According to current treatment principles, enterocutaneous fistulas often require more than two surgical procedures. We have seen patients with episiotomy who have undergone more than 12 surgical procedures for enterocutaneous fistulas. In the course of treating these patients, we have learned that the timing, planning and implementation of surgery, and perioperative management of multiple surgical procedures for enterocutaneous fistula patients are different from those for first-time emergency surgery and elective surgery. The experience of multiple surgical treatment of enterocutaneous fistula is presented here.
The factors that determine the timing of surgery in patients with enterocutaneous fistula include: nutritional status, organ function, and release of abdominal adhesions. According to the current principles of enterocutaneous fistula treatment, it is generally feasible to perform definitive surgery again after the infection is controlled, the nutritional status is improved, and the abdominal adhesions are released about 3 months after the occurrence of an enterocutaneous fistula. The so-called definitive surgery is the removal of the intestinal fistula segment and intestinal anastomosis.
In the case of abdominal adhesions, it usually takes about 3 months between the last surgery for the abdominal adhesions to loosen and facilitate surgical separation. However, time is not a decisive factor. The complete release of abdominal adhesions also depends on the extent of the previous surgery, the extent of postoperative bleeding and infection, and drainage. The greater the extent of the fistula-causing surgery, the more severe the infection at the time of the fistula and the poor drainage will aggravate the abdominal adhesions, which will be further aggravated by abdominal chemotherapy and radiotherapy. In some patients with a milder infection and less extensive adhesions at the time of extra-intestinal fistula, reoperation may be possible within about 6 weeks of the occurrence of the fistula. On the contrary, in some patients with extensive abdominal infection, poor nutritional status and heavy abdominal adhesions, the waiting time for reoperation needs to be extended appropriately, in some cases up to 6 months. The longest individual cases have been treated surgically up to 10 years later. However, most patients can be treated with reoperation within 6 weeks to 6 months. In any case, the treating surgeon should overcome the impatience and must choose the timing of reoperation carefully.
The timing of reoperation for extra-intestinal fistulas can generally be determined from the following aspects: (1) there is no possibility of self-healing of the fistula; (2) understanding the extent of surgery or trauma, the presence of extensive peritonitis or abscess formation at the time of the fistula. (3) Periodic examination of the abdomen, dynamic observation of the presence of inflammatory masses, the degree of abdominal wall tenderness, and intestinal peristalsis. The softer the abdominal wall, the more active the intestinal peristalsis, the lighter the adhesions. (4) Whether the patient’s nutrition and general condition are significantly improved, and whether the organ function can tolerate the major surgical stress. (5) Abdominal CT examination should be performed before reoperation to observe the distribution and degree of intra-abdominal adhesions. (6) When possible, the timing of surgery should be advanced to reduce the occurrence of various complications and shorten the treatment time.
If the patient is young, has good organ function, good nutritional status, and has the conditions for reoperation of intestinal resection and intestinal anastomosis, he can be operated again within 14 days of the occurrence of an extraintestinal fistula by resecting the intestinal segment of the fistula and performing intestinal anastomosis, i.e. early definitive surgery [1].
The most profound experience of the authors, who have been following academician Li Jieshou for many years, is to analyze the causes of the fistula repeatedly before surgery and to design various surgical plans taking into account all possible situations that may occur during surgery. It is important not to wait until the operation to see (decide). This kind of thinking often leads to intraoperative unpreparedness for unexpected situations, panic and confusion, and ultimately violates the principles of treatment.
The function of the heart and lungs and other important organs, especially the condition of the gastrointestinal tract, must be very clear. Specifically, the preoperative routine and special examinations should be improved. Barium meal of the whole gastrointestinal tract (in case of obstruction, 60% pantopamine) and fistulography are used to understand the fistula course and the whole gastrointestinal tract course, and whole abdominal CT is used to understand the presence of potential infection and abdominal adhesions [2]. Various routine examinations were then performed to investigate any contraindications to surgery.
