Sigmoid-gluteal fistula as a rare complication of diverticular disease
Sofía Mansilla, Fabiana Domínguez, Nicolás Muniz, Fernando Castelli
Department of Surgery, Médica Uruguaya Corporación de Asistencia Médica (MUCAM). Montevideo, Uruguay
Diverticular disease is common in Western countries. Its importance derives from the infectious, inflammatory and hemorrhagic complications.1,2
Among the infectious complications, fistulas constitute 3% of the causes of admission for diverticular disease.3 They are the result of spontaneous or therapeutic drainage of pericolic abscesses.
The most common diverticular fistulas are colo-vesical (65%), followed by colo-vaginal in hysterectomized patients.1,2 Colocutaneous fistula is rare, especially in the absence of prior surgery or percutaneous drainage.2
A 90-year-old woman, without previous health check-ups, consulted for pain in the lower abdomen and fever. On physical examination, she did not present signs of sepsis or peritoneal irritation, highlighting an asymmetry due to the presence of a painful mass in the left gluteal region with subcutaneous emphysema.
The laboratory showed leukocytosis of 24,000 103/Ul, without organic dysfunctions. The computed tomography (CT) revealed complicated sigmoiditis with perforation towards the retroperitoneum, forming an abdominal collection in the left iliac fossa that fistulized towards the gluteal region through a course superior to the left iliac wing (Fig. 1).
With the diagnosis of sigmoid-gluteal fistula with an intermediate cavity, surgical drainage was performed obtaining discharge of fecal content and fetid pus. Subsequently, lavage with saline solution, placement of a latex drainage, and packing of the surgical wound were performed.
A broad-spectrum empirical antibiotic was indicated for germs of the intestinal flora (ampicillin sulbactam). The patient was discharged with an indication for ambulatory wound care.
Figure 1. Computed tomography showing an abdominal collection in the left iliac fossa
(asterisk) and the fistulous orifices with the sigmoid colon and gluteal region (arrows).
Colocutaneous diverticular fistulas are rare and generally occur in oligosymptomatic patients with a subacute or chronic course, so the symptoms are nonspecific. Diagnosis is made with CT.1,2,4
Although fistulization is an indication for surgical treatment, there are patients such as the one described who may benefit from initial conservative treatment by draining intra-abdominal abscesses and/or subcutaneous collections. Eventually, delayed elective resective surgery can be considered in this group.1,2,4
1. Hall J, Hardiman K, Lee S, Lightner AM, Stocchi L, Paquette I, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum. 2020; 63:728-47.
2. Coakley KM, Davis BR, Kasten KR. Complicated diverticular disease. Clin Colon Rectal Surg. 2021; 34:96-103.
3. Underhill J, Pinzon MCM, Ritz E, Grunvald M, Jochum S, Becerra A, et al. Defining diverticular fistula through inpatient admissions: a population study. Surg Endosc. 2023; 37:645-52.
4. Barbalace NM. Manejo actual de la enfermedad diverticular aguda del colon. Rev Argent Coloproct. 2017; 28:181-91.