Surgical Management of a Complex Enterocutaneous Fistula with Small Bowel and Gluteal Cleft Involvement Post-Resection of Rectal Adenocarcinoma

Purpose: The purpose of this case report is to discuss the importance of recognizing the presentation of an enterocutaneous fistula (ECF) as well as its management. Methods: This case report describes a 51 year old African-American male with a past medical history of status post rectal cancer resection performed 9 months ago presented to clinic for follow-up of a persistent perirectal wound with constant drainage. The patient had no complications during the initial hospital stay for the surgery, but later returned to the emergency department 2 weeks later with symptoms of fever and abdominal pain. The patient was found to have a presacral abscess which was drained by interventional radiology. The patient continued to receive wound care, but the perianal wound failed to heal with persistent mucopurulent drainage over many months. Five months later, the patient underwent a fistulogram to visualize the extent of the wound. The fistulogram revealed 2 draining gluteal cleft wounds that converged into 1 tract extending cephalad with small bowel communication. The patient followed up 2 months later, and due to failure of the fistula to heal, it was determined that surgical repair of the ECF was necessary. Results: The patient was taken to the operating room to undergo open repair of the ECF. Due to potential bladder involvement, a urologist performed a cystoscopy but was not able to visualize any obvious fistula involvement. Ureteral stents were placed bilaterally. Afterwards, an open laparotomy was performed and bowel was carefully dissected in order to visualize bowel involvement of the fistula. Once loops of small bowel were freed from the fascia, an obvious opening along the dorsal aspect of bowel was found. There was no obvious visual evidence of an enterovesical fistula. At this point, about 12-14 cm of small bowel was resected with primary anastomosis of the small bowel. Afterwards, 180 cc of methylene blue was injected into the bladder to assess for a leaking fistula, but no leakage was found. The peritoneal cavity was irrigated and the abdominal fascia and skin was closed. The patient tolerated the procedure well. The patient’s postoperative stay was non-eventful and the patient was discharged postoperative day 6 and was instructed to follow-up in clinic. Conclusions: An ECF is a potentially catastrophic complication of surgery, and it continues to remain a significant challenge in its management. While definitive surgical repair is often purposefully delayed for months, it is imperative to recognize the signs of an ECF, as uncontrolled sepsis as well as electrolyte imbalances will result in very poor outcomes. However, this case reveals that it may be rather difficult in definitively diagnosing an ECF, especially when it develops postoperatively outside of the hospital stay. This case hopes to illustrate a presentation of an ECF as well as clinical considerations of its management.