound healing and tissue fragility, underscore the importance of vigilant monitoring and proactive management to mitigate the risk of severe sequelae in these patients.\u003c/p\u003e\n\u003cp\u003eIn this patient, HAC likely contributed to delayed wound healing at the JT removal site, culminating in the formation of an enterocutaneous fistula four months later. At the initial presentation, the patient did not exhibit any clinical signs suggestive of HAC, so diagnostic test was not performed. However, when the fistula developed, clinical signs such as polydipsia, polyuria and panting were observed, prompting an ACTH stimulation test that strongly indicated HAC. Therefore, HAC was presumed to have caused delayed wound healing and persistent active inflammation at the JT removal site, ultimately leading to fistula formation. An abscess developed in the abdominal wall, progressed to a subcutaneous abscess, and resulted into skin perforation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePotential risk factors, such as intestinal inversion or ischemic necrosis due to the purse string suture around the tube were evaluated after the jejunopexy separation, but no evidence of inversion or excessive tissue ischemia was identified.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFortunately, the interlocking box technique used for jejunopexy effectively prevented enteral fluid leakage into the abdominal cavity. Leakage of enteral fluids or food into the body cavity could have led to fatal peritonitis. The technique ensured a secure fixation of the jejunum to the abdominal wall, preventing any gaps and leakage\u003csup\u003e23\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTan \u003cem\u003eet al\u003c/em\u003e. reported that most fistulas in human patients resolved spontaneously with conservative treatment within 6 weeks to 2 months, but 15% of cases fail to close even after 2 months and require surgical intervention\u003csup\u003e8\u003c/sup\u003e. In these non-closing cases where conservative management fails, traditional intra-abdominal techniques or less invasive options such as fibrin glue application, skin grafts, flaps and T-tube intubation are utilized\u003csup\u003e8\u003c/sup\u003e. However, less invasive extraperitoneal methods are difficult to apply when the fistula size is more than 1.5 cm\u003csup\u003e8\u003c/sup\u003e. In this case, surgical reconstruction was deemed necessary due to the chronic nature and larger diameter of the fistula, as well as the underlying HAC. After discussing potential complications with the owner, surgical intervention was chosen over conservative management to close the fistula and prevent further infection or inflammation. The surgery, along with appropriate management of HAC, resulted in successful resolution of enterocutaneous fistula.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo the authors\u0026rsquo; knowledge, this is the first reported case of an enterocutaneous fistula following JT placement associated with HAC. This case highlights the importance of considering the potential for enterocutaneous fistula formation as a long-term sequela in patients with underlying conditions that impair wound healing, such as HAC. In such cases, incomplete closure of the jejunal stoma may lead to serious complication following enteral tube placement. Although rare, clinicians should be aware of this risk when employing JT in patients with compromised wound healing.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eIV, intravenous; KUVMTH, Konkuk Veterinary Medical Teaching Hospital; CBC, Complete blood count; ALKP, alkaline phosphatase; cPL, Serum canine pancreatic lipase; ACTH, An adrenocorticotropic hormone; HAC, hyperadrenocorticism; CT, computed tomography; PEG, percutaneous endoscopic gastrostomy\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was not required for this case report, as it complied with local regulations and institutional guidelines. All necessary consents for medical treatment and inclusion of patient data were obtained from the animal owner or legal guardian. The study did not involve experimental procedures or interventions beyond standard veterinary care, and the patient\u0026apos;s well-being and privacy were protected through informed consent procedures. Written informed consent was obtained from the owner for the participation of their animal in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the owner of the dog in this case for the publication of this case report and accompanying images.