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.