Clinical case: multiple intestinal fistulas

[ele190]

In our ward we have this patient: 47 year-old male with a difficult life story. Recovered in 2010 for idiopatic megacolon: first they just resected the sigma-rectum (flogosis of the neural plexis at the hystology) but, since he didn't evacuate, he underwent subtotal colectomy with terminal ileostomy.
Last fall he came back to us with intestinal obstruction, a massive pelvic abscess from a rectal stump leak and diffuse bowel sufference: he was operated and the surgery resulted in multiple small bowel fistulas. He was re-operated twice (with a lot of difficulties due to plastic peritonitis) to try and repare the fistulas with the help of intraperitoneal VAC-therapy (kept in site for a week), all of that unsuccessfully. He was then re-operated and they made an upper jejunostomy (in addiction to the previous ileostomy) with resolution of the sepsis and leak.
He was kept in the hospital with a double stoma for 3 months, in the meantime he lost a lot of weight despite the parenteral nutrition and he's now way underweight and defedated.
One month ago we ran a transit exam and it showed diffuse adhesions and just one entero-cutaneous fistula excluded by the jejunostomy: he underwent another surgery with the exeresis of the fistolized intestinal tract and closure of the jejunostomy.
Then we had to open him again cause he had massive biliar leak from the drainage, so we discovered more fistulas: the surgeon decided to put a catheter into the bigger one to drain some of the intestinal fluid.
The patient is now (just as always) fully conscious, willing to fight; the catheter works but he still has biliar-fecal leak from the abdominal drainage and from the surgical scar.
Do any of you has some experience of cases like that and some suggestion to make? Surgery is now extremely difficult on him because of the plastic peritonitis. Thank you very much if you answer!

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[SLUser11]

In our ward we have this patient: 47 year-old male with a difficult life story. Recovered in 2010 for idiopatic megacolon: first they just resected the sigma-rectum (flogosis of the neural plexis at the hystology) but, since he didn't evacuate, he underwent subtotal colectomy with terminal ileostomy.
Last fall he came back to us with intestinal obstruction, a massive pelvic abscess from a rectal stump leak and diffuse bowel sufference: he was operated and the surgery resulted in multiple small bowel fistulas. He was re-operated twice (with a lot of difficulties due to plastic peritonitis) to try and repare the fistulas with the help of intraperitoneal VAC-therapy (kept in site for a week), all of that unsuccessfully. He was then re-operated and they made an upper jejunostomy (in addiction to the previous ileostomy) with resolution of the sepsis and leak.
He was kept in the hospital with a double stoma for 3 months, in the meantime he lost a lot of weight despite the parenteral nutrition and he's now way underweight and defedated.
One month ago we ran a transit exam and it showed diffuse adhesions and just one entero-cutaneous fistula excluded by the jejunostomy: he underwent another surgery with the exeresis of the fistolized intestinal tract and closure of the jejunostomy.
Then we had to open him again cause he had massive biliar leak from the drainage, so we discovered more fistulas: the surgeon decided to put a catheter into the bigger one to drain some of the intestinal fluid.
The patient is now (just as always) fully conscious, willing to fight; the catheter works but he still has biliar-fecal leak from the abdominal drainage and from the surgical scar.
Do any of you has some experience of cases like that and some suggestion to make? Surgery is now extremely difficult on him because of the plastic peritonitis. Thank you very much if you answer!

I'm trying to decide if English is your second language, or if this is common terminology in English-speaking European countries (Ireland, England)...either way it's sort of hard to read.

This patient has what we call in the states a "nightmare abdomen." While they are not common, thankfully, they do exist and most surgical residents have dealt with similar patients over years....sometimes the same patient over several years.

As for what to do with the patient, you should rule out Crohn's disease, then treat his sepsis with diversion, bowel rest, and TPN....next you re-define the current location and number of fistulas, and give his abdomen some time to cool off (lots of time). If it's available, he should be referred to a tertiary care center where crazy-@$$ surgeons actually specialize in such disasters. When he is in "good shape," you go back in and give it another crack....don't be surprised if there's a similar outcome. Ultimately, this patient is at a very high risk of short-gut syndrome.