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll clinical data presented in this case report are included in the article. Further inquiries can be directed to the corresponding author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that this study was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJM and HC conducted the clinical examination, assisted with the surgery, and performed postoperative follow-ups. HH was the primary surgeon for this case. JM and HC analyzed the case and drafted the manuscript. HH supervised the study, contributed to manuscript revisions, and approved the final version. All authors (JM, HC, HH) have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eTsuruta K, Mann FA, Backus RC. Evaluation of jejunostomy tube feeding after abdominal surgery in dogs. \u003cem\u003eJ Vet Emerg Crit Care\u003c/em\u003e. 2016;00(0):1-7. doi:10.1111/vec.12494\u003c/li\u003e\n \u003cli\u003eCrowe DT, Devey JJ. Clinical experience with jejunostomy feeding tubes in 47 small animal patients. \u003cem\u003eJ Vet Emerg Crit Care\u003c/em\u003e. 1991;7(1):7-19.\u003c/li\u003e\n \u003cli\u003eTapia J, Murguia R, Garcia G, Espinoza de los Monteros P, O\u0026ntilde;ate E. Jejunostomy: techniques, indications, and complications. \u003cem\u003eWorld J Surg\u003c/em\u003e. 1999;23(6):596-602. doi:10.1007/PL00012345\u003c/li\u003e\n \u003cli\u003eAllen SW, King JM, Reimann KA, Mason JC. Complications associated with use of jejunostomy tubes in dogs and cats: 40 cases (1989-1994). \u003cem\u003eJ Am Vet Med Assoc\u003c/em\u003e. 1996;209(10):1611-1615.\u003c/li\u003e\n \u003cli\u003eTsuruta K, Mann FA, Backus RC. Evaluation of jejunostomy tube feeding after abdominal surgery in dogs. \u003cem\u003eJ Vet Emerg Crit Care\u003c/em\u003e. 2016;00(0):1-7. doi:10.1111/vec.12494\u003c/li\u003e\n \u003cli\u003eZullinger M, Hackett TB, McKenzie EC, et al. Postoperative complications associated with jejunostomy tube placement using the interlocking box technique compared with other jejunopexy methods in dogs and cats: 76 cases (1999-2003). \u003cem\u003eJ Am Vet Med Assoc\u003c/em\u003e. 2004;225(6):897-902.\u003c/li\u003e\n \u003cli\u003eInoue H, Miyazaki Y, Hori Y, et al. Enterocutaneous fistula as a result of chronic bite wound repair in a dog. \u003cem\u003eJ Vet Med Sci\u003c/em\u003e. 2002;64(6):569-571.\u003c/li\u003e\n \u003cli\u003eTan KC, Chua CL, Tan HK. Extraperitoneal approach for closure of epithelized enterocutaneous fistulas following late removal of jejunostomy tube. \u003cem\u003eSurg Today\u003c/em\u003e. 2001;31(3):255-258.\u003c/li\u003e\n \u003cli\u003eDudrick SJ, Evans BC. Current management of enterocutaneous fistula. \u003cem\u003eJ Am Coll Surg\u003c/em\u003e. 1995;180(4):485-491.\u003c/li\u003e\n \u003cli\u003eLevy E, Frileux P, Cugnenc PH, et al. An 11-year experience of enterocutaneous fistula. \u003cem\u003eBr J Surg\u003c/em\u003e. 1989;76(6):563-566.\u003c/li\u003e\n \u003cli\u003eFischer JE. Current management of enterocutaneous fistulas. \u003cem\u003eSurg Clin North Am\u003c/em\u003e. 2011;91(3):481-491.\u003c/li\u003e\n \u003cli\u003eLindberg E, Jarnerot G, Huitfeldt B. Smoking in Crohn\u0026rsquo;s disease: effect on localization and clinical course. \u003cem\u003eGut\u003c/em\u003e. 1992;33(6):779-782.\u003c/li\u003e\n \u003cli\u003eLloyd DA, Gabe SM, Windsor AC. Classification and pathophysiology of enterocutaneous fistulas. \u003cem\u003eBr J Surg\u003c/em\u003e. 2006;93(9):1045-1055.\u003c/li\u003e\n \u003cli\u003eDixon RT, Balfour RJ, Johnson CA. Rectal perforation, rectocutaneous fistula formation, and enterocutaneous fistula formation after pelvic trauma in a dog. \u003cem\u003eJ Am Anim Hosp Assoc\u003c/em\u003e. 1994;30(1):58-62.\u003c/li\u003e\n \u003cli\u003eAshdown RR, Niles JD, Brown MP. Enterocutaneous fistula in a dog secondary to an intraperitoneal gauze foreign body. \u003cem\u003eAust Vet J\u003c/em\u003e. 1985;62(2):69-72.\u003c/li\u003e\n \u003cli\u003ePearson H. Enterocutaneous fistula formation in a dog as a result of colonic foreign body perforation. \u003cem\u003eVet Rec\u003c/em\u003e. 1983;113(15):355-356.\u003c/li\u003e\n \u003cli\u003eCrosby J, Thomas P, Williams JG. Enterocutaneous fistula: a rare complication of PEG tube placement. \u003cem\u003eClin Nutr ESPEN\u003c/em\u003e. 2007;2(3):125-127.\u003c/li\u003e\n \u003cli\u003eSziklavari Z, Heiss MM. Bronchocutaneous fistula after chest-tube placement: a rare complication of tube thoracostomy. \u003cem\u003eJ Thorac Cardiovasc Surg\u003c/em\u003e. 2009;137(5):1296-1298.\u003c/li\u003e\n \u003cli\u003eMyers JG, Page CP, Stewart RM, Schwesinger WH, Sirinek KR, Aust JB. Complications of needle catheter jejunostomy in 2,022 consecutive applications. \u003cem\u003eAm J Surg\u003c/em\u003e. 1995;170(6):547-550.\u003c/li\u003e\n \u003cli\u003eGreco DS. Hyperadrenocorticism in 10 dogs with skin lesions as the only presenting clinical signs. \u003cem\u003eJ Am Anim Hosp Assoc\u003c/em\u003e. 2001;37(2):107-113.\u003c/li\u003e\n \u003cli\u003eBehrend EN. Canine hyperadrenocorticism. In: Feldman EC, Nelson RW, Reusch CE, et al., eds. \u003cem\u003eCanine and Feline Endocrinology\u003c/em\u003e. 4th ed. Saunders; 2015:377-451.\u003c/li\u003e\n \u003cli\u003eNelson RW, Feldman EC, Reusch CE, Scott-Moncrieff JC. Hyperadrenocorticism (Cushing\u0026apos;s syndrome). In: Mooney CT, Peterson ME, eds. \u003cem\u003eBSAVA Manual of Canine and Feline Endocrinology\u003c/em\u003e. 4th ed. British Small Animal Veterinary Association; 2012:167-189.