In Reply.—Dr Schein disagrees with our supposition that the occurrence of nontraumatic small-bowel perforations during open treatment for intra-abdominal sepsis has not been described so far and states that it is a well-known and documented entity.
Intestinal perforations and fistulizations are indeed common complications in patients treated for intra-abdominal sepsis, but there are obvious causes for fistulization in all cases reported in the literature, such as abdominal reentry damage, anastomotic breakdown, or abdominal-wall dehiscence.
Dr Schein cites several references to support his argument but, again, all these cases had obvious causes. The article by Sitges-Serra et al deals with 87 fistulas, all secondary to either anastomotic breakdown, direct trauma to the small bowel, or small-bowel inflammation. In the article by Levy et al, causes for fistulization were anastomotic dehiscence (52%), small-bowel trauma (41%), abdominal-wall necrosis (1.7%), and a combination of these factors (5.3%). Schein's own group1 described a