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Case Presentation
A 65 year old male with an extensive operative history for Crohn's disease, including 4 laparotomies with small bowel resections to ameliorate small bowel obstructions presented to us. His first surgery was performed in England in 1991, and the next 3 were performed in Peru, one in 1998 and two in 2007. Over the past few years he has been suffering from nutritional deficiencies and osteopenia associated with his resultant short bowel syndrome. He has had, in addition, intermittent drainage from his previous midline incision. The drainage was non-bilious, serosanguenous fluid that would egress approximately every 2–3 days. Several sutures were removed through the tract in the past but the wound still failed to heal. The drainage volume and quality did not change significantly over the past year. Although he did suffer from short bowel syndrome, he has had no change in his gastrointestinal symptomatology or body weight over the past year. On physical examination, his vital signs were within normal limits. His chest and abdominal examinations were unremarkable, except for an infra-umbilical surgical scar with, what appeared to be, a chronic sinus draining a minimal amount of serous fluid. A number of subcutaneous sutures were palpable, adjacent to the orifice of the sinus but no erythema or purulence was observed. A CT fistulogram done in 2008, 1 year after his most recent bowel resection, revealed a possible enterocutaneous fistula (Figure 1).
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Figure 1.
Patient CT fistulogram 2008.
Given his history of inflammatory bowel disease, multiple prior surgical procedures and physical findings, the working diagnosis was a chronically draining abdominal wall sinus tract most likely secondary to a previously infected suture. The possibility of an enterocutaneous fistula was also entertained; however, his clinical picture, with minimal and intermittent drainage of non-succus fluid made the latter possibility less likely. The fistula noted on the CT fistulogram 5 years ago was believed to have closed given his presentation.
After explaining the risks, benefits and possible complications of surgical intervention, our patient elected to have a wound exploration with possible laparotomy under general anesthesia for the purpose resecting this sinus tract.
An elliptical incision was made around the suspected sinus tract and followed down to the fascia. A hemostat was placed in the lumen of the sinus tract which traveled below the fascia, necessitating entry into the abdomen. Sharp dissection along the previous midline incision revealed moderate to severely thickened abdominal wall adhesions, most likely a result of prior obliterative peritonitis. Extensive lysis of adhesions and mobilization of the small bowel took approximately 10 hours. Once the extensive adhesions were lysed and the bowel mobilized, the tract was traced to a 15 cm blind ended portion of small bowel, closed on one end with the fistulous tract emanating from the other. After running the bowel from the Ligament of Trietz to the peritoneal reflection multiple times revealing the rest of the bowel to be fully continuous, it was clear that the suspected sinus tract, was in fact, a fistula tract connected to a blind segment of small bowel which had its own mesenteric blood supply. A second surgeon was called into the OR to confirm the continuity of bowel and the intraoperative findings. Only after multiple confirmations of bowel continuity, was the tract and blind segment resected.
Postoperatively, our patient regained bowel function and promptly improved in overall health. At follow-up his wound was healing well without complications with resolution of his chronic draining sinus.
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