Discussion
With regards to our patient, the surprising intraoperative findings suggested that the remnant small bowel was inadvertently overlooked and left in the abdomen after one of his previous extended operations. The remnant piece of small bowel continued to secrete fluid, which, after building up enough pressure, escaped though the path of least resistance to the abdominal wall which was the sutured end of the small bowel and the site of a prior incision. This was supported by sutures found in proximity of the enterocutaneous fistula. The probability of this being an overlooked remnant loop was given additional credence after discussions with the patient revealed that the patient's last operation was approximately 10 hours in duration and that the senior surgeon, due to his physical and mental exhaustion, turned over responsibility for completing the surgery, including closure of the abdomen, to a second surgeon, who may not have had as intimate an understanding of the anatomy, prior procedural details and what the senior surgeon had done and intended. During our procedure, the surgical director and chief resident were present throughout its entirety.
The rapidity of the patient's recovery bolstered the diagnosis of enterocutaneous fistula secondary to a remnant loop of bowel with a chronic draining sinus. In retrospect, the diagnosis of a fistulized blind segment of bowel fits well with the clinical history and presentation. Since the segment of bowel was a blind loop, it would be expected to be of low output, with no source of succus or feculent drainage.