Laparoscopic resection of chronic sigmoid diverticulitis with fistula

Retrospective study on the feasibility and safety of laparoscopic surgery for complicated fistulizing diverticular disease in a high-volume colorectal center

BACKGROUND

We assessed feasibility and safety of laparoscopic sigmoidectomy for complicated fistulizing diverticular disease in a tertiary care colorectal center.

METHODS

A single-center retrospective study of patients undergoing sigmoidectomy for fistulizing diverticular disease between 2011 and 2021 was realized. Primary outcomes were rates of conversion to open surgery and severe postoperative morbidity at 30 days. Secondary outcomes included rates of postoperative bladder leaks on cystogram.

RESULTS

Among the 104 patients, 32.7% had previous laparotomy. Laparoscopy was the initial approach in 103 (99.0%), with 6 (5.8%) conversions to laparotomy. Clavien-Dindo grade ≥ III complication rate at 30 days was 10.6%, including two (1.9%) anastomotic leaks. The median postoperative length of stay was 4.0 days. Seven (6.7%) patients underwent reoperation, six (5.8%) were readmitted, and one (0.9%) died within 30 days. Twelve (11.5%) ileostomies were created initially, and two (1.9%) were created following anastomotic leaks. At last follow-up, 101 (97.1%) patients were stoma-free. Urgent surgeries had a higher rate of severe postoperative complications. Among colovesical fistula patients (n = 73), postoperative cystograms were performed in 56.2%, identifying two out of the three bladder leaks detected on closed suction drains. No differences in postoperative outcomes occurred between groups with and without postoperative cystograms, including Foley catheter removal within seven days (73.2% vs. 90.6%, p = 0.08).

CONCLUSIONS

Laparoscopic surgery for complicated fistulizing diverticulitis showed low rates of severe complications, conversions to open surgery and permanent stomas in high-volume colorectal center.

Open versus laparoscopic surgery for the treatment of diverticular colovesical fistulas: A systematic review and meta-analysis

BACKGROUND

The aim of this study was to analyze the evidence regarding open versus laparoscopic surgery for the treatment of diverticular colovesical fistula (CVF) in terms of perioperative outcomes.

METHODS

A systematic review was performed using PubMed, Cochrane, Google Scholar, and Web of Science databases for studies comparing laparoscopic versus open surgery for CVF. We pooled odds ratios (OR) and mean differences (MD) using random or fixed effects models.

RESULTS

Five non-randomized studies with 227 patients met the inclusion criteria. All were retrospective studies, published between 2014 and 2020. For laparoscopic surgery, the pooled rate for conversion to laparotomy was 36%. Laparoscopic and open procedures required similar operative time (MD: -11.62; 95% confidence interval [CI]: -51.41 to 28.16). No difference was found in terms of stoma rates between laparoscopic and open surgery (OR: 1.12; 95% CI 0.44-2.86). Overall, the rate of total postoperative complications was lower in the laparoscopic group (OR: 0.55; 95% CI: 0.30-0.99). The pooled analysis showed equivalent rates of anastomotic leaks (OR: 0.61; 95% CI 0.15-2.45), surgical site infections (OR: 0.44; 95% CI 0.19-1.01), and mortality (OR: 0.18; 95% CI 0.03-1.15). The length of stay was significantly reduced with laparoscopic surgery (MD: -2.89; 95% CI -4.20 to -1.58).

CONCLUSION

Among patients with CVF, the laparoscopic approach appears to have shorter hospital length of stay, with no differences in anastomotic leaks, surgical site infections, stoma rates, and mortality, when compared with open surgery.