With fistulas like this, there is zero chance of them closing with bowel rest/TPN, but there's no reason that you shouldn't be able to control the sepsis with enough drains/catheters.

I have some side questions/comments, but I think they are ultimately irrelevant:

1. How far out from the subtotal colectomy/ileostomy did the patient present with a rectal stump leak? Why did the surgeons decide to operate on this leak, as opposed to doing percutaneous drainage of the abscess?

2. What the hell is flogosis of the neural plexus? How did I get this far without knowledge of such flogosis?

3. Intraperitoneal Wound Vac wouldn't actually treat a fistula, obviously.

4. Bringing up a diverting jejunostomy is extremely uncommon, and usually a last resort. It's extremely hard to manage the high output, and it can be debilitating for the patient....but it's sometimes the only thing that works.

5. The patient needs better TPN. He'll never reach normal nutrition with it, but he shouldn't continue to waste away.

 

[doc05]

you should transfer to a tertiary center and probably to somewhere he can be evaluated for a small bowel transplant.

p.s. please work on your English.

 

[ele190]

Sorry, i didn't mention that, i'm writing from Italy and english is my second language; it was actually pretty difficult to explain this case in a foreign language, but this is also good excercise so please correct me if i write something wrong.
I don't know what a tertiary center is but my ospital is quite big itself and we handle most of the surgical procedures, specially in other departments which are very cutting-edge My menthor IS the "crazy" surgeon specialized in those kind of situations but we've tried almost everything and we're out of ideas, that's why i wrote on an international forum.
The sepsis is now controlled with the drainage and antibiotics, but we must decide something more to actually resolve the situation.
About your doubts:
1- the leak was discovered about one year after the colectomy and it was probably due to the diagnostic procedures he underwent to close the ileostomy (rectoscopy, manometry and fecal transit). We didn't drain it percutaneously because he had an intestinal obstruction in that moment.
2- it's kind of a secondary Hirschprung's disease in the adults, in 4 year i saw just a couple of cases
4- yes, the jejunostomy was a "desperate" decision because we couldn't do anything better in that situation but it actually worked! The problem was of course the output (he was followed very closely by nutritionists) but also the major skin irritation
5- He's of course on a special TPN, nutritionists come and check him at least once a week

Anyways, flash news: today he underwent another transit-CT which found a substenosis in the upper bowel, a small entero-cutaneous fistula from the ileum and a massive perforation of the middle ileum with a pelvic abscess (fortunately properly drained). We have no choice but to open him again on monday My thought was closing the current ileostomy, resecting the ileum from there to the perforated tract and make a new ileostomy, what do you think?
We thought about bowel transplant a lot but it's actually not very spread in Italy, and it's often unsuccessful. Plus, would it be possible to do that on a badly contaminated surgical field?

 

[SLUser11]

About your doubts:
1- the leak was discovered about one year after the colectomy and it was probably due to the diagnostic procedures he underwent to close the ileostomy (rectoscopy, manometry and fecal transit). We didn't drain it percutaneously because he had an intestinal obstruction in that moment.
2- it's kind of a secondary Hirschprung's disease in the adults, in 4 year i saw just a couple of cases
4- yes, the jejunostomy was a "desperate" decision because we couldn't do anything better in that situation but it actually worked! The problem was of course the output (he was followed very closely by nutritionists) but also the major skin irritation
5- He's of course on a special TPN, nutritionists come and check him at least once a week

Anyways, flash news: today he underwent another transit-CT which found a substenosis in the upper bowel, a small entero-cutaneous fistula from the ileum and a massive perforation of the middle ileum with a pelvic abscess (fortunately properly drained). We have no choice but to open him again on monday My thought was closing the current ileostomy, resecting the ileum from there to the perforated tract and make a new ileostomy, what do you think?
We thought about bowel transplant a lot but it's actually not very spread in Italy, and it's often unsuccessful. Plus, would it be possible to do that on a badly contaminated surgical field?

If English is your second language, then you are doing quite well overall.

