|Year : 2022 | Volume
| Issue : 1 | Page : 88-90
Enterocutaneous fistula in thigh
MK Dinu, E Sugeeth
Department of Surgery, Government Medical College, Kozhikode, Kerala, India
|Date of Submission||09-Jan-2022|
|Date of Decision||11-May-2022|
|Date of Acceptance||11-May-2022|
|Date of Web Publication||14-Jul-2022|
Dr. M K Dinu
Government Medical College, Kozhikode - 673 008, Kerala
Source of Support: None, Conflict of Interest: None
Enterocutaneous fistula is a condition with a mortality rate as high as 10% in recent reports. Hence, early detection is important. This is a case report of a 53-year-old male with a rare presentation of an enterocutaneous fistula as a thigh abscess.
Keywords: Abdomino-perineal resection, entero-cutaneous fistula, thigh abscess
|How to cite this article:|
Dinu M K, Sugeeth E. Enterocutaneous fistula in thigh. Kerala Surg J 2022;28:88-90
| Introduction|| |
Fistula is an abnormal communication between two epithelium-lined surfaces. The majority of the enterocutaneous fistulas are iatrogenic (75%–85%) and only 15%–25% are spontaneous fistula. The majority of these present as febrile patients with an erythematous wound and are managed based on the fistula output and the cause of the fistula.
| Case Report|| |
A 53-year-old male patient with a past history of abdominoperineal resection (APR) for carcinoma rectum, followed by adjuvant chemoradiation and a history of radiation enteritis now presented with complaints of fluctuant swelling in the left lateral aspect of the thigh with throbbing pain and fever of 2 weeks for which he underwent incision and drainage. Initially, the discharge was purulent, but later on it turned out to be faeculent [Figure 1]. He was evaluated with multiple imaging modality to identify the source of enterocutaneous fistula. Contrast-enhanced computed tomography of the abdomen and pelvis was taken which showed an ill-defined fluid density lesion with air pockets and enhancing wall noted in presacral space of 2 cm × 7.2 cm [Figure 2]. The collection was noted to extend underneath the left gluteal muscles through the left sacro sciatic notch and extending to the intermuscular compartment of the left thigh between rectus femoris and vastus lateralis of maximum thickness of 1.8 cm extending for a distance of 11 cm. The bodies of S2 and S3 segments of vertebrae adjacent to the collection showed erosive changes. An ill-defined soft-tissue density area was noted in the presacral region extending to adjacent ileal loops – possibly fibrosis.
|Figure 1: Clinical presentation of faecal fistula in the lateral aspect of the left thigh|
Click here to view
|Figure 2: Contrast computed tomography showing oral dye accumulating in the right ileac fossa and tracking superficially|
Click here to view
Even with a battery of investigations, the source of this enterocutaneous fistula could not be found out and hence, we proceeded with laparotomy, which showed clumping of ileal loops in the pelvis with a blind loop of the terminal ileum [Figure 3] with perforation [Figure 4] acting as the source of enterocutaneous fistula through the left sciatic notch. Intact ileo-transverse anastomosis and descending colostomy were seen. We proceeded with resection of the involved segment of the ileum and closure of the free ends. HPR showed only inflammatory changes in the resected specimen.
| Discussion|| |
Fistulas are abnormal communications between two epithelium-lined surfaces. Enterocutaneous fistula is an abnormal communication between the bowel and skin. The aetiology may vary and hence the treatment plan. Majority of these fistulas are iatrogenic with only 15%–25% being spontaneous. Enterocutaneous fistula even though is a relatively well-known entity, it usually presents as discharge through the wound or as wound infection. However, the present case is a relatively rare presentation of an enterocutaneous fistula as thigh abscess. Here, the pus crossed the anatomical barriers and took an unusual course from the pelvis to reach the thigh through the greater sciatic notch and along the gluteal muscles. The presentation may be either acute on chronic. Substantial morbidity is associated with the presence of enterocutaneous fistula. Fistulas associated with peritoneal contamination, abscess and malignancy carry a poor prognosis. The best possible approach is the prevention of its occurrence, but this is not always feasible.
| Conclusion|| |
A 53-year-old male patient, a known case of carcinoma rectum, for which he underwent APR 6 years, had an acute intestinal obstruction after 6 months, for which he underwent ileo-transverse anastomosis. Now, he presented with left thigh abscess. I and D were done, which turned out to be feculent. He was managed conservatively, but the fistula neither healed nor revealed the source. After a battery of investigations, we finally proceeded with laparotomy and the source of the fistula was identified as terminal ileum.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that the name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Townsend CM Jr., editor. The biological basis of modern surgical practice. In: Sabiston Textbook of Surgery. USA: Elsevier-Health Sciences Division; 2021. p. 75-84.
Yeo CJ. Shackelford's Surgery of the Alimentary Tract. In: Yeo CJ, DeMeester SR, McFadden DW, editors. Shackelford's Surgery of the Alimentary Tract, 2 Volume Set. 8th
ed. USA: Elsevier-Health Sciences Division; 2018. p. 93-8.
Huda T, Pandya B. Treatment of colocutaneous fistula in the left thigh. Surg J (N Y) 2019;5:e113-9.
Rubartelli A, Cocchi L, Solari N, Cafiero F, Minuto M, Bertoglio S. Left lower limb fasciitis due to sigmoid colonic perforated diverticulitis: A rare case of colocutaneous fistula. J Surg Case Rep 2020;2020:rjaa264.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]