Discovery of Gut Bacteria Specific to Alzheimer's Associated Diseases is a Clue to Understanding Disease Etiology: Meta-Analysis of Population-Based Data on Human Gut Metagenomics and Metabolomics

Alzheimer's disease (AD)-associated sequence (ADAS) of cultured fecal bacteria was discovered in human gut targeted screening. This study provides important information to expand our current understanding of the structure/activity relationship of ADAS and putative inhibitors/activators that are potentially involved in ADAS appearance/disappearance. The NCBI database analysis revealed that ADAS presents at a large proportion in American Indian Oklahoman (C&A) with a high prevalence of obesity/diabetes and in colorectal cancer (CRC) patients from the US and China. An Oklahoman non-native group (NNI) showed no ADAS. Comparison of two large US populations reveals that ADAS is more frequent in individuals aged ≥66 and in females. Prevalence and levels of fecal metabolites are altered in the C&A and CRC groups versus controls. Biogenic amines (histamine, tryptamine, tyramine, phenylethylamine, cadaverine, putrescine, agmatine, spermidine) that present in food and are produced by gut microbiota are significantly higher in C&A (e.g., histamine/histidine 95-fold) versus NNI (histamine/histidine 16-fold). The majority of these bio-amines are cytotoxic at concentrations found in food. Inositol phosphate signaling implicated in AD is altered in C&A and CRC. Tryptamine stimulated accumulation of inositol phosphate. The seizure-eliciting tryptamine induced cytoplasmic vacuolization and vesiculation with cell fragmentation. Present additions of ADAS-carriers at different ages including infants led to an ADAS-comprising human sample size of 2,830 from 27 studies from four continents (North America, Australia, Asia, Europe). Levels of food-derived monoamine oxidase inhibitors and anti-bacterial compounds, the potential modulators of ADAS-bacteria growth and biogenic amine production, were altered in C&A versus NNI. ADAS is attributable to potentially modifiable risk factors of AD associated diseases.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

AIM

The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons.

METHODS

The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements.

RESULTS

This guideline contains 38 evidence based consensus statements on the management of diverticular disease.

CONCLUSION

This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

Colovesical Fistula: Applicability of the Laparoscopic Approach and Results According to Etiology

INTRODUCTION

Colovesical fistulae have significant morbidity. The aim of our study was to describe a case series of benign and malignant colovesical fistulae, focusing on the viability of the laparoscopic approach.

METHODS

We reviewed the characteristics of 34 patients with diverticular and colon adenocarcinoma-related colovesical fistulae treated surgically from January 2001 to March 2018, 28 with elective surgery and 6 by urgent surgery. The diagnosis was established by abdominal CT scan, colonoscopy and cystoscopy. Clinically stable patients, with no retroperitoneal or bladder trigone invasion, were approached laparoscopically.

RESULTS

There were 13 benign cases (all of them approached by sigmoidectomy), 9 performed by laparoscopy with 3 conversions. Partial cystectomy was done in 11 cases, and in two cases conservative management with urinary catheter. Five laparoscopic approaches were performed in 21 patients diagnosed with malignant colovesical fistula, with 3 conversions and 16 laparotomies. The procedures were sigmoidectomy, left colectomy, anterior resection and pelvic exenteration. All of them required partial or total cystectomy. Sixteen patients had complications, most of which were minor (Clavien-Dindo classificationI-II) and with laparotomy approach.

CONCLUSIONS

The laparoscopic approach can be feasible in well-selected and stable patients, but we have to take into consideration that the conversion rate can be high and this surgery should be performed by experienced surgeons.

Laparoscopic surgery for colovesical fistula associated with sigmoid colon diverticulitis: a review of 39 cases

Objectives: Colonic diverticular disease is widespread in Western countries and its associated with aging. In Japan, diverticulitis and colovesical fistula are also occurring more frequently. Colonic resection for diverticula-related fistulas is frequently technically demanding because of associated acute or chronic inflammation. We evaluated the safety and efficacy of a standardized laparoscopic procedure. Methods: Data from 39 consecutive patients who had undergone laparoscopic surgery for colovesical fistula between October 2006 and August 2017 were retrospectively reviewed. Results: The patients' median age was 60 years and comprised 35 men and four women. Sigmoidectomy was performed in 33 patients, Hartmann's procedure in four, and anterior resection in two. The median operative time was 203 minutes and estimated blood loss 15 mL. There were no intraoperative complications or conversion to open surgery. No patients required bladder repair; three had minor postoperative complications, and none had recurrent diverticulitis or fistula at a mean follow-up of 5.1 years. Conclusions: The magnified vision and minimal invasiveness make a laparoscopic approach the ideal means of managing colovesical fistula. To our knowledge, this is the largest study of colovesical fistula managed by a standardized laparoscopic procedure.