As for your decision to reoperate, this is an extremely hostile abdomen. If any of his other surgeries have been recent, then I would do everything in my power to avoid a return trip to the OR. The only things that would require reoperation are 1) dead bowel, 2) uncontrolled sepsis.

Bowel transplant is not an option here. I have zero experience with it (although apparently my new center specializes in it), but it's something to consider once the other variables (sepsis, EC fistula, hernia) have been controlled.

I still don't understand the rectal stump perforation. Someone perforated it with a scope, causing leak and abscess, but the patient had a simultaneous small bowel obstruction requiring operation?

Good luck. If you're still interested in surgery after your case is over, I'll be impressed.

 

[Buzz Me]

I'm also a little confused by your descriptions but I applaud you for your attempts to describe a very complicated situation in a language other than your native tongue.

I agree with much of what SLUser11 said above. My thoughts:

(1) Intra-abdominal WoundVACs don't work for fistulae. A lower-strength vac-type system may help quantify output and control drainage (e.g. the Prospera system).
(2) Jejunostomies are typically frowned upon due to their proximal nature and risk of dehydration from high output. It sounds like this patient may have a tube jejunostomy/enterostomy now? What types of drains are these?
(3) I'm also confused as to why this patient developed a rectal stump leak - after a subtotal colectomy with end ileostomy and Hartmann's, the fecal stream is completed diverted and the rectal stump should only produce the occasional scant mucus.
(4) No way any of the major small bowel transplant centers here would place someone on lifelong immunosuppression with this patient's current comorbidities and malnutrition.
(5) We do a lot of big fistulae operations here. The pre-op planning phase - which can take 6-12 months and includes investigational studies (CT scans, barium/Gastrografin enemas, fistulograms), nutrition (usually TPN) and control of intra-abdominal/wound sepsis is critical. This patient will have a terribly hostile abdomen with obliterative peritonitis and retractile mesenteritis. I would avoid reoperating at all costs (unless absolutely forced to).

 

[Apollyon]

The pre-op planning phase - which can take 6-12 months and includes investigational studies (CT scans, barium/Gastrografin enemas, fistulograms), nutrition (usually TPN) and control of intra-abdominal/wound sepsis is critical.

Just a quick question - in cases like this, what is the yield for a resident? Rotating blocks monthly, how much would a resident get out of this case on this patient? Or, provided the guy was "healthy", as much as possible, would this be outpatient, and would one resident have him in C/R clinic, or just a fellow/attending?

 

[Buzz Me]

Just a quick question - in cases like this, what is the yield for a resident? Rotating blocks monthly, how much would a resident get out of this case on this patient? Or, provided the guy was "healthy", as much as possible, would this be outpatient, and would one resident have him in C/R clinic, or just a fellow/attending?

Ideally you would see patients in various stages of pre-op and post-op during your rotation (which can be anywhere from 4-8 weeks long). So in clinic you may see some post-ops from the previous rotation...and on the ward or in the ICU you may see patients getting ready to have their huge operation. And then of course you get the experience in scrubbing into these tough cases (which can be 6-12 hours long).

 

[blue2000]

Just a quick question - in cases like this, what is the yield for a resident? Rotating blocks monthly, how much would a resident get out of this case on this patient? Or, provided the guy was "healthy", as much as possible, would this be outpatient, and would one resident have him in C/R clinic, or just a fellow/attending?

Where I trained, there were 2 attendings (on two different services) that specialized in these kind of problems. Both of them had several long term players over the years, some of whom lived in the hospital for most of my residency. What did I learn from these patients as a resident?

1) The workup of complex fistulas
2) Creative wound care for open abdomens, succus draining from bizarre places, etc
3) The need to wait for as long as is practical to operate on these patients
4) The reason these patients need tertiary care (nutrition, social work, ostomy nurses)
5) Empathy for what a devastating life this is for the patients

Overall, there was a lot of "pain" in taking care of these patients. A lot of them were (unsurprisingly) very emotionally needy, and on the one hand we weren't "doing" much for them (wound care, TPN) and required a lot time for the residents. But I developed a comfort level dealing with the issues, a practical stepwise approach to diagnosing them. I also have a keen awareness, now as a rural surgeon, which patients should be transferred to tertiary care center.

