Colon fistula after appendectomy
My partner has a 38 year old previously healthy, obese white male who presented 4 weeks ago with gangrenous retrocecal appendicitis. I helped him do a very difficult appendectomy through a right lower quadrant incision. The appendix was gangrenous, and was completely retrocecal, with the tip lying at the level of the hepatic flexure. We had to do quite a bit of mobilization of the cecum and ascending colon to get that sucker out. We left a Jackson Pratt drain in for several days, although it didn’t drain much. His wound was packed open, and despite looking great at POD 5, failed delayed primary closure (developed excessive drainage), so was reopened.
Two weeks ago, he developed fever and right lateral abdominal tenderness. CT scanning revealed a retrocecal abscess, which was drained percutaneously. C&S showed bacteroides, non-fragilis. Drainage ceased after about 4 days, however a fistulogram revealed a possible communication with the ascending colon – no tract was evident but there appeared to be some contrast in the ascending colon. There was still no further drainage after 24 hours, and the patient’s WBC and temp were normal, so the radiologist pulled the catheter. Within 48 hours, the patient’s WBC was up to 19K and his temp was 102F. A repeat CT revealed only inflammation, so he was started on IV Primaxin. His WBC came down, but his temp kept spiking, and a third CT late last week showed another abscess cavity. This was again drained, again showing bacteroides. A fistulogram performed today reveals a small cavity with two tiny tracts extending towards the ascending colon, and contrast appearing in the colon after a short while.
My partner seems resigned to performing a right hemicolectomy, however I am concerned that this will be extremely difficult due to the inflammation, as well as the patient’s marked obesity. I am inclined to give him a trial of complete bowel rest (he has been on a regular diet), TPN, continued drainage and antibiotics. There is no reason to suspect primary colon pathology, so I don’t see why the fistula shouldn’t heal.
Any suggestions would be most appreciated.
Could even try vivonex enteral feed – or tpn. Try and place a pic-line stead of a cvl.
It will heal in the absence of the usual reasons for failure: i.e., ischemia, obstruction, IBD, radiation, etc. A low residue diet should suffice rather than the more expensive elemental formulas. I would not consider colectomy for at least 3 months and by then he should be long sicne healed.
All cecal fistulas will close spontaneously provided there no distal obstruction, bowel pathology, FB, bla bla bla and all PUS is drained.
Cecal fistual will close when the patients eats pork steak , ensure, or TPN …
I would be certain that all pus is drianed (PC or openly); if you really want, give him some low residue diet and in 4-21 days his fistula will close.
When once I started a patient with a cecal fistula on TPN my attending laughed at me; pulled the central line out and started a “full word diet”. The fistula closed in a week.
If the patient has improved clinically after second drainage proceedure, it remains adequately drained, and there is no underlying colon pathology I would wait it out. Adding bowel rest with either elemental diet or tpn. If radiolgy has failed to get it drained, operative drainage could be indicated. No right colectomy yet…
I completely agree with you and I think this small fistula with no distal obst. should heal in time. You have to be sure that there is no continuing sepsis of course via CT.
I would use a R hemicolectomy as a last resort. If the patient is afebrile, nontoxic and has a normal WBC, an elemental diet might even be enough to allow this to heal. You should obtain good drainage.
I’m looking forward to all your answers on this one. Since the patient has failed 2 attempts at “conservative” therapy, I would be inclined to agree with your partner and do the R. Hemicolectomy with lots of peritoneal toilet and drainage.
I agree with you, hyperal, adequate drainage and time should do the trick.
I agree with your plan to simply treat your patient with percutaneous drainage and IV antibiotics. If the fistula is considered “low output”, then the use of “bowel rest” and TPN is controversial. If you DO decide to use bowel rest and TPN, then certainly consideration should be given to using Octreotide (Somatostatin analog), which will significantly decrease the closure interval.
Obviously the best treatment is prevention and the retrospectroscope is always 20/20. I’ve had good success with performing a partial cecectomy in cases of gangrenous appendicitis where the case may be extremely difficult and/or the appendiceal base of questionable viability. I simply use a GIA-type stapler and remove a few millimeters or more of adjacent cecum.
I have had no success with somatostatin in accelerating the healing of low output fistuli(which is echoed by the literature).
What did colonoscopy show? Are you certain he doesn’t have Crohn’s disease?
What do you lose by waiting, as long as the infection is controlled?
Good question. Answer: I don’t know if he has Crohn’s disease – he hasn’t been colonoscoped. I suppose that one may have both lice and fleas, but there has never been any reason to suspect Crohn’s on top of appendicitis.
At this point, he is doing better, with no more fever. He is on TPN and had a larger drainage catheter inserted by our interventionalist, yielding an additional 40 cc of pus. The current plan is to wait it out and see if the fistula will heal, however it would probably be a good idea to perform colonoscopy if it doesn’t.
We have a patient hospitilized with a colon fistula. Three weeks ago he underwent a routine appendectomy for phlegmonous appendicitis, with an uneventful 3 day post op stay and discharge. Two weeks later he returned with fever and RLQ tenderness, and US and subsequent CT revealed a large intra-abdominal abcess which underwent percutaneous drainage under CT guidance. The drain remained in for a couple of days until only a few ml of pus came out, and before removal was sent for a fistulogram to see if there was communication to the colon. Sure enough, the film showed communication to…sigmoid colon! Figure that one out.
A few possibilities:
1. The patient had “just” an abscess without a cecal fistula. The radiologist went through the sigmoid or the rigid pigtail erroded the nearby sigmoid; have seen it happen before.
2. There was a iatrogenic injury to the sigmoid during appendectomy 3. Your resident mistook a sigmoid diverticulitis for acute appendicitis (a joke).
The first possibility is probably correct.
The first thought that springs to mind is that the possibility that his “appendicitis” was actually sigmoid diverticulitis, with the appendix merely being an innocent bystander. Of course, this is not consistent with what you describe as such a benign post-op course. However, it may be worth reviewing the pathology from the appendectomy – was it true appendicitis, with transmural inflammation and mucosal ulceration?
If this wasn’t sigmoid diverticulitis, I’d blame the radiologist (why not? – let them get some blame for a change!
The mobile sigmoid colon would only be doing it’s job in wrapping itself around Appy site along with whatever else..omentum,small bowel,… Spontaneous development of fistula is a possibility, but human intervention certainly CAN help.