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.

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