 

[Dr.LeoSpaceman]

Where I trained, there were 2 attendings (on two different services) that specialized in these kind of problems. Both of them had several long term players over the years, some of whom lived in the hospital for most of my residency. What did I learn from these patients as a resident?

1) The workup of complex fistulas
2) Creative wound care for open abdomens, succus draining from bizarre places, etc
3) The need to wait for as long as is practical to operate on these patients
4) The reason these patients need tertiary care (nutrition, social work, ostomy nurses)
5) Empathy for what a devastating life this is for the patients

Overall, there was a lot of "pain" in taking care of these patients. A lot of them were (unsurprisingly) very emotionally needy, and on the one hand we weren't "doing" much for them (wound care, TPN) and required a lot time for the residents. But I developed a comfort level dealing with the issues, a practical stepwise approach to diagnosing them. I also have a keen awareness, now as a rural surgeon, which patients should be transferred to tertiary care center.

What's the value in taking care of these patients as a resident?

Learning that it's probably the last thing you want to specialize in.

I'm at a small bowel transplant center, and we have two attendings that not only handle patients being considered for SB/multi-visceral transplant, but essentially all patients with these nightmare abdomens. Rotating on the service you really understand that taking care of these patients requires a multi-disciplinary team with people who are completely focused on the types of issues involved. It also helps that the two attendings are uniformily recognized around the hospital system as the two most technically gifted surgeons anyone has seen.

But I agree with blue that the value is seeing how these complex problems are handled, and how to "think outside the box" sometimes. Sure, very few people are going to manage these types of problems for a living, but there is a lot that can be extrapolated to general practice. It certainly crystallizes the idea that sometimes there isn't an "answer" in the literature or the textbooks for a particular situation, but by drawing on your own experience and knowledge base you can synthesize a plan of action.

 

[ele190]

Well, the radiologist described not just a fistula but an entire bowel tract completely open into the pelvis without any transit beyond, which i think changes the situation a lot. Surgery is necessary but not urgent because as you said he is properly drained (that's why we scheduled it for monday) but NOT diverted: we closed the jejunostomy a month ago (I wrote it in the first post). With a situation like this i can't see the advantages of waiting more, that bowel will never heal on its own and in 4 weeks or so i think the abdomen will be just as hostile as it is now.
To answer your other questions, i don't know exactly how this rectal leak caused the abscess: he underwent the routinary instrumental tests to close his ileostomy, then he came to us with anal pain and at a rectal exploration there was a flow of pus. Then we ran a CT which described this pelvic abscess with signs of intestinal sufference and obstruction: hence the first surgery in his second hospital stay.
In my department i saw a lot of desperate cases (he's the second one in 2 years with a major fistula-problem); it's not easy to deal with them, even because you get emotionally attached, but if you (by you i mean your team) succeed and manage to send them home it's a feeling comparable to nothing. Plus, i agree it helps thinking outside the box: my menthor is the kind of surgeon that always finds a solution in cases you will never find on the books and i want to be just like him! I find urgent and atypical cases way more interesting than routine elective surgery, even if it's major.

 

[JayDoc06]

This patient is in deep **** with little chance of ever being "made right". I have no real recs outside what has already been said. I would, however, like to point out for those junior residents/medical students out there that this case highlights the importance of a well indicated, well thought out, well designed and well executed index operation. Most "nightmares" like this you hear about all seem to begin with a marginal indication for operation (ie- appears as though all bad dile duct injuries are after lap chole for dyskinesia.) A subtotal colectomy is never a minor case and is always the last resort for "constipation" or whatever you were describing (they almost always have global intestinal and supratentorial dysfunction as well.)

Just cause you're a surgeon, doesn't mean you have to operate, no matter how bad the patient/family/consultants beg.

Good luck.

 

[Buzz Me]

A subtotal colectomy is never a minor case and is always the last resort for "constipation" or whatever you were describing (they almost always have global intestinal and supratentorial dysfunction as well.)

Just cause you're a surgeon, doesn't mean you have to operate, no matter how bad the patient/family/consultants beg.