Over 1-Year Followup of Laparoscopic Treatment of Enterovesical Fistula

Background and Objective:

Entero vesical fistulas (EVFs) are an uncommon complication mainly of diverticular disease (70%) and less commonly of Crohn's disease (10%). Only about 10% are caused by malignancies. At this time, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with EVF. The aim of this study was to assess the feasibility and safety of laparoscopic surgery in the treatment of EVFs in patients with complicated diverticular and Crohn's disease.

Methods:

All patients with the diagnosis of EVF who underwent laparoscopic surgery were identified from prospective collected data based in two institutions between 2007 and 2017. Patients with malignancy were excluded. Recorded parameters included operative time, conversion to open surgery, the presence of a protective loop ileostomy, perioperative complications, number of units of blood transfused, postoperative course, and histologic findings.

Results:

Seventeen patients were included in the study: 10 patients with a colo-vesical fistula due to diverticular disease, and 7 patients with an ileo-vesical fistula due to Crohn's disease. There were no conversions to open surgery and none of the patients needed a protective ileostomy. The bladder was sutured in 12 patients (70%). No intra-operative complications were met, and no blood transfusions were needed; there were no anastomotic leaks, nor mortality in both groups.

Conclusions:

The laparoscopic approach for benign EVF in selected patients is both feasible and safe in the hands of experienced surgeons with extensive expertise in laparoscopic surgery.

Colovesical Fistula Complicating Diverticular Disease: A 14-Year Experience

OBJECTIVE

Colovesical fistulas (CVF) constitute the most common type of spontaneously occurring fistulas associated with diverticular disease. One-stage laparoscopic resection has been shown to be feasible, but studies comparing this approach to open surgery are scarce. The aim of this study was to compare the clinical outcomes of open and laparoscopic surgery for CVF of diverticular origin.

MATERIALS AND METHODS

From January 2000 to July 2014, 37 colectomies were performed for diverticular disease-related CVF. Twenty-eight patients who underwent resection and primary anastomosis were divided in 2 groups: the laparoscopic surgery group (group A) and the open surgery group (group B). We have analyzed the following parameters: operative time, complication rate, hospital stay, recurrence, and early mortality rate.

RESULTS

Groups A and B were comparable in terms of age, sex, diverticulitis episodes, previous abdominal surgery, and body mass index.The mean duration of surgery was significantly shorter in group B: 175 versus 237 minutes (P=0.011). There was a faster recovery of gastrointestinal transit in group A (2 vs. 13; P=0, 0002). However, there were no significant differences between the groups with respect to serious postoperative morbidity [(Clavien-Dindo scores of 3, 4, and 5) 4 vs. 0; P=0.098)] and with respect to hospital stay (10.5 vs. 9.5 d; P=0.537). There was no recurrence during a median follow-up of 12 months.

CONCLUSIONS

Laparoscopic resection and primary anastomosis should be considered a safe and feasible option for the management of diverticular CVF. Despite progresses in minimally invasive colorectal surgery, the conversion rate and morbidity are still high.

Laparoscopic approaches to complicated diverticulitis

BACKGROUND

The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis.

PURPOSE

The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis.

CONCLUSIONS

New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.

Risk factors associated with postoperative morbidity in over 500 colovesical fistula patients undergoing colorectal surgery: a retrospective cohort study from ACS-NSQIP database

PURPOSE

The aim of this study was to evaluate the impact of various factors on 30-day postoperative morbidity in patients who underwent colorectal surgery (CRS) for colovesical fistula (CVF) in the elective and emergency settings.

METHODS

Patients who underwent CRS for CVF between 2005 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database by using current procedural terminology codes. Demographics, perioperative, and operative factors were assessed and compared between two groups classified according to the presence or absence of postoperative complications.

