Colo-broncho-cutaneous fistula complicating traumatic diaphragmatic rupture

Dr Biswas and colleagues (February 2001 JRSM, pp. 88-89) indicate that the main message of their case report is that traumatic diaphragmatic hernia can be associated with serious intrathoracic complications, particularly if the colon is ruptured. However, I venture to suggest that this particular case report has a much more important message relating to the failure to follow cumulated experience on how to manage intestinal fistulation following breakdown of intestinal anastomotic repair. It is noteworthy that the previously fit 45-year-old man had two further colonic resections after his initial resection had broken down and formed a fistula. At his second operation, resection was undertaken after failure of attempts at percutaneous drainage and parenteral nutrition to close the fistula. Anastomosis was carried out, despite the fact that there were abscess cavities in the subphrenic space. To those experienced in fistula surgery it would come as no surprise that this second anastomosis, performed in an adverse environment, also broke down and formed a fistula. Despite this, at the third laparotomy yet another anastomosis was carried out although it was considered prudent to ‘protect’ it by a defunctioning loop ileostomy.

Although biochemical details are not given, it is almost certain that this patient would have been hypoalbuminaemic at the time of his second and third operations, a finding known to be predictive of anastomotic failure and other complications. However, even if the albumin was in the normal range it has long been recognized by those units with considerable experience of dealing with recurrent fistulation following an anastomotic leakage that anastomoses placed in a septic environment almost invariably lead to further leakage. Exteriorization of both ends of the colon should have been the preferred option at the first operation, but certainly no later than the second operation. Though the management pathway for recurrent fistulation given above has been known for many years¹, the message concerning exteriorization still fails to get through.