It is important to be very clear about the surgical objectives to be achieved by reoperation, and there should be generally three types of prognosis: upper, middle and lower. That is, how the best option is designed; what is the second-best option; and what is the fallback in the worst conditions, i.e., the option that ensures the patient’s life.
The correct surgical approach is the key to successful surgery. Sometimes, the intestinal canal is damaged as soon as the incision is opened. At this point, not only is the mind of the surgeon damaged, but the difficulty of further surgery is significantly increased. It is important to ensure that the reoperative access should be at the site where the abdominal adhesions are least severe and where the surgical field is fully exposed at the same time. The incision from the previous surgery should generally be avoided because under this incision is often also where the adhesions are heaviest. If the original incision is still needed, the abdomen should be entered as close as possible to the upper and lower part of this incision without scarring. For those who have multiple vertical incision scars and are not comfortable using a vertical incision, transverse epigastric incisions and curved lower abdominal incisions can also be used, and most of them can be successfully entered.
Successful visualization of the surgical field is also one of the key factors for successful execution of the procedure. A tip for traction is presented here. Since most abdominal adhesions in patients with enterocutaneous fistulae are diffuse, even after successful access, there are still extensive adhesions in the abdominal cavity. It is still difficult to expose the surgical field using a normal retractor (pulling hook). The solution is to make a suture at about 5 cm interval on both sides of the incision using a #7 silk thread in the full subcutaneous layer, use a straight vascular clamp to tighten the suture and lift the incision, which will expose the surgical field well. We refer to this method as incisional sling traction.
It is very important to separate the adhesions between the intestines with patience and care. Abdominal adhesions are generally classified as membranous adhesions, dense adhesions (scarred adhesions), and inflammatory adhesions. There are two main methods of separating adhesions, namely sharp separation and blunt separation. Sharp separation should be adopted as much as possible to separate adhesions, which can be supplemented with blunt separation for very mature membranous adhesions. Sharp separation is mainly based on scissors, and the scissors used are curved blunt-tipped scissors. For dense adhesions, a scalpel can be used for sharp separation, but this requires a good grasp of the softness and anatomy of the adhesions to be separated, as well as a specific feel for the scalpel.
It is necessary to emphasize here the method of repairing extraintestinal fistulas and intraoperative bowel injuries. The surgeon should not be alarmed by intraoperative rupture of the intestinal canal due to separation. The injured intestinal canal can be trimmed first and then interrupted with fine silk sutures, supplemented by interrupted pulpy sutures to reinforce the repair opening. If longitudinal sutures along the intestinal canal are likely to be narrowed, transverse sutures can be used instead. For small fistulae that can be repaired, a similar approach should be taken. If the inflammatory scars and damaged tissue are not removed and the repair is performed directly on top of them, it is difficult to achieve satisfactory healing of the damaged intestine.
The causes of extraintestinal fistulas are poor tissue healing at the local anastomosis and repair port, and obstruction at the distal end of the anastomosis. Therefore, after dealing with the fistula, the distal intestinal canal should also be fully explored to exclude distal obstruction. For example, if a duodenal stump fistula is complicated by gastrojejunostomy after major gastrectomy, after repairing and removing the duodenal stump, it is necessary to understand whether there is obstruction of the input collaterals. If necessary, the gastrojejunostomy can be replaced by a jejunal Roux-en-Y anastomosis.
To ensure successful surgery and shorten the operative time, advanced surgical instruments, such as purse-string suture forceps, disposable anastomoses and sutures, can be used as much as possible.
After the procedure is completed, extensive abdominal irrigation with saline should also be performed. The amount of saline flushing is determined by the degree of abdominal contamination. It is usually above 100 ml/kg body weight and up to 300 ml/kg body weight. The greatest benefit of abdominal irrigation is to reduce abdominal contamination to prevent secondary abdominal infection and to reduce postoperative intestinal adhesions.
