Discussion
A fistula is an abnormal connection between two epithelialized surfaces.
An enterocutaneous fistula (ECF) specifically refers to an abnormal
communication between the intestinal tract and the skin. One study found
that 51% of fistulas were low-output, while 49% were high-output.
Approximately 95% of ECFs resulted from postoperative complications,
with the ileum being the most common site of ECF formation(5).
Globally, colon cancer is the second leading cause of cancer-related
deaths. A recent report by the World Health Organization (WHO)
highlighted that in 2020, there were over 1.9 million new cases of
colorectal cancer and more than 930,000 deaths from the disease(6).
According to prior research, the cecum has been identified as the site
of colorectal malignancy in 20% of cases, making it a lesser prevalent
tumor site(7). Up to one third of patients with CRC may present to the
emergency room with complications like perforation and obstruction,
while patients with CRC frequently present to the outpatient setting
with changes in bowel habit, rectal bleeding, or iron deficiency
anemia(2).
However, perforation of right sided colon cancer may cause a localized
collection inside the abdomen that spreads superficially into the skin
to form a fistulous tract, making it a rare occurrence. Furthermore, in
areas where tuberculosis (TB) is prevalent, Mycobacterium tuberculosis
is frequently the cause of primary psoas abscess(8).
The clinical presentations of gastrointestinal tuberculosis share
similarities with those of cecal malignancy and enterocutaneous fistula,
posing diagnostic challenges. Misdiagnosis can lead to delays in
appropriate treatment, potentially allowing the condition to progress to
an advanced stage, as demonstrated in this case.
Subsequently, the emergence of enterocutaneous fistula (ECF) as a
complex complication in cancer patients further complicates management,
especially if they have previously undergone treatments such as surgery,
radiation, and chemotherapy. Beyond addressing the intricacies of
misdiagnosis, our case also explores one of the rarest complications of
cecal carcinoma: the development of an enterocutaneous fistula. Existing
literature primarily concentrates on more common complications of
colorectal carcinoma, like perforations and bowel obstructions. The
onset of ECF in cecal cancer patients complicates their treatment, often
delaying or even precluding palliative care or additional adjuvant
therapy. This has significant consequences on patients’ quality of life
and overall survival.
Initial management of ECF involves resuscitation, infection control,
skin protection, providing nutritional support to the patient, and
managing ECF effluent. Surgical repair is commonly required. The
preparatory phase is crucial for the surgical treatment of these
patients. In some scenarios, non-surgical therapy might be the primary
or sole treatment, based on the tumor type(5,7,9).The primary goal of
surgery is the curative resection of the tumor, which includes excising
the fistula tract and the tumor en bloc. In our case, this approach was
paired with postoperative chemotherapy (10).
The development of ECF in colorectal carcinoma can be traced back to
localized perforation, leading to the tumor invading neighboring regions
and the skin. Often, the presentation of such cases is delayed,
resulting in unfavorable prognosis and heightened morbidity and
mortality rate(5).In conclusion, there’s an urgent need for more
extensive research and more strategic interventions to deepen our
understanding and enhance the management of these severe complications
linked to colorectal carcinoma.