What is the management of a colonic fistula to a presacral collection?

From the Guidelines

The management of a colonic fistula to a presacral collection typically requires a multidisciplinary approach involving surgical intervention, antibiotic therapy, and supportive care. Initial management should focus on controlling sepsis with broad-spectrum antibiotics such as piperacillin-tazobactam 4.5g IV every 8 hours or a combination of ciprofloxacin 400mg IV twice daily and metronidazole 500mg IV three times daily 1.

Key Considerations

• Drainage of the presacral collection is essential, either percutaneously under radiological guidance or surgically 1.
• Nutritional support should be optimized, potentially requiring parenteral nutrition if the patient cannot maintain adequate oral intake.
• For definitive treatment, surgical options include diverting colostomy to reduce fecal contamination, followed by delayed repair of the fistula once inflammation subsides, typically after 3-6 months 1.
• Direct surgical repair may involve resection of the affected bowel segment with primary anastomosis or temporary diversion.
• In some cases, endoscopic approaches using clips, fibrin glue, or endoscopic vacuum-assisted closure may be attempted for smaller fistulas 1.

Approach Selection

The choice of approach depends on the fistula size, location, underlying cause, patient's overall condition, and local expertise 1. This condition requires careful management as presacral collections can lead to significant morbidity due to their anatomical location and potential for systemic infection. According to the most recent guidelines, a multidisciplinary team approach is recommended for the management of enterocutaneous fistulae, including medical therapy with anti-TNF agents and surgical intervention as needed 1.

From the Research

Management of Colonic Fistula to Presacral Collection

The management of a colonic fistula to a presacral collection involves several approaches, including:

• Preoperative percutaneous drainage of the abscess 2
• Use of fibrin glue to obliterate the fistula 3
• Surgical intervention, such as resection and reanastomosis of the offending intestinal segment 4, 2
• Management of underlying conditions, such as diverticulitis or adenocarcinoma of the colon 4, 5

Diagnostic Approaches

Diagnostic investigations aim to confirm the presence of a fistula and may include:

• Computed tomography (CT) scan 4, 5
• Colonoscopy 4
• Cystoscopy 4
• Upper gastrointestinal endoscopy 5

Treatment Outcomes

Treatment outcomes may vary depending on the underlying condition and the approach used. Some studies have reported:

• High success rates with fibrin glue in obliterating proximal rectal, colonic, and pouch fistulas 3
• Good perioperative and long-term outcomes with surgical treatment of colovesical fistulas 4
• Successful management of gastrojejunocolic fistula secondary to adenocarcinoma of the colon using a multidisciplinary approach 5