Good luck.

Agreed. So-called "colonic inertia" is a bad, bad problem.

Residency training is all about learning when NOT to operate on someone.

 

[45408]

Just a quick question - in cases like this, what is the yield for a resident? Rotating blocks monthly, how much would a resident get out of this case on this patient? Or, provided the guy was "healthy", as much as possible, would this be outpatient, and would one resident have him in C/R clinic, or just a fellow/attending?

Two of the worst abdomens I've had as a resident ended up being patients that kept coming back when I was on service, so I've seen a few of them come "full circle," if you will. It's pretty interesting to me.

But I agree with blue that the value is seeing how these complex problems are handled, and how to "think outside the box" sometimes. Sure, very few people are going to manage these types of problems for a living, but there is a lot that can be extrapolated to general practice. It certainly crystallizes the idea that sometimes there isn't an "answer" in the literature or the textbooks for a particular situation, but by drawing on your own experience and knowledge base you can synthesize a plan of action.

It also might help you from turning a bad situation into a nightmare abdomen, just by averting disaster at some stage. I've had a few patients that have taught me what never to do...

Most "nightmares" like this you hear about all seem to begin with a marginal indication for operation (ie- appears as though all bad dile duct injuries are after lap chole for dyskinesia.)

Two of the three worst ones I had were on patients that did have an appropriate indication, but the third one was elective. We certainly get a lot of dumps from Outside Hospital where they did something shady for an even shadier reason. Sometimes they'll literally invent a surgical technique that wasn't previously invented for a reason.

 

[LucidSplash]

All of this keeps reminding of me of a patient who was direct-admitted to the floor and I was paged to come write orders, etc. The admitting diagnosis was "fistula" on the paperwork but this did not prepare for a patient who had adult diapers duct-taped to cover his entire abdomen. Apparently adult diapers and duct tape are way cheaper than ABD pads and surgical tape. I think I still have PTSD from taking all that down to get a look at what I was dealing with. Really, it was an excellent dressing except for the duct tape eroding the skin.

 

[ele190]

I think the colectomy was appropriate because when he was first admitted he was underweight and defedated with a huge belly diameter, and at the CT the colonic diameter was like 16 cm! It was really not just constipation, it was a secondary Hirschprung's. About the surgical tecnique...well...the chief operated on him and i'm not supposed to criticize.
So, i know he has little chances, but do you think my idea of resecting the last ileal tract including the big hole and make a new stoma above it right? We can't just give up on him now, he's fully conscious!

 

[SLUser11]

I think the colectomy was appropriate because when he was first admitted he was underweight and defedated with a huge belly diameter, and at the CT the colonic diameter was like 16 cm! It was really not just constipation, it was a secondary Hirschprung's. About the surgical tecnique...well...the chief operated on him and i'm not supposed to criticize.
So, i know he has little chances, but do you think my idea of resecting the last ileal tract including the big hole and make a new stoma above it right? We can't just give up on him now, he's fully conscious!

I'm not sure a subtotal colectomy is the right operation for a patient with a Hirschprung's-like disease. Isn't the rectum involved in this process as well? Also, maybe it's just semantics, but "subtotal" colectomies for slow-transit constipation are not a good operation, as there are frequent recurrences. If a patient truly qualifies for an operation, he/she should get a total abdominal colectomy with ileorectostomy.

I think it's quite easy to get a pelvic abscess from a rectal stump leak, even though the patient is diverted. However, the vast majority of these can be managed with percutaneous drains because the patient is diverted.

Well, the radiologist described not just a fistula but an entire bowel tract completely open into the pelvis without any transit beyond...

Did you guys forget to do one of your anastomoses?

Nobody here is recommending that you "give up" on the patient. Instead, we are suggesting that non-operative management would be safer and more beneficial than slaughtering his abdomen even more.

