eP109 - Coloarticular Fistula as a Long-Term Sequela of Hartmann Procedure

Purpose/Background: Proctosigmoidectomy, commonly referred to as the Hartmann's procedure, is commonly employed in the surgical management of complicated diverticulitis and other distal-colon pathologies. The procedure includes resection of the rectosigmoid colon, closure of the anorectal stump, and formation of an end colostomy. This procedure is known to carry potential complications including infection, parastomal hernia, and especially concerning, chronic anorectal stump leak. Chronic stump leak can have significant post-operative implications, potentially leading to recurrent infection, delayed wound healing, and the need for additional surgical intervention. Coloarticular fistulae, particularly those emerging from the anorectal stump, are extremely rare and previously unreported.Methods/Interventions: Our patient is a 78-year-old female with a history of recurrent diverticulitis, right hip arthropathy, diabetes, and end-stage renal disease who presented to a colorectal clinic with a psoas abscess. Four years prior, she underwent an emergent Hartmann procedure and small bowel resection due to perforated diverticulitis; the postoperative course was unremarkable. The patient reported a remote history of Crohn's disease to which the abscess was initially attributed; however, a thorough review of clinical history suggested a diagnosis of Crohn's disease was doubtful. Further abscess evaluation revealed extensive fistulization involving her hip prosthesis, cecum, and rectal stump. She underwent aspiration of the psoas abscess and prosthesis explant with antibiotic-impregnated cement spacer placement.Results/Outcomes: One month later, definitive management of the fistulae was performed with exploratory laparotomy, proctectomy (rectal stump revision), and ileocecectomy. Air leak test of the new rectal staple line was negative. Extensive lysis of dense adhesions resulted in two unavoidable enterotomies necessitating small bowel resection. The patient had an uneventful postoperative course, was discharged on day six, and continues to follow up without disease recurrence.Conclusion/

Discussion: This case highlights the importance of thorough postoperative assessment in complex patients after a Hartmann procedure. Our patient, with multiple risk factors including advanced age, end-stage renal disease, and diabetes, had compromised healing capacity at baseline. Although fistula formation is a well-established complication, communication between the anorectal staple line and hip arthroplasty is a previously unreported consequence of the Hartmann procedure. Additionally, the initial confounder of a previous misdiagnosis of Crohn’s disease delayed the recognition and treatment of her underlying surgical complication, stressing the need for precise clinical, radiological, and pathological diagnoses in colonic disorders.Figure 1. Computerized tomography of the abdomen and pelvis with intravenous contrast demonstrating retroperitoneal abscess communicating with bowel loops, bladder wall, hip implant, and adnexaLarge, multiloculated left retroperitoneal abscess arising from the left iliopsoas which tracks anteriorly and inferiorly and is closely associated with adjacent bowel loops and the left lateral wall of the urinary bladder, with loss of fat plane between these structures. No air is seen within the collection on current examination, though impending fistulous communication is suspected. Additionally, there is loss of fat plane between left pelvic extension of the abscess in the left ovary.