Some patients can heal on their own after treatment with nutrition plus drainage, but in some patients, the lesions do not heal for a long time and even form periappendiceal abscesses, which affect the quality of life of patients. Improper treatment often leads to medical disputes. Early definitive surgery allows some patients to be cured, and patients who do not heal are often referred to a higher level hospital, and if the patient cannot recover successfully from another surgery, it is inevitable that the degree of medical disputes will increase. “Drainage plus elective surgery” is an important principle in the treatment of enterocutaneous fistula in recent years. In our department, right hemicolectomy was performed on patients with post-appendectomy intestinal fistula, and they all recovered successfully.
Information and methods
I. Surgical methods and precautions:
A right parasternal median incision or trans-rectal exploratory incision (for patients with original trans-rectal exploratory incision) was used to enter the abdomen, and the abdominal cavity was explored, especially the distal intestinal tract and the lesion in the fistula area, and a modified midline approach was used to perform right hemicolectomy.
Precautions are as follows.
1. depending on the condition of the distal colon, right hemicolectomy or enlarged right hemicolectomy should be performed (some patients with combined special diseases need to be resected to transverse colon resection to the middle section or near splenic flexure).
2. Pay attention to the posterior peritoneal level and do not damage retroperitoneal organs such as the ureter, and pay attention to the protection of the descending duodenum and horizontal duodenum during surgery.
3. after removal of the specimen, turn the end of the ileum to the left via the posterior aspect of the superior mesenteric artery, and turn all the small intestine to the right side of the abdomen to reveal the beginning of the jejunum.
4, perform ileo-transverse colonic anastomosis, placing the anastomosis on the left side of the abdomen.
5.Lateral ileo-colonic anastomosis with a linear cutting suture.
6.If the condition permits, take the tipped large omentum to pave the surgical wound.
7. Place a drainage tube on the original surgical wound to adequately drain the wound; if an irregular wound cavity is found intraoperatively, place the drainage tube in the deepest part of the wound cavity.
8. The original appendiceal incision was closed with full sutures.
Discussion
There are many reasons for the occurrence of postoperative intestinal fistula in appendicitis, some patients are related to complex local lesions of the appendix and improper surgical management; some patients are combined with other diseases and have poor distal intestinal function after surgery leading to postoperative intestinal fistula. In patients with extra-intestinal fistula, after infection control and nutritional support, there is a certain rate of self-healing (40%-60%) if there are no factors affecting healing such as obstruction or specific lesions, and the proposal of drainage plus elective surgery results in a 98.2% success rate of late definitive surgery. There is a long waiting period, usually 3 months, between initial drainage and definitive surgery. In our group of cases, 22 patients had postoperative formation of inflammatory masses in the appendiceal region with varying time of formation, therefore we suggest that definitive surgery must wait for local stabilization of the lesion before performing it. Two patients in our group were found to have intraoperative localized segregated pus accumulation, but the imaging presentation was not specific, and preoperative and postoperative attention needs to be paid to such cases.
The inflammatory adhesions in the area of postoperative enterocutaneous fistula are often heavy, and the secondary surgical incision should be chosen far away from the initial surgical area to avoid collateral damage and to facilitate the purpose of abdominal exploration, using a right parasternal median or median incision, and most of them can enter and explore the abdomen smoothly.
Resection of the diseased bowel segment is the basic method of surgical treatment of intestinal fistula, but performing intestinal anastomosis in the inflammatory state may lead to postoperative reanastomotic fistula. In our group of cases, secondary intraoperative exploration revealed varying degrees of edema and toughness of the intestine on both sides of the ileocecal region, and some patients had inflammatory edema of the ascending colon with significant length shortening. The occurrence of anastomotic fistula after secondary surgery was still seen in some reports, which may be related to secondary factors. Therefore, we recommend performing right hemicolectomy to ensure normal bowel wall bilaterally at the anastomosis to facilitate anastomotic healing.
In this group of cases, the original right lower abdominal surgical area had different degrees of inflammatory edema and tough texture (as shown in the figure below), and the anastomotic location after local resection was located at the original inflammatory wound, and the exudation of inflammatory factors might lead to local edema of the anastomosis and anastomotic stenosis, resulting in increased pressure in the proximal intestinal lumen of the anastomosis and difficulty in anastomotic healing. Therefore, we positioned the anastomosis in the left side of the abdomen where it is not affected by inflammation (outside the surgical wound area), and turned the end of the ileum posteriorly through the mesenteric artery to the left upper abdomen and anastomosed with the transverse colon to achieve the ideal purpose.
The advantages of ileocolic anastomosis performed with a straight cutting suture are.
1.Simple operation, reduce the operation time, the anastomosis can be completed by two closures, which can reduce about 15min on average compared with the traditional operation.
2.Reducing the contamination caused by manual anastomosis, the traditional suture stitches inside in and out, plus the process of knotting, inevitably bring the intestinal contents into the abdominal cavity, resulting in postoperative infection.
3.It can meet the anastomosis of different caliber of intestine, and it is not necessary to consider the thickness of intestinal caliber when anastomosis is performed, especially when combined with intestinal obstruction and wide diameter of colon.
4.It can ensure the width of the anastomosis and not cause narrowing of the anastomosis, which can be used in this operation to simplify the operation and increase the safety of the operation, etc. Good results were achieved in this group of cases.
The reason why some patients do not heal after intestinal fistula is because of distal colon lesions, in this group of cases four patients had multiple polyps in the distal intestine and one patient had tuberculosis infection. Therefore, the presence of specific lesions in the distal intestine needs to be determined before definitive surgery is performed. In case of specific lesions in the distal intestine, an enlarged right hemicolectomy was performed to remove the distal lesions to treat the intestinal disease and facilitate postoperative healing. Because of long-term abdominal infection and multi-drug resistant bacteria, the effect of antibiotic treatment may be poor, and unobstructed drainage is the main principle of treatment, and most of the patients in this group have irregular trauma cavities. The greater omentum has a rich vascular network with good ductility and tends to be anti-inflammatory. If the patient’s condition permits, we recommend freeing the greater omentum and laying it on the surgical wound.
To achieve the following two purposes.
1, filling the surgical local wound cavity: because most patients have irregular postoperative wound cavities, and in one patient in this group of cases the abscess extended about 125 px retroperitoneally (as shown in the figure below), the application of large omentum filling can effectively eliminate the surgical wound cavity (as shown in the figure below) and avoid postoperative fluid accumulation infection.
2. Eliminating the inflammatory trauma and using large omentum to pave the retroperitoneal trauma, the intestine and the posterior wall of the abdominal cavity are effectively isolated to avoid the occurrence of adhesions, and there are no patients with postoperative intestinal dysfunction in this group of cases.
In this group of cases, the original incision was incised and the epithelialized tissue around the incision and the surrounding inflammatory area were excised to avoid postoperative necrosis and difficult healing. Because of the heavy inflammation of the abdominal wall, the layers are not clear and the tissue texture is fragile, the layered suture may lead to difficult healing of the incision or even incisional dehiscence, and the full layer suture can effectively avoid this situation.
In conclusion, postoperative intestinal fistulas after appendicitis often do not heal for a long time and even form periappendiceal abscesses, which affect the quality of life of patients and easily lead to medical disputes. By keeping good control of the operation time, strictly grasping the indications for surgery, elective right hemicolectomy, and paying attention to the surgical skills during the operation, patients can mostly recover successfully and be discharged from the hospital.