The jejunostomy plays a role in both decompression and nutrition in extra-intestinal fistula surgery [3]. A jejunostomy tube placed in and around the proximal end of the repair and anastomosis is used to drain intestinal fluid, reduce pressure on the anastomosis, and ensure healing of the anastomosis. This method is also known as internal drainage. The jejunostomy tube placed distal to the anastomosis is to facilitate early postoperative initiation of enteral nutrition and also to reduce the cost of waiting for the next surgery and to reduce complications such as infection and biliousness associated with long-term parenteral nutrition in the event of another postoperative enterocutaneous fistula. The long duration of parenteral fistula surgery should not be used as a reason to forego this important insurance measure. Regardless of the purpose, the jejunostomy should follow the three elements of the Witzel jejunostomy method, i.e., purse-string fixation, tunnel encasement, and abdominal wall draping. This is to prevent the occurrence of extra-jejunostomy fistulas due to artificial jejunostomy. Avoid choosing latex and silicone tubing for the stoma tube, as these two types of tubes on the market are mostly thicker and have less ability to form sinus tracts themselves. We have experienced that the choice of red rubber catheter for jejunostomy has fewer complications and is less expensive.
Finally, attention should also be paid to postoperative external drainage, which is to place a drip double-lumen negative pressure suction tube (Lai’s tube) at the site where fistula may occur again, such as near the intestinal anastomosis and repair port and each potential gap. This method of drainage has been described in detail by academician J.S. Lai and has been an effective method for the treatment of extraintestinal fistulas with abdominal infections for three decades [4]. The basic principle of Lai’s drainage tube is to change passive drainage to active drainage; to change simple drainage to drip flushing drainage, which is also called drip double-lumen negative pressure suction tube. Because of the variety of the so-called double cannulae on the market, both the production materials and the use and effect are significantly different from the double cannulae we currently use. Some of them are active negative pressure drainage, but it is very easy to form a local vacuum and block the catheter, so it is also difficult to achieve the effect of drainage. For the sake of distinction, the double cannula we are currently using will be referred to as the Lai double cannula.
In order to maximize the success rate of reoperation of patients with enterocutaneous fistula, we must also work on the perioperative period of enterocutaneous fistula. Simply put, we must pass the “five hurdles”, i.e., endostasis imbalance, bleeding, infection, organ dysfunction and malnutrition, in order to ensure the success of reoperation for patients with parenteral fistula.
The issues related to perioperative nutritional support and infection in patients with parenteral fistula have been emphasized by the authors in other articles [4,5] and will not be repeated. It is worth mentioning that because the intestinal function of patients with extra-intestinal fistula is incomplete, artificial nutrition is not yet perfected and vitamin K deficiency is likely to occur, which affects the coagulation function of patients and should be supplemented in time before surgery. As the patient with an extra-intestinal fistula is re-operated due to the separation of adhesions, the stripping surface is larger. It is important to stop the bleeding properly during the operation. In case of postoperative bleeding tendency, various hemostatic drugs should be used promptly. Sometimes, a large amount of postoperative abdominal bleeding, especially late bleeding and gastrointestinal bleeding, is often an early manifestation of an extra-intestinal fistula, which should be observed and interventions should be taken when appropriate.
Patients with extra-intestinal fistula who are reoperated should be ventilated by various methods such as nasal catheter oxygen, mask oxygen and BIPAP. patients with extra-intestinal fistula who have pulmonary dysfunction due to impaired ventilation and air exchange should be ventilated by tracheotomy without hesitation.
Efforts should also be made to use enteral nutrition support for a period of time before definitive surgery for parenteral fistula. In addition to the advantages of lower cost, fewer complications, and safety and effectiveness compared with parenteral nutrition, we found that patients who were able to use enteral nutrition for a period of time before surgery had significantly less abdominal adhesions than those who had been using parenteral nutrition. This may be related to the ability of enteral nutrition to increase intestinal motility.
In conclusion, many aspects of reoperation and multiple operations in patients with enterocutaneous fistulas are different from the first abdominal operation. The abdominal surgeon should avoid rigidly copying the experience of the first surgery and further refine the preoperative, intraoperative, and postoperative management of multiple intestinal fistula surgeries based on the authors’ experience with multiple intestinal fistula surgeries.