Small Bowel Sigmoid Colon Fistula Resulting from Diverticulitis Causing an Internal Hernia
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Small Bowel Sigmoid Colon Fistula Resulting from Diverticulitis Causing an Internal Hernia Kortney Robinson 1 & Sean Hersey 2 & Nisha Narula 3 Received: 2 April 2020 / Accepted: 6 April 2020 # 2020 The Society for Surgery of the Alimentary Tract
Case Presentation A 39-year-old male presented to the emergency department with abdominal pain of 24-h duration that was progressive in nature and associated with nausea, emesis, fevers, and chills. His only medical history was an episode of complicated diverticulitis requiring interventional radiology drain placement approximately 10 years prior. He was hemodynamically stable but appeared uncomfortable. On exam, his abdomen was soft but mildly distended with diffuse tenderness and rebound tenderness. He had a leukocytosis of 12.6. Computed tomography (CT) scan was completed prior to surgical consultation revealing dilated loops of small bowel to 3.4 cm and a transition point in the lower abdomen just left to midline with significant mesenteric edema (Fig. 1). Given a peritoneal exam on surgical evaluation, the patient was taken as an emergency to the operating room for a diagnostic laparoscopy. Access to the abdomen was gained via Hassan trocar and upon insufflation, the entire visible bowel appeared ischemic, and the surgery was converted to an exploratory laparotomy. Upon inspection of the bowel, there was an internal hernia with the lead point being a small bowel sigmoid fistula, which was taken down (Fig. 2). A small bowel resection and sigmoid colectomy encompassing the area of the fistula were completed. There was no gross evidence of diverticulitis. Two hundred ninety centimeters of bowel remained that appeared
* Nisha Narula [email protected] 1
Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
2
Division of Acute Care Surgery, Trauma, Surgical Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
3
Division of Acute Care Surgery and Trauma, Department of Surgery, Beth Israel Deaconess Medical Center, 110 Francis Street, Suite 2, Boston, MA 02215, USA
ischemic with significant mesenteric hemorrhage and edema though no frank necrosis (Fig. 3). The appearance did improve during the case, but given concern for viability, a temporary dressing was placed, and he was taken to the intensive care unit (ICU) for resuscitation. He was extubated in the ICU and taken back to the operating room 48 h later where only a small area of small bowel adjacent to the prior resection required further resection. Both small and large bowel continuity were restored, and a diverting loop ileostomy was created for protection of the anastomosis. Here, a staged operation was helpful given the extensive nature of the ischemic insult with 290 cm involved, which would have given the patient short gut if resected in its entirety. Given the planned second-look operation, only a small fraction of his bowel was ultimately resected. His pathology showed diverticular disease with chronic inflammation in the colon
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