A novel approach to management of a sacral defect in ileal pouch-sacral fistula
A 20-year-old man was admitted with pelvic and hip pain, anorexia and loss of weight. His past surgical history revealed a proctocolectomy with ileo-pouch anal anastomosis for familial adenomatous polyposis (FAP) carried out in another institution 3 years previously. This had been complicated by an anastomotic leak treated with a loop ileostomy that was taken down 6 months later. Subsequently, he developed a new pelvic collection and persistent pouch-presacral space fistula that was treated with a laparoscopic drainage and repeat loop ileostomy. A follow-up magnetic resonance imaging (MRI) showed improvement but persistence of pelvic phlegmon. Cultures of presacral fluid revealed a polymicrobial flora including Escherichia Coli, Enterococcus, Bacillus species and Eikenella Corrodens.\nAt the time of evaluation at our institution, he was afebrile and the laboratory tests, including inflammatory markers, were unremarkable. A computed tomography (CT) scan of the abdomen and pelvis showed a presacral fluid collection with a fistula between the pouch and the sacrum (Fig. ). An MRI of the pelvis was performed and this revealed signs of osteomyelitis involving the S2–S4 vertebrae (Fig. ). A laparotomy was performed and the ileal-anal pouch anastomosis was taken down, the sacrum was debrided leaving a large anterior bony defect. No omentum was available, so a 10 cm × 10 cm piece of Alloderm was used to cover the defect. The pouch fistula was excised and closed and the revised pouch re-anastomosed to the anus. The patient made an uneventful recovery and was discharged on the seventh postoperative day. Cultures from the sacral debrided tissue yielded Actinomyces spp. and a 12-week course of antibiotics (clindamycin) was commenced.