\u003c/li\u003e\n \u003cli\u003eDevitt CM, Schultz P, Kirpensteijn J, Monnet E. Interlocking box jejunostomy: a new technique for enteral feeding. \u003cem\u003eVet Surg\u003c/em\u003e. 2001;30(5):497-503.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-veterinary-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Veterinary Research](http://bmcvetres.biomedcentral.com/)","snPcode":"12917","submissionUrl":"https://submission.nature.com/new-submission/12917/3?","title":"BMC Veterinary Research","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"enterocutaneous fistula, hyperadrenocorticism, jejunostomy tube, enteral feeding, veterinary surgery","lastPublishedDoi":"10.21203/rs.3.rs-6117162/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6117162/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJejunostomy tube (JT) feeding is widely recommended for early nutritional support in critically ill patients or those undergoing gastrointestinal surgery. While generally well-tolerated, complications such as enterocutaneous fistula formation can occur. Hyperadrenocorticism (HAC) is associated with impaired wound healing and increased susceptibility to infections, potentially predisposing affected patients to delayed complications following enteral feeding tube placement and removal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn 11-year-old, 2.9 kg Maltese dog presented with persistent gastrointestinal signs and focal cellulitis with purulent discharge. The dog had previously undergone intestinal anastomosis and JT placement for foreign body removal, with an uneventful recovery. Four months postoperatively, ultrasonography and fistulography confirmed an enterocutaneous fistula extending from the subcutaneous tissue to the intestinal lumen. Concurrently, HAC was diagnosed based on a post-stimulation cortisol level exceeding 20 µg/dL following an adrenocorticotropic hormone (ACTH) test. Given HAC’s pathophysiological effects —including glucocorticoid-induced dermal atrophy, diminished tissue elasticity, and increased infection susceptibility— HAC was suspected to have contributed to fistula formation. Surgical treatment comprised jejunal resection and anastomosis, as well as excision and debridement of the fistular tract. The patient exhibited no recurrence over a three-year follow-up period with sustained medical management of HAC using trilostane therapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case highlights enterocutaneous fistula as a delayed and previously unreported complication of JT placement in a dog with HAC. Given the adverse effects of HAC on wound healing, clinicians should recognize the potential for such complications and implement vigilant postprocedural monitoring and appropriate endocrine management in patients undergoing enteral tube placement.\u003c/p\u003e","manuscriptTitle":"Enterocutaneous fistula as a long-term complication of jejunostomy tube placement in a dog with hyperadrenocorticism","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 09:59:51","doi":"10.21203/rs.3.rs-6117162/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-02T08:10:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-23T01:58:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113841436693894043760307822923681156656","date":"2025-04-27T13:22:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-22T16:01:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"307405321197970483843846845780221082618","date":"2025-04-16T12:02:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-15T17:55:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-15T17:54:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-15T14:12:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-09T04:59:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Veterinary Research","date":"2025-04-09T04:58:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-veterinary-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Veterinary Research](http://bmcvetres.biomedcentral.com/)","snPcode":"12917","submissionUrl":"https://submission.nature.com/new-submission/12917/3?","title":"BMC Veterinary Research","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"90bf2cc1-53e9-49da-ac66-701cb27745b9","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:05:19+00:00","versionOfRecord":{"articleIdentity":"rs-6117162","link":"https://doi.org/10.1186/s12917-025-05048-5","journal":{"identity":"bmc-veterinary-research","isVorOnly":false,"title":"BMC Veterinary Research"},"publishedOn":"2025-10-06 15:58:16","publishedOnDateReadable":"October 6th, 2025"},"versionCreatedAt":"2025-05-06 09:59:51","video":"","vorDoi":"10.1186/s12917-025-05048-5","vorDoiUrl":"https://doi.org/10.1186/s12917-025-05048-5","workflowStages":[]},"version":"v1","identity":"rs-6117162","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6117162","identity":"rs-6117162","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}