Management of a Complex Peristomal Fistula

Abstract

BACKGROUND: We describe our experiences caring for a patient with a peristomal fistula (PF), characterized by suppuration from a peristomal abscess. The challenges associated with this case included management of a complex fistula and prevention of abdominal necrotizing fasciitis and peritonitis. CASE: A 63-year-old man presented with severe peristomal swelling and pain resulting from an abscess adjacent to his ileostomy. He was malnourished and depressed. He underwent a low anterior resection (Dixon procedure) for rectal cancer 2 years ago and an abdominoperineal resection (Miles procedure) for the recurrence of rectal carcinoma 1 year later. In addition, he underwent bowel resection with the creation of an ileostomy due to intestinal obstruction caused by a second recurrence approximately 1 month prior to this admission. Following evaluation of the fistula anatomy, incision and drainage of the abscess was performed. Diversion of the effluent was used to control infection and promote fistula closure. A registered dietitian and a psychologist were consulted to optimize nutrition and treat his depression. After 20 days of treatment, the patient recovered and was safely discharged. CONCLUSION: Peristomal fistula management should include anatomical assessment, incision and drainage of the abscess, diversion to control effluent, and skin protection. For complex cases, the coordinated efforts of the interdisciplinary team are imperative.

Etiology and Management of Peristomal Pseudoepitheliomatous Hyperplasia

“…We believe the underlying cause of this fistula is inadvertent enterotomy during the process of fistula maturation. While peristomal fistulas have been described before with resultant abscess formation, chronic peristomal fistulas inducing pseudoverrucous lesions are unique and can create a diagnostic challenge [13]. One can postulate the chronic chemical irritation of the skin facilitates PEH growth as a protective mechanism.…”