Colorectal carcinoma presenting as spontaneous colocutaneous fistula - A rare case report and review of literature

INTRODUCTION AND IMPORTANCE

Colon cancer presenting as spontaneous enterocutaneous fistula are rare with only few cases reported in the literature. Such presentation signifies locally advanced disease with poorer outcomes. Enterocutaneous fistula increases morbidity and mortality in cancer and may potentially delay the definitive care. It poses a difficulty in management in terms of patient optimization, determining the type of resection (palliative or curative) and the operative timeline.

CASE PRESENTATION

A 47 years old female presented with complaints of foul smelling discharge from a fistulous opening in right iliac fossa with occasional per rectal bleeding for the past six months. Imaging showed ascending colon mass breaching the peritoneum with fistulous tract opening into subcutaneous plane. Exploratory laparotomy with right hemicolectomy and en bloc resection was performed.

CLINICAL DISCUSSION

Cutaneous fistula can be caused by traumatic, postoperative etiologies and about 20 % are of spontaneous etiologies. Colon cancer has the ability to mimic any abdominal disease with a wide spectrum of presentations. The locoregional extension from the bowel creates a passage of colonic contents to evacuate from the external opening. The fistulous tract of colon cancer is less likely to close spontaneously and may require surgical intervention following appropriate resuscitation. Due to features suggestive of bowel obstruction an early single stage surgery was performed in our case.

CONCLUSION

There are no existing guidelines for colon cancer with colocutaneous fistula because they are the same for benign fistulas (resuscitation, control of output, eradication of the infection, nutritional optimization, surgery) along with a multidisciplinary oncology team approach.

Complexities in the management of a Richter's supraumbilical hernia with colocutaneous fistula in a patient with morbid obesity: A case report with a review of literature

Abdominal wall Richter's hernia is rare. The usual presentation is with irreducibility, obstruction and strangulation. Occasionally, enterocutaneous fistula containing small bowel has been reported. Management is frequently difficult due to emergency presentation and contamination. A 60-year-old male with a history of suture repair of umbilical hernia presented with faecal discharge from a long-standing recurrent hernia in the background of obesity and history of pulmonary embolism. There were no features of peritonitis or obstruction. After optimisation, we took the patient for a diagnostic laparoscopy with curative intent. Diagnostic laparoscopy revealed a Richter's hernia containing transverse colon. The patient was treated with resection of the involved colonic segment, anastomosis, complete excision of the fistula tract along with surrounding skin, negative pressure wound therapy and delayed skin closure. To our knowledge, this is the first report of a spontaneous umbilical Richter's hernia complicated with a colocutaneous fistula. Management was challenging due to emergency presentation, multiple comorbidities as well as faecal contamination. Minimal access approach may have helped by decreasing the contamination and surgical site infection in the postoperative period.

Management of colocutaneus fistula with laparoscopic surgery: Case report

BACKGROUND

Colocutaneous fistulas can occur as the result of complications from diverticular colon surgery. Enterocutaneous fistula is a type of fistula that accounts for about 88.2% of all fistulas. In this report, we describe a case reports of the management of colocutaneous fistula with laparoscopic surgery.

CASE PRESENTATION

In this case reports, both patients complained of increased amount of abdominal discharge after surgery. In Case 1, a 43-year-old female patient complained of a lump in her lower abdomen which had been there for three months. After removal of the lump, there was blood in the drainage tube. After three months, her surgeon advised to close the stoma. In Case 2, a 47-year-old male patient lived with colocutaneous fistula for a year. He had been involved in a traffic accident and underwent laparotomy sigmoidostomy. Both patients experienced pain, and there also were feces and bad odor coming out from the surgical incision. Then, both patients underwent colonoscopy, which revealed coloncutaneous fistulas. Laparoscopic surgery was conducted and there was adhesion between the sigmoid colon and ileum in the ventral abdomen wall. After the laparoscopic procedure, the patients were discharged 3 days later without any complaints.

CONCLUSIONS

Laparoscopic colectomy has recently replaced open resection as standard surgery. This procedure is safe, feasible, and effective for diverticular disease.

A case report of unexpected pathology within an incarcerated ventral hernia

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Incarcerated appendicitis could be due to an unexpected inflammatory etiology.

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Elucidating the etiology of inflammation is essential for directing management.

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Ongoing inflammatory process after appendectomy may be due to Crohn’s disease.

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Laparoscopic management of perforated hernial appendicitis provides excellent visualization.

Introduction

Incidence of hernial appendicitis is 0.008%, most frequently within inguinal and femoral hernias. Up to 2.5% of appendectomy patients are found to have Crohn’s disease. Elucidating the etiology of inflammation is essential for directing management.

Presentation of case

A 51-year-old female with achondroplastic dwarfism, multiple cesarean sections, and subsequent massive incisional hernia, presented with ruptured appendicitis within her incarcerated hernia. She underwent diagnostic laparoscopy, appendectomy, intra-abdominal abscess drainage, and complete reduction of ventral hernia contents. She developed a nonhealing colocutaneous fistula, causing major disruptions to her daily life. She elected to undergo hernia repair with component separation for anticipated lack of domain secondary to her body habitus.

