Luca Stocchi, M.D., a colorectal surgeon at Mayo Clinic in Florida, presents a surgical case involving a 53-year-old male with long-standing, fistulizing Crohn's disease. The patient had a prior open ileocolic resection and subsequently developed progressive weight loss and anemia. Colonoscopic biopsy revealed an inflammatory polyp. After multidisciplinary discussion, the patient elected to proceed with operative management.
This is a case of a fistulizing Crohn's disease on a 53 year old male with a long history of disease. He had undergone an open ilocholic resection in 2002 and based on his own choice, had not used medications except for bouts of prednisone when he had disease flare-ups. He, however, over time had developed weight loss and anemia which had. Partially corrected, but his symptoms did not improve, underwent a colonoscopy which had indicated a 3 centimeter polyp in the transverse colon near a colonic fistula. Another colonic fistula had been described in the rectum at the time of colonoscopy. The biopsy of this large polyp was consistent with inflammatory polyp. He underwent an MR of the. Abdomen which indicated inflammation in the terminal 15-20 centimeters of ileum going to the ileocholic anastomosis and a complex interlooped fistula arising from there and involving the proximal transverse colon and the proximal sigmoid colon. There was a 2 centimeter abscess abutting the urinary bladder dome without any clear fistulous communication. Therefore, we decided to undergo surgery. We made a midline incision and this is the dissection from the sigmoid colon which had a small fistula which was not immediately closed since it was not associated with any spillage. There was no fistulization to the bladder. This is the complex of the fistula between the neo terminal ileum the anastomosis and the transverse colon still difficult to assess. We inserted an extra large wound protector and retractor. This is the dissection of the duodenum and this is the dissection of the neoterminal ileum from the transverse colon. This was densely adherent and our goal was to take down the fistula to the transverse colon first. Identify the segment that we plan to resect which included the inflamed neoterminal lilium and the anastomosis. And ultimately closed the sigmoid fistula which we temporarily left out of the field. This is the polyp that had been previously detected on colonoscopy. We decided to excise it as we entered the fistula with the transverse colon, and this was confirmed to be inflammatory polyp. Following that we completed the separation of the transverse colon from the Diseased anastomosis. And this is the final separation between the two. So now at the top of the video in the Babcock clamp we have the transverse cone with the opening and in the bottom of the screen we have the ilocolic anastomosis, which is now raised and we temporarily closed the opening at the level of the ocolic anastomosis with a number one viro suture so that we could minimize spillage and this was also to facilitate manipulation. As we plan to resect this area. So in the transverse colon there were actually two fistulas side by side and so we decided to take down the bridge of tissue in between them so that we could combine them into a large fistula opening and then we closed the opening transversely given that the status of the mucosa was good and we considered this a target organ despite the inflammatory polyps, so we closed transversely the running suture of trioacryl for the mucosa as you can see here. And then your muscular interrupted triviros to complete the closure at the level of the transverse colon. We then focused on the anastomosis. This is a soft and pliable segment of bile just proximal to the disease neo terminal ileum, and this is the transaction line for the dist ascending colon, so that ultimately we did resect the disease anastomosis and plan for reconstruction between the two segment of grossly normal bowel. So we're completing here the transaction of the specimen which will be sent for pathology and we oriented the. Anastomotic segments for the small bowel and the Ascending column which was reapproximated in two layers interrupted 3 micro sutures. This is the posterior layer. Running through a viro sutures for the mucosa and then ultimately Uh, closed, uh, in the anterior layer. This is the completion of the anastomosis. And finally, we closed the small opening in the sigmoid, since it's a very small opening, we just closed it with interrupted trio viro sutures. Given the complexity of the operation, we decided in favor of a diverting loostomy. These are the orienting sutures placed temporarily and then we created the stoma opening. It's still my aperture to pass the. Diverting the ileostomy. Once appropriately oriented. And after that, we closed the abdomen and we then matured the diverting ileostomy. Using 3ochromic. And this is the Protruding portion of the ileostomy and The end result of our operation. Thank you for your attention.