 

[ele190]

He didn't get subtotal colectomy right away in his first hospital stay, we tried first with multiple enemas, then with a surgical washing from a colotomy and then with sigmoid-upper rectal resection. The remaining colon still didn't work so we performed the subtotal colectomy with ileostomy, which was working just fine (the patient stayed at home for more than one year before we discovered the asbcess).
I sincerely don't know why the chief didn't totalize the colectomy, he probably wanted to avoid an ileo-ano-anastomosis; just the lower-middle rectum remained in site.
I wasn't there in the last surgery, but isolating the bowel was extremely difficult and anastomoses were very likely to fail because of the scarce bowel vitality; so, instead of resecting the surgeon put a catheter into this fistula to divert the transit. That's the tract of bowel which is completely open now.
So, you really think waiting is better in the current situation? How can it possibly get better in the next weeks?

 

[Buzz Me]

The solution to a patient's problem doesn't always involve making a cut on their belly.

 

[ele190]

I know that, and believe me we're not exactly thrilled about opening him again...so what do you suggest instead? I'm very open minded

 

[doc05]

is your imaging adequate in really identifying his anatomy? I'm having a hard time understanding what's left and at what level his various fistulae originate. Sounds like he needs drainage of abscesses and a better fistulogram. Does anyone here have experience with MR-enterography in this setting?

 

[doc05]

p.s. this is why you don't do colectomies for constipation.

 

[ele190]

The images were pretty clear, maybe i didn't explain that well due to language issues
He has about 2 meters of small bowel left with a substenosis in the jejunum, a small entero-cutaneous fistula from the ileum and, beyond that, an ileal tract completely open into the pelvis. Nothing transits beyond that. In the last surgery we put a catheter into the largest fistula because the surgeon thought a suture wouldn't last, so he wanted to divert the transit from the bowel beyond which he knew was barely vital.
Unfortunately, that largest fistula is now corresponding to that ileal tract completely open; so, in this moment, the patient has the catheter and the abdominal drainage both draining the biliar and fecal material coming out from that.
Maybe i'm wrong, but i think this situation will not get better by itself: even if he's drained he still has biliar-fecal material in contact with the ileum.
In synthesis, if we have to intervene we should have to take out the substenotic tract, close the small entero-cutaneous fistula and do something about the last ileal tract which is now completely excluded and submerged into biliar-fecal material.
I thought a solution could be resecting the whole last ileal tract (which i think is irreparable) with a new ileostomy.
What do you think? Would it be better to postpone that and how long?

 

[Buzz Me]

When was his last laparotomy?

 

[JayDoc06]

Does anything drain out the rectum? Often pelvic abscesses or hematomas will find a way out- in this case a stapled off rectum. Always remember not to cause a "closed loop" when doing a Hartmann or anything that leaves a distal defunctionalized sigmoid/rectum (ie obstructing rectal cancer or in this patient a functional obstruction from supposed Hirschprung's-like disease which probably caused a blow out if I understand correctly).

One thing we have done with some success- if the issue is difficult pelvic abscess from a fistula or whatever, is drain it back into the rectal stump transluminally with a double-j stent placed by a skilled endoscopist- in this case our surgical ERCP guy. Not sure I understand everything right but bilious/enteric contents out the rectum usually much better than abdominal wall. Unless of course he does have Hirschprung's...

 

[ele190]

His last laparotomy was about one month ago...i don't understand how another drainage could make things better, the problem right now is the fact that the bowel is completely open and the "abscess" is more like a biliar-fecal pond currently drained by 2 drainages.
For another case, sure i will keep that in mind! Sounds brilliant, but isn't it bothering for the patient having a constant leak from the anum...?
Another thing, someone earlier spoke about VAC-therapy in fistulas...which kind did you say you use? We currently use the Ab-Thera system, its suction is too strong for fistulas right? (i put my hands forward, we have no intention on using it on this patient)
Another thing, what does "closed loop" mean?

 

[Buzz Me]

He's only a month out from his last laparotomy? With his hostile abdomen? Stay far, far away if possible. IR is your friend.

 

[ele190]

Mmmm..what is IR?

 

[ele190]

I'm completely aware of that, just i'm not sure things will ever get better. Did it get better in your experience if you just waited?

 

[doc05]

things will not get better, but waiting is most appropriate, as one month postop is a very bad time to reenter the abdomen.
the patient needs IR drainage of any abscesses, and several months of nutrition. then you can think about a laparotomy.