Her operative course consisted of open abdominal exploration, adhesiolysis, colocutaneous fistula repair, ileocolic resection and anastomosis, and hernia repair with bioresorbable mesh. She tolerated the procedure well. Unexpectedly, ileocolic pathology demonstrated chronic active ileitis, diagnostic of Crohn’s disease.

Discussion

Only two cases of hernial Crohn’s appendicitis have been reported, both within Spigelian hernias. Appendiceal inflammation inside a hernia sac may be attributed to ischemia from extraluminal compression of the hernia neck. This case demonstrates a rare presentation of multiple concurrent surgical disease processes, each of which impact the patient’s treatment plan.

Conclusion

This is the first report of incisional hernia appendicitis with nonhealing colocutaneous fistulas secondary to Crohn’s. It is a lesson in developing a differential diagnosis of an inflammatory process within an incarcerated hernia and management of the complications related to laparoscopic hernial appendectomy in a patient with undiagnosed Crohn’s disease.

Communicating Fistula Between Colocutan and Nephrocutan With Renal Stones and Renal Replacement Lipomatosis. A Case Report

Colocutaneous fistula with nephrocutaneous fistula is a rare condition. Renal replacement lipomatosis is the result of the atrophy and destruction of renal parenchyma. We report a 60-year-old male with intermittent drainage mucus and fluid from ulcer of his right lumbar region. Renal ultrasound and plain abdominal X-ray revealed a chronic parenchymal disease with stone of the right kidney. Fistulography showed a fistula tract connecting the skin and the right pelvicalyceal system and the colon. Computerized tomography demonstrated a renal calculus with a massive fatty proliferation. The patient was planned for right nephrectomy and excision of the sinus tract.

Wandering Gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is a relatively safe and effective method of providing nutrition to patients with neurologic deficits or proximal gastrointestinal pathology. Complications that follow this common procedure include dislodgement, dysfunction, infection, gastric/colonic perforation, bleeding, peritonitis, or death. The emergency physician should be aware of the complications and symptoms/signs associated for appropriate management of these patients. We present a case of a young lady who developed a cerebral infarction following amniotic fluid embolism during her cesarean section and had undergone a PEG tube placement. She developed displacement of this PEG tube and underwent another PEG tube placement. She later presented to us with PEG tube migration into the transverse colon and required surgical removal of the same PEG tube.

Does phenytoin improve the healing of gastrointestinal fistulas?

Pancreatic fistulas are among the most devastating complications after pancreatic surgery. Their subsequent development can be lethal. We report two cases of pancreatic fistulas treated with phenytoin. Fistula tract healing consists of several processes, including cell migration and the formation of a new extracellular matrix. Multiple studies have shown that phenytoin can promote wound healing and induce faster fibrosis. We postulate that such a positive effect can be used to enhance fibrosis of the pancreatic fistula tract. We treated two patients who had developed high-output pancreatic fistulas after pancreatic surgery. The first underwent hand-assisted laparoscopic pancreatic necrosectomy and developed two high-output pancreatic fistulas and a colocutaneous fistula. The second occurred post Whipple surgery. Both were given oral phenytoin after failure to respond to other measures. In conclusion, oral phenytoin may have a positive effect in the treatment of fistulas. Prospective studies are needed to indicate this possible effect of phenytoin on fistula healing.

Colocutaneous fistula secondary to amoebiasis

Here we present an interesting and extremely rare case of a 66 year old male who developed a colocutaneous fistula secondary to amoebiasis. The patient presented with an acute history of right lower abdominal pain, weight loss and a palpable mass. A CT scan demonstrated a fluid filled cavity in the right iliac fossa consistent with an appendiceal abscess which was drained under radiological guidance. However, following drainage his symptoms remained requiring open surgical drainage, and a controlled caecostomy was performed due to a small caecal perforation. Despite appropriate conservative therapy he failed to progress, and developed localised sepsis in the right iliac fossa with a colocutaneous fistula, requiring a formal right hemicolectomy. The histological examination confirmed the presence of abundant trophozoites of Entamoeba histolytica.We highlight the fact that in the modern age of immigration and long distance travel, it will become increasingly likely that the so-called 'tropical' diseases will present throughout the world. This case also highlights the need to keep an open mind in cases that do not progress as expected, and to react accordingly to any unusual developments.

A Delayed Recrudescent Case of Sigmoidocutaneous Fistula due to Diverticulitis

Colocutaneous fistula caused by diverticulitis is relatively rare, and a delayed recrudescent case of colocutaneous fistula is very uncommon. We herein report a rare case of a Japanese 56-year-old male with delayed recrudescent sigmoidocutaneous fistula due to diverticulitis. A colocutaneous fistula was formed after a drainage operation against a perforation of the sigmoid colon diverticulum. After 5 years from treatment, he was admitted to our hospital because of lower abdominal pain. We diagnosed the recrudescent sigmoidocutaneous fistula by abdominal computed tomography and gastrografin enema, and managed the patient with total parenteral nutrition and antibiotics. As the fistula formation did not improve, a low anterior resection with fistulectomy was performed. The postoperative course was uneventful and the patient was discharged. It has been reported that, in fistulas of the skin caused by diverticular disease, complete closure of the fistula by conservative therapy may not be possible. This case also implies the possibility of a recurrence of the fistula even if the conservative treatment was effective. In cases of colocutaneous fistulas due to diverticulitis, radical surgery is considered necessary because of possibility of recurrence of the fistula.