RESULTS

Five hundred twelve patients met the inclusion criteria [mean age of 61.4 (±14.7) years, female 214 (42%)]. Etiology of fistula was diverticulitis [N = 438 (85.5%)], colon cancer [N = 39 (7.6%)], and Crohn's disease [N = 35 (6.8%)]. One hundred fifty-two procedures (29.7%) were performed laparoscopically. In 186 patients (36%), no bladder intervention was performed. One hundred forty-nine patients (29.1%) had at least one postoperative complication. Patients who developed complication were older (P = <0.001), more often female (P = <0.001), hypertensive (P = 0.005), anemic (P = <0.001), preoperatively transfused (P = 0.02), and with class 2-3 wound classification (P = 0.01). Independent risk factors affecting morbidity were increased age [odds ratio (OR) 1.23 (1.03-1.47), P = 0.01], decreased hematocrit level [OR 3.04(1.83-5.06), P < 0.0001], and open approach [OR 2.56 (1.35-4.84), P = 0.003].

CONCLUSIONS

Morbidity for CVF remains high. Lower preoperative hematocrit level and increased age were associated with higher risk of complication. Laparoscopic surgery may be preferable when possible as morbidity is less with this approach.

[Colovesical fistulas : An interdisciplinary challenge]

BACKGROUND

The aim of treatment of patients with colovesical fistulas should be prompt elimination of the infection and the social burden. We focused on the question whether a minimally invasive surgical approach as a cooperation between surgeons and urologists is possible. This requires effective diagnostics prior to the operation.

METHODS

Since 2007 a total of 32 patients with the clinical suspicion of colovesical fistula have undergone extensive preoperative diagnostics. Operative treatment aimed primarily for a minimally invasive approach. In particular, the validity of preoperative diagnostics was analyzed and surgical results were characterized by clinical success, complications and long-term effects.

RESULTS

The medical history significant for colovesical fistula and detected urinary infection provided the best evidence for the specific diagnosis. Cystoscopy, computed tomography (CT) scan and colonoscopy were only partially effective for predicting a fistula as subsequently diagnosed by histopathological investigations. Fistulas due to diverticulitis of the sigmoid colon occurred in 28 cases, while in 3 subjects there was a gynecological and inflammatory cause (malignant tumor growth, n = 1). A laparoscopic approach achieving repair and healing of the fistula was possible in 29 cases including conversion in 3 subjects because of intraoperative complications. The remaining patients underwent conventional treatment. The disease-related complication rate as revealed during follow-up was 10%.

DISCUSSION

Laparoscopic repair and healing of a colovesical fistula is possible in the majority of cases by the recommended preoperative ureteral stenting. As part of diagnostic measures, the medical history significant for a fistula and detection of urinary infections are the most reliable aspects. In the case of this combination together with a further diagnostic measure, a laparoscopic approach is always recommended. The recurrency rate is 0%.

Single-incision laparoscopic (SIL) sigmoid colectomy and uterus-preserving repair for colo-uterine fistula secondary to severe diverticular disease: an unusual technical solution for an unusual presentation of a common disease

Colouterine fistula as a potential complication of chronic diverticulitis is a rare entity with less than 30 cases reported worldwide. Generally, patients require a multidisciplinary approach including a major laparotomy with hysterectomy and sigmoid colectomy, and, occasionally, temporary colostomy. We report the first attempt of a novel, minimally invasive technique for managing a case of benign colouterine fistula with single-incision laparoscopic (SIL) sigmoid colectomy and uterus preservation. A small, 3 cm incision site provided access for the whole operation, as well as played a role as the specimen extraction site. Malignant fistulas and large uterine defects may require hysterectomy, however, laparoscopic closure of uterine wall defects can be considered as a reasonable alternative in selected patients, avoiding the higher risks associated with hysterectomy and keeping fertility at younger ages. Single incision laparoscopy in complicated diverticular disease and fistula formation cases is a challenging but technically feasible option, in experienced hands.

Laparoscopic treatment of complicated colonic diverticular disease: A review

Up to 10% of acute colonic diverticulitis may necessitate a surgical intervention. Although associated with high morbidity and mortality rates, Hartmann’s procedure (HP) has been considered for many years to be the gold standard for the treatment of generalized peritonitis. To reduce the burden of surgery in these situations and as driven by the accumulated experience in colorectal and minimally-invasive surgery, laparoscopy has been increasingly adopted in the management of abdominal emergencies. Multiple case series and retrospective comparative studies confirmed that with experienced hands, the laparoscopic approach provided better outcomes than the open surgery. This technique applies to all interventions related to complicated diverticular disease, such as HP, sigmoid resection with primary anastomosis (RPA) and reversal of HP. The laparoscopic approach also provided new therapeutic possibilities with the emergence of the laparoscopic lavage drainage (LLD), particularly interesting in the context of purulent peritonitis of diverticular origin. At this stage, however, most of our knowledge in these fields relies on studies of low-level evidence. More than ever, well-built large randomized controlled trials are necessary to answer present interrogations such as the exact place of LLD or the most appropriate sigmoid resection procedure (laparoscopic HP or RPA), as well as to confirm the advantages of laparoscopy in chronic complications of diverticulitis or HP reversal.

