J. Coloproctol. (Rio J.) vol.37 número2

jcoloproctol(rioj).2017;37(2):157–159

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Case

Report

Appendico-cutaneous

fistula

following

hysterectomy:

first

case

report

夽

,

夽夽

Antonio

Sérgio

Brenner

,

Antonio

Baldin

,

Rafaela

Molteni

,

Renata

Fróes

Ramos

de

Lima

_,

_Lígia

_Heinrichs

_Freitas

_,

_Maria

_Cristina

_Sartor

_,

Emerson

Luis

Neves

a_{UniversidadeFederaldoParaná(UFPR),HospitaldeClínicas,Curitiba,PR,Brazil} b_{UniversidadeFederaldoAmazonas(UFAM),Manaus,AM,Brazil}

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Articlehistory:

Received16January2017 Accepted25January2017 Availableonline17March2017

Keywords: Fistula

Colorectalsurgery Appendix

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Appendico-cutaneousfistulasnotrelatedtoacuteappendicitisorcancerarerareandshow spontaneousresolutionafterconservativetreatment,mainlywhentheyshowlowoutput, absenceofobstructionorsepsisandinpatientswithgoodnutritionalstatus.Wefoundno reportintheliteratureonappendico-cutaneousfistulaafterhysterectomy.Theevolutionof thiscaseshowsthatthistypeoffistulacanhavelow,butpersistentdebt,requiringdefinitive surgery.

©2017PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileirade Coloproctologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Fístula

apêndico-cutanea

pós

histerectomia:primeiro

relato

de

caso

Palavras-chave: Fístula

Cirurgiacolorretal Apêndice

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Fístulasapendico-cutâneasnãorelacionadasàapendiciteagudaouneoplasiassãorarasede resoluc¸ãoespontâneaapóstratamentoconservador,sobretudoquandoseapresentamcom baixodébito,ausênciadeobstruc¸ãoousepseeempacientesembomestadonutricional. Nãoencontramosrelatonaliteraturadefístulaapendico-cutâneaapóshisterectomia.A evoluc¸ãodessecasodemonstraqueaessetipodefístulapodeapresentardébitobaixo,mas persistente,demandandocirurgiadefinitiva.

©2017PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileirade Coloproctologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudycarriedoutatUniversidadeFederaldoParaná(UFPR),HospitaldeClínicas,DepartamentodeCirurgia,Servic¸odeColoproctologia, Curitiba,PR,Brazil.

夽夽

StudysubmittedforpresentationatIICongressoSetorialdoCBC,CapítulodoAmazonas.October,2016.

∗ _{Correspondingauthor.}

E-mail:drbrenner@iadcuritiba.com.br(A.S.Brenner).

http://dx.doi.org/10.1016/j.jcol.2017.01.002

158

Introduction

Digestivefistulasareabnormalcommunicationsbetweentwo epithelialsurfaces. Theyare classifiedasinternal(between the digestive tract and intra-abdominal organs) and exter-nal(betweenthedigestive tractandthe skin).Theycanbe congenital or acquired. Digestive fistulas occur postopera-tivelyin85%ofcases,mostlyduetofailuretohealdigestive sutures. They can also be spontaneous and appear as a complicationduringthe evolutionofCrohn’sdisease(39%), ulcerativecolitis(13%),malignancy(9%),radiation(6%), diver-ticulardisease (5%),amongothers.1 _{Theappendixisrarely} involved,predominantlyduetocomplicatedacute appendici-tisorneoplasms.Wedidnotidentifyreportsintheliterature onappendico-cutaneousfistulaliteratureaftertotal abdomi-nalhysterectomy(TAH).

Case

report

A40-year-oldfemalepatientwithtype2diabetes,systemic arterialhypertension,gradeIIIobesitywithaprevioushistory ofgastroplastythroughmedianlaparotomyin2006(priorBMI: 57.40kg/m2_{and current:46.2kg/m}2_)developeda

moderate-sizedincisionalhernia.

Shewassubmittedtototalabdominalhysterectomy(TAH) (Pfannenstielincision)duetouterinemyomatosisand refrac-torydysmenorrhea.Shewasdischargedfromthehospitalon the2ndpostoperative(PO)day,beingreadmittedonthe8thPO dayduetosurgicalwoundinfectionandskindehiscencewith pointsofnecrosis.Shedevelopednecrotizingfasciitis requir-ingdebridementandantibiotictherapy.Onthe30thPOday, the patientshowed entericsecretiondrainage (100mL/day) through the labiate ostium in the granulation area of the

Fig.1–Appendicularfistulaorificeingranulationtissue.

Fig.2–Vermiformappendixfistulizinginthegranulation area.

surgicalwound(Fig.1).Noextravasationwasobservedafter methylene blue was swallowed. The abdominal tomogra-phywas normaland afistulographyshowedashortfistula pathwaycontrastingtherightcolon.Initiallywechosea con-servativetreatmentwithfastingandtotalparenteralnutrition (TPN).Theoutputremainedstable,andsurgicaltreatmentwas decided.

The patient was submitted to mid-incision exploratory laparotomy approachingthesupra-umbilicalincisional her-niaup to theinfra-umbilical granulationtissue, wherethe labiatefistulawaslocated.Duringthelaparotomy,the pres-enceofadheredandfistulizingcecalappendixwasobserved inthegranulationareaoftheabdominalwall(Fig.2).The path-waywascatheterized,confirmingtheappendicularfistula.An appendectomywasperformedassociatedwithhernioplasty, usingapolypropylenemeshanddermolipectomy.

Thepatientevolvedwithsurgicalwoundinfectionand bor-dernecrosis,requiringantibiotictherapywithMetronidazole and Vancomycin,associatedwithsurgicaldebridement and subsequent closure ofthe abdominalwall by freegrafting throughplasticsurgery.

Discussion

Appendico-cutaneous fistula unrelated toacute appendici-tis are rare. There are reports in the literatureon fistulas caused by appendicular mucinous cystadenocarcinoma2–6 and/orcongenitalones.7_{Inthisreview,wefoundnoreports} ofappendico-cutaneousfistulasduetoiatrogenicorsurgical complications,unrelatedtoappendixdiseasesor appendec-tomies.

jcoloproctol(rioj).2017;37(2):157–159

159

The expected outcome of an appendico-cutaneous fis-tulawouldbeits spontaneousresolutionafterconservative treatment,mainlyconsideringitscharacteristicsoflow out-put,postoperativeetiology,absenceofobstructionorsepsis, patientwithgoodnutritionalstatusandprimarysurgery per-formedatthesame institution.8 _{Theevolutionofthis case} showsthattheappendico-cutaneousfistulacanshowspecific characteristicsoflowandpersistentflowevenaftertheuseof TPN,demandingdefinitivesurgicalcorrection.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.MishinI,GhidirimG,VozianM.Appendicealmucinous cystadenocarcinomawithimplantationmetastasistothe incisionscarandcutaneousfistula.JGastrointestCancer. 2012;43:349–53.

3.Hadj-TaiebI,MasmoudiA,AyadiL,MeziouTJ,KhabirA, CharfeddineA,etal.Appendicularcystadenocarcinomawith cutaneousfistula.AnnDermatolVenereol.2010;137:198–202.

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ZastavnitchiG.Mucinouscystadenocarcinomaoftheappendix complicatedwithspontaneouscutaneousfistula.Chirurgia (Bucur).2007;102:231–5.

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7.JagdishS,NinanS,PaiD,RatnakarC.Spontaneous appendicocutaneousfistula.IndianJGastroenterol. 1996;15:31.