An uncommon abdominal fistula: Colonic diverticular disease complicated with colocutaneous fistula

Abstract

Dear Editor, Colocutaneous fistulas are very rare, account for 1%-4% of the total number of fistulas complicating diverticular diseases, and may be caused by percutaneous drainage of diverticular abscesses without subsequent resection (1). They are more likely to occur in a patient who has undergone resection and primary anastomosis. In this letter, we report a case of a patient with a fistula connecting the sigmoid colon with left iliac fossa skin as a complication of sigmoid diverticulitis.A 45-year-old male was admitted to our department for cutaneous fistula formation and seropurulent secretion in the fistulous opening. Initially, the patient with complicated colon diverticular disease had been admitted to another hospital 3 months previously with an abscess in the left iliac fossa, and its drainage was performed. Postoperative evolution was unfavorable with fistula formation in the scar (Figure 1). Physical examination indicated the presence of a postoperative scar with signs of inflammation and at the lower pole of the postoperative scar, a fistulous orifice with a diameter of 0.2-0.3 cm discharging the seropurulent fluid.Fistulography of the left iliac fossa emphasized opacification of the sigmoid loop with inflammatory changes and incomplete lumen stenosis over a distance of approximately 10 cm.Abdomen and pelvis computed tomography (CT) revealed infiltration with inflammatory aspect of subcutaneous fat in the anterior and left abdominal wall. At the lower pole of the postoperative scar, inflammatory process spread in the intrapelvic region without extending to the left iliac muscle, but with no cleavage plane toward the ileal loops. It also revealed the presence of fluid and air bubbles in the abdominal wall muscles (Figure 2).During surgical intervention, we found inflammatory process in the left iliac fossa involving the side of the sigmoid colon, anterior abdominal wall, and greater omentum. Releasing the sigmoid loop was difficult. A fistulous orifice with a diameter of 0.4 0.5 cm, thickened wall, and irregular edges was identified. Sigmoidectomy with end-to-end colorectal anastomosis was performed as a one-step procedure.Postoperative specimen consisted of a 25-cm sigmoid segment, which contained three perforated diverticula (when it 248

Spontaneous Bilateral Lumbar Region Colocutaneous Fistulae. A Case Report

“…Other modalities include magnetic resonance imaging (MRI), MR fistulography, and endoscopy. Indeed, a colonoscopy can help identify an occasional malignancy and contribute in the assessment for distal obstruction (12). Our patient did not have a colonoscopy during the peri-operative period and histology from fistula site was negative for malignancy-this informed the decision to book for a colonoscopy in the following year after surgery.…”

“…The patient we report on, was neither immunosuppressed nor did he have any identifiable risk factor for spontaneous fistulae. Spontaneous colocutaneous fistulae are very rare globally (12,13). Nagaraja and colleagues opine that this could be due to the lack of population-based studies (13).…”

Retrograde injection of methylene blue as a technique for identification of obscure colonic fistulae

“…Diverticular fistulae are typically a consequence of an abscess spontaneously discharging through an area of least resistance, the bladder or vagina (in females who had a hysterectomy), consequently resulting in colovesical or colovaginal fistulae 1 . Colocutaneous fistulae are rare, arising in only 1–4% of diverticular fistulae and are most commonly associated with prior iatrogenic abscess drainage 1,2 …”

“…1 Colocutaneous fistulae are rare, arising in only 1-4% of diverticular fistulae and are most commonly associated with prior iatrogenic abscess drainage. 1,2 Presentations of complicated diverticular disease in patients younger than 50 years are atypical and therefore there is a greater impetus on the clinician to exclude other pathologies such as colorectal cancer, segmental colitis associated with diverticulosis and inflammatory bowel disease. 3 While it was likely that the aetiology of the fistula in the above-described patient was diverticular, endoscopic inspection was required to exclude an iatrogenic injury to the rectum (from prior percutaneous drainage), colorectal malignancy and Crohn's disease.…”