 

[Buzz Me]

We all seem to be saying the same thing here. Are you looking for someone to agree with your plan to re-enter the abdomen? I think you'll be waiting for a while if that's what you're seeking...

 

[45408]

I'm completely aware of that, just i'm not sure things will ever get better. Did it get better in your experience if you just waited?

Yes, actually. One patient we had (not as bad as yours, but still quite bad) was left alone for >9 months, allowed to form a mature fistula tract, let the wounds heal as much as possible, then we closed it in a single-stage procedure. She did well and went home in a week or so.

On the flip-side, I've also had a patient that was an inpatient for all of eternity, and her wound never healed, despite TPN and oral nutrition. She also had cancer and eventually died...

 

[SocialistMD]

Just a quick question - in cases like this, what is the yield for a resident? Rotating blocks monthly, how much would a resident get out of this case on this patient? Or, provided the guy was "healthy", as much as possible, would this be outpatient, and would one resident have him in C/R clinic, or just a fellow/attending?

The yield is, "please, don't ever let me f***ing do this to anyone..."

 

[ele190]

Yes, you're telling me to wait and i see your point, i will discuss with my attending today. I kept asking because i wanted to understand "physiologically" how this abdomen could get better in time and to know about the timing and the tecnique to use when he's ready. Also, i was not sure i explained it properly but for sure i didn't wanna hear "yes, you're right".
So, how long do you thing we should be waiting? Months if i got it right....

 

[45408]

Yes, you're telling me to wait and i see your point, i will discuss with my attending today. I kept asking because i wanted to understand "physiologically" how this abdomen could get better in time and to know about the timing and the tecnique to use when he's ready. Also, i was not sure i explained it properly but for sure i didn't wanna hear "yes, you're right".
So, how long do you thing we should be waiting? Months if i got it right....

Physiologically, the inflammation cools way down, the scar tissue can be remodeled and devascularized so it's not a giant bloodbath with tons of enterotomies, and their nutritional status improves enough so that they can actually heal from the operation.

 

[ele190]

Ok, you got me. I talked to my attending and he agrees it wouldn't be bad waiting some more, but unfortunately the other attendings and the chief are pushing badly to operate again tomorrow, i hope we can convince them. Let's see and hope for the best...

 

[dpmd]

Ok, you got me. I talked to my attending and he agrees it wouldn't be bad waiting some more, but unfortunately the other attendings and the chief are pushing badly to operate again tomorrow, i hope we can convince them. Let's see and hope for the best...

The idea isn't that the patient is going to magically heal the fistulas, but that if you operate now that you will make the patient worse than he already is (new enterotomies, everything you touch falling apart, big inflammatory response, etc). As long as you can control the sepsis by getting things to drain to the outside (by whatever methods you can, percutaneous drainage, creative wound dressings, wound vac-yes you can use a vac in the presence of a fistula assuming the drainage isn't too solid for it to actually keep suction) you can then work on keeping the guy as healthy as possible so that in 8 mths or more you can have a shot at fixing him.

If I understand correctly the guy has a proximal fistula that is low output and distally has a giant opening that is possibly the result of an anastomosis completely disrupting. This opening is draining into the pelvis, but you have a couple of drains in it and the guy is not sick from it. Abdomen is open or closed (is the fascia or skin open)? How are you managing the output right now, ostomy bag over the enterocutaneous fistula and bags attached to the catheters? If that is all draining the output adequately I would say you are doing better than the ileorectal anastomotic disruption with open abdomen that I have been dealing with for the past few months (having trouble getting an appliance to stick and his skin is getting really irritated, but at least he quit getting septic every few weeks though)

 

[ele190]

Yes, you got it right except for the fact the gian hole doesn't come from a disrupted anastomosis (which is kind of irrelevant). The cutaneous fistula doesn't even require a bag, we use medications. The abdomen is closed, with of course the exception of the fistula. As i said, attendings are pushing to open again; in any case, if we have to do it we'll try to be "minimally invasive" Wish us luck

 

[dpmd]

Yes, you got it right except for the fact the gian hole doesn't come from a disrupted anastomosis (which is kind of irrelevant). The cutaneous fistula doesn't even require a bag, we use medications. The abdomen is closed, with of course the exception of the fistula. As i said, attendings are pushing to open again; in any case, if we have to do it we'll try to be "minimally invasive" Wish us luck

Oh, man. I hope they change their minds. The fact that the giant hole wasn't from a disrupted anastomosis is worse in my mind, because it means that perfectly normal bowel opened up. Only badness can come from operating now.