Laparoscopic surgery of benign entero-vesical or entero-vaginal fistulae

PURPOSE

Entero-vesical or entero-vaginal fistulae (EVF) are an uncommon septic complication mainly of diverticular disease. The fistulae are usually situated within extensive and dense inflammatory masses occluding the entrance of the pelvis. There are still some controversies regarding laparoscopic feasibility and treatment modalities of this disorder.

METHODS

A retrospective chart review of all patients with EVF operated at our department since 2008. Patients were identified by use of the computerized hospital information system.

RESULTS

In nineteen patients (ten males), median age 68 years, 13 patients had entero-vesical fistulae, and 6 patients had entero-vaginal fistulae. The fistulae were caused by complicated diverticular disease in 16 patients (84 %), Crohn's disease (two patients), and ulcerative colitis (one patient). All cases were attempted laparoscopically. Operative treatment involved separation of the inflammatory mass and resection of the affected colorectal segment. There were three conversions (16 %), all three requiring bladder repair considered too extensive for laparoscopic means. In two further patients small bladder defects were sutured laparoscopically, the remaining patients required no bladder repair. The inferior mesentric artery (IMA) was preserved in all cases. Median operative time was 180 min. Two patients received a protective ileostomy: one converted patient and one cachectic patient with Crohn's disease under immune-modulating therapy. Both ileostomies were closed. Altogether, there were five complications in five patients (26 %), four of them were minor (Clavien grade I and II). The cachectic patient with Crohn's disease suffered a major (grade IIIb) complication (stoma prolapse, treated by early closure of the ileostomy). There was no anastomotic leakage and no mortality. Median hospital stay was 12 days.

CONCLUSIONS

The laparoscopic approach is a safe option for the treatment of EVF of benign inflammatory origin. In most cases it offers all the advantages pertaining to minimally invasive surgery. For a definite and causal approach, the disorder belongs primarily within the therapeutic domain of the visceral surgeon. Following the separation of the inflammatory colon, most of the bladder lesions caused by EVF will heal without further surgical measures.

Is laparoscopic surgery the best treatment in fistulas complicating diverticular disease of the sigmoid colon? A systematic review

INTRODUCTION

Laparoscopic surgery is considered in the treatment of diverticular fistula for the possible reduction of overall morbidity and complication rate if compared to open surgery. Aim of this review is to assess the possible advantages deriving from a laparoscopic approach in the treatment of diverticular fistulas of the colon.

METHODS

Studies presenting at least 10 adult patients who underwent laparoscopic surgery for sigmoid diverticular fistula were reviewed. Fistula recurrence, reintervention, Hartmann's procedure or proximal diversion, conversion to laparotomy were the outcomes considered.

RESULTS

11 non randomized studies were included. Rates of fistula recurrence (0.8%), early reintervention (30 days) (2%) and need for Hartmann's procedure or proximal diversion (1.4%) did not show significant difference between laparoscopy and open technique.

DISCUSSION

there is still concern about which surgery in complicated diverticulitis should be preferred. Laparoscopic approach has led to less postoperative pain, shorter hospital stay, faster recovery and better cosmetic results. Laparoscopic resection and primary anastomosis is a possible approach to sigmoid fistulas but its advantages in terms of lower mortality rate and postoperative stay after colon resection with primary anastomosis should be interpreted with caution. When there is firm evidence supporting it, it is likely that minimally invasive surgery should become the standard approach for diverticular fistulas, thus achieving adequate exposure and better visualization of the surgical field.

CONCLUSION

The lack of RCTs, the small sample size, the heterogeneity of literature do not allow to draw statistically significant conclusions on the laparoscopic surgery for fistulas despite this approach is considered safe.