 

[Buzz Me]

This story is not going to have a happy ending.

 

[ele190]

Yesterday we operated again. I was there the whole time even if i wasn't scrubbed in. They approached the abdomen with a pubic-subomelical cut (where the skin was already open) and performed and additional cut from the pube to the stoma in the right iliac zone. They isolated the last ileal tract from the giant hole to the stoma and cut it, isolated a tract above and made a new stoma from the hole (which appeared fully vital) and placed it where the lattest was. I must say they didn't cause enterotomies or deserosations or massive bleeding, the tecnique was flawless. The patient was hemodinamically stable for the whole surgery and required just one unit of blood, he woke up without consequences.
The only issue is a skin suffering of the triangle between the two surgical cuts.
We're gonna see now how it works out, let's hope for the best; i will keep you up to date.

 

[Buzz Me]

I'm not sure I totally understood what you just typed.

 

[ele190]

I'm sorry, it's quite difficult to explain even in italian. They made a first middle incision in the lower abdomen, from there they could see the hole but they couldn't isolate the bowel due to the strong adhesions. So, they made another diagonal incision which went from the lowest point of the first one to the ileostomy he had in the right iliac zone. In that way there was a triangle of abdominal wall floating. From that perspective they could isolate the former ileostomy and the last ileal tract, which was totally twisted and stenotic (nothing could have passed from there). They resected that tract, that went from the hole to the former ileostomy; after that, they isolated an upper tract to mobilize more bowel and they performed a new ileostomy from the hole, which appeared completely vital, esteriorizing it in the spot where the former was. As i said they didn't cause enterotomies or deserosations or massive bleeding and the patient was hemodinamically stable.
Now the patient is in POD2 and looks fine: conscious, hemodinamically stable with good urine output. The new ileostomy is working and today the output was 600 ml, he had to output from the abdominal drainages.
The current problem is the sufference-necrosis of the abdominal wall triangle which was floating during the surgery. They're treating it with medications now, but i think we could use VAC-therapy on it (since it's not on the bowel).
Another problem is that, even from before the last surgery, the blood tests show some liver sufference. I think this could be from a non-optimal parenteral nutrition, what do you think?

 

[tussy]

The missed enterotomies will take a week to appear.

I would not have re=entered the abdomen. As long as there is adequate drainage I would have waited a minimum of 6 months to go back in (12 months is even preferable)

Would not have done a flank incision (or whatever it was) because now that entire portion of the abdominal wall that is necrotic will break down. That is likely where the enterotomies that you are not yet aware of will start to drain out. Then the remaining abdominal wall will dehisce.

First rule of surgery: do no harm (and always do the right operation the first time because re-operative surgery is not fun).

I am the expert on these disasters in my region. I hate them but somehow have become stuck with them.

 

[ele190]

I would have waited too but unfortunately i don't have a say, and if the 90% of attendings push to operate the other one kind of has to do it. Let's hope for the best and keep our fingers crossed...

 

[Buzz Me]

The mobilized skin flap ("triangle") will likely have lost its perforators and will become ischemic over the next few days.

Any missed enterotomies will show up on POD #4-7.

Just keep an eye out for enteric looking drainage.

 

[ele190]

We re in POD#5 and nothing happened so far..of course we ll keep an eye! What do you think about the necrotic flap? Is VAC ok in your opinion? We re using medications right now

 

[doc05]

VAC wont work. if its necrotic you'll need to resect. And good luck with all of the problems associated w that.

 

[ele190]

Resect? But i was talking about the abdominal wall not the bowel..

 

[Buzz Me]

Yup, so was he. Can't leave necrotic abdominal wall behind.