Laparoscopic surgery for sigmoidocutaneous fistula due to diverticulitis: A case report

Sigmoidocutaneous fistulas due to sigmoid colon diverticulitis are very rare. Here we report a case in which laparoscopic sigmoidectomy was used to successfully treat a sigmoidocutaneous fistula due to diverticulitis. A 41-year-old man was admitted to our hospital because of redness and swelling of the left inguinal skin. Enhanced abdominal CT revealed a subcutaneous abscess in the left lower abdomen. Percutaneous drainage was performed, and fistulography revealed a fistula between the sigmoid colon and left inguinal skin. Therefore, a sigmoidocutaneous fistula was diagnosed, and laparoscopic sigmoidectomy and fistulectomy were performed. The sigmoid colon had several diverticula, and a pathological examination revealed that the sigmoidocutaneous fistula was due to diverticulitis. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. In cases of sigmoidocutaneous fistula, laparoscopic treatment can be safely performed.

Single incision laparoscopic resection for diverticulitis

BACKGROUND

Laparoscopic sigmoidectomy is the standard procedure in elective surgery for recurrent diverticular disease. Recently, Single Incision Laparoscopic Surgery (SILS) have been developed as the next generation technique of minimally invasive surgery. SILS advantages include reduced surgical trauma due to reduction in the number of surgical incisions, faster recovery times, and reduced hospitalization. However, the use of SILS in colorectal surgery is technically demanding and requires expert surgeons, which has hampered the reproducibility and the diffusion of this technique.

METHODS

Between October 2009 and August 2013, 488 consecutive patients were referred to Evangelisches Hochstift Hospital (Worms, Germany) and/or Stadt Klinikum Frankental Hospital (Frankenthal, Germany) for sigmoidectomy for diverticular disease. SILS sigmoidectomy via the umbilicus was performed in 484/488 cases. Clinical outcomes such as the rate of conversion to standard laparoscopy and/or to open surgery, operation time, post-operative complications and hospitalization time were recorded.

RESULTS

SILS sigmoidectomy was successfully completed for 484 out of 488 patients. SILS was converted to standard laparoscopy in 3 patients (0.6%) and to an open procedure in 1 patient (0.2%). Median time for the procedures was 103.26 min (range, 52-156 min). No mortalities or major complications were noted. The average hospitalization period was of 5 days.

CONCLUSION

Our work demonstrates that SILS sigmoidectomy via the umbilicus is effective in the treatment of patients affected by diverticular disease on a routine basis and, moreover, is technically feasible also in patients who have been subjected to previous abdominal surgery, with high Body Mass Index and/or patients with perforation at presentation. Thus this procedure represents a valid alternative to standard laparoscopy.

Perforated diverticulitis of the sigmoid colon revealed by a perianal fistula

INTRODUCTION

Diverticular disease of the colon is a frequent pathology; however, perforated diverticulitis with a spontaneous sigmoidocutaneous fistula revealed by a perianal abscess is an uncommon presentation. We present this extremely rare case of a perforated sigmoid diverticulum in the perianal area, which is the first case that we have encountered in our practice and in the literature, along with the accompanying diagnostic and therapeutic issues and a review of the literature.

PRESENTATION OF CASE

We report the case of a 47-year-old man who was admitted to the emergency room due to a perianal abscess. The patient was taken to the operating room on an emergency basis. In the lithotomy position, the abscess was located at the 4 o'clock position. Incision and drainage was performed. Intraoperatively, the abscess was found to be deep, and considered an ischiorectal abscess. No fistulous tract was identified. An MRI of the pelvis was performed one month postoperatively which revealed a perforated diverticulitis of the sigmoid colon causing a perianal fistula. After the abscess was successfully treated, a sigmoidectomy was performed. Fifteen centimeters of the colon were resected. No postoperative complications occurred.

DISCUSSION

Perianal fistula is an obvious physical sign but its etiology is complex to determine. The pathophysiological mechanism involved is the emergence of a pressure gradient between the peritoneum and surrounding structures, causing rupture of the perianal tissue, allowing gas from a perforation to diffuse along tissue planes.

CONCLUSION

General surgeons should bear in mind this rare presentation of a sigmoid diverticulitis.