Originally published in Journal of Clinical Surgery 2007, 15(10): 662-663
After the occurrence of an intestinal fistula, the surgeon’s first instinct is to reoperatively remove the fistula and reanastomize the intestinal canal. Back in the 1960s, this was the main surgical approach used for intestinal fistulas that occurred after surgery. However, because there is no ideal means of controlling the combined infection, bleeding and organ dysfunction that occurs after an enterocutaneous fistula, and the intestine is moderately inflamed and edematous, anastomosis is often difficult to satisfactorily perform. In addition, systemic and local factors such as malnutrition that lead to intestinal fistula are not eliminated, and intestinal fistula often occurs again. The blow caused by repeated multiple surgeries and postoperative complications eventually led to the death of the patient from infection, bleeding and multiple organ failure. At that time, the mortality rate of patients with enterocutaneous fistulas was as high as 70%. This was not unrelated to the early and definitive surgical strategy performed for extra-intestinal fistulas at that time. Ren Jianan, Department of General Surgery, Nanjing Military General Hospital
After the 1970s, the mortality rate of patients with enterocutaneous fistulas decreased significantly to about 20%, with the lowest being 5%. In addition to medical advances, this result is closely related to changes in the treatment strategy for extraintestinal fistulas. When it was recognized that early definitive surgery for enterocutaneous fistulas was difficult to succeed, there was a shift to a staged treatment strategy of resuscitation, drainage, maintenance, and finally definitive surgery. The high complications and mortality associated with combined enterocutaneous fistulas were finally stifled. But since then, there has also been the question of when is the best time to operate.
For patients with enterocutaneous fistulas, it is important to ask not only when is the time for definitive surgery to remove the fistula, but also to answer when is the best time for surgery to drain and control complications such as bleeding.
In the immediate aftermath of an enterocutaneous fistula, the results are infection caused by spillage of intestinal fluid, bleeding caused by digestion of tissue by intestinal fluid, malnutrition due to intestinal dysfunction, and biliary sludge and biliary cholecystitis due to prolonged fasting. Some of these complications can be cured by non-surgical methods, while others need to be addressed by another caesarean section.
In the case of intestinal fistula combined with abdominal infection, the original drainage site can be evaluated by trans-fistulography and CT to see if the drainage is reasonable and adequate. Whether the infection can be resolved by improving drainage, such as switching to negative pressure double cannula drainage or adding local irrigation on top of drainage. If an undrained abscess does exist, it should be managed by ultrasound or CT-guided percutaneous abscess puncture and drainage if possible. In patients with severe abdominal infection and combined organ compromise, direct drainage of the abdominal cavity can also be performed by opening the incision at the bedside. Only if all means have been used and the infection still cannot be drained is another dissection considered to remove the infection and drain the abscess cavity.
Bleeding is a common complication in patients with extra-intestinal fistulae. In the case of bleeding in combination with parenteral fistula, it is important to analyze whether the bleeding is due to stress-induced gastrointestinal mucosal erosion, mucosal bleeding from the fistula, or bleeding from rupture of the abdominal vessels due to digestive decay of intestinal fluid. The healing of bleeding due to extensive gastrointestinal mucosal erosion can be improved by improving ischemia and hypoxia and providing mucosal nutrition. Mucosal bleeding from fistulas can be reduced and eliminated by improving drainage and controlling the spillage of intestinal fluid. If necessary, DSA angiography can be used to identify the site of bleeding and vascular embolization can be used to stop the bleeding. Only if all measures fail should a repeat dissection be considered to stop the hemorrhage.
Silicotic cholecystitis caused by prolonged fasting can be completely cured by ultrasound-guided gallbladder puncture and drainage. For patients with gastric fistula, duodenal fistula, and high jejunostomy without jejunostomy, enteral nutrition can be provided by gastroscopy-assisted or X-ray-assisted nasogastric tube placement. There is no need for a specific reoperation for a jejunostomy.
Every surgery, such as infection is a blow to the patient as are complications such as bleeding. Surgeons must be cautious about reoperation!
Ostensibly, what determines definitive surgery for enterocutaneous fistula again is the timing, i.e., the patient needs to wait about 3 months before surgery. The reason for this time period is that the release of abdominal adhesions takes such a long time. Only then is it possible to surgically break down the adhesions, access the abdominal cavity, remove the intestinal canal distal and proximal to the fistula and reanastomize it.
It has been observed that in patients with small fistulae, the scope of fistulae is less contaminated, the extent of abdominal adhesions is smaller, and the severity of abdominal adhesions is less severe, so the operation time can be advanced in such patients. However, at most, the operation can be advanced to 6 weeks after the last surgery, such as a combined cecum stump fistula or ileocecal fistula after appendectomy, or a sigmoid fistula due to an inadvertent injury after inguinal oblique repair.
In general, the longer the waiting time, the lighter the adhesions and the easier the surgical separation. Analysis of the release of abdominal adhesions can also be performed by physical examination with CT. A marked softening of the abdominal cavity on palpation is an important sign of loosening of abdominal adhesions. Protrusion of the intestinal canal through the fistula is also a sign of loosening of intestinal adhesions near the fistula. A CT scan of the patient after oral administration of 30% pantopamine is more likely to provide further information about the adhesions in various parts of the abdominal cavity, thus indicating the difficulty of surgery and whether it can be performed.
In fact, in addition to the time factor dictated by abdominal adhesions, the patient’s diagnosis, systemic and local conditions, and the psychological and technical preparation of the medical staff are all important in determining whether a patient with intestinal repeat is ripe for surgery.
Once again definitive surgery still carries the risk of failure, and during the maintenance phase, self-healing of the parenteral fistula should be promoted by various means. The timing of surgery should be considered only when there is no real possibility of self-healing in patients with enterocutaneous fistulae. Efforts should be made to promote spontaneous healing of enterocutaneous fistulas within 3 months of their occurrence. Factors that may prevent spontaneous healing include obstruction distal to the fistula, localized infection or foreign bodies, sinus tracts shorter than 1.5 cm, radiological injury, and labyrinthine fistulas. When these factors cannot be removed, reoperation to remove the fistula should be considered. At this point, the control of infection, nutritional status and general condition, as well as the psychological and technical readiness of the surgeon become important in determining the timing of definitive surgery.
In some patients, although they have waited for 3 months, their nutrition and organ function are not satisfactory, so they cannot be operated at this time, and efforts must be made to improve their nutritional status. Parenteral nutrition can maintain the nutritional status of patients with enterocutaneous fistulas, but it is somewhat inadequate to further improve the nutritional status of patients with enterocutaneous fistulas. An attempt should be made to restore enteral nutrition for a period of time before considering definitive surgery. In addition to the recognized improvement of intestinal mucosal barrier function and promotion of patient recovery, in patients with enterocutaneous fistula, enteral nutrition can also reduce the difficulty of surgery by promoting intestinal motility, reducing intestinal adhesions, and increasing intestinal wall thickness.
Before surgery, attention should also be paid to vitamin K and B12 deficiencies, which are most commonly seen in patients with enterocutaneous fistulas. The causes of this are, first, chronic parenteral nutritional deficiencies and, second, inadequate absorption in the terminal ileum due to high intestinal fistulas and ileal lesions. Vitamin K deficiency can lead to insufficient synthesis of hepatic coagulation factors II, VII, IX and X, ultimately leading to impaired coagulation mechanisms. Intraoperative bleeding is very likely to occur in the surgical field and is difficult to stop. This can be corrected by preoperative vitamin K1 supplementation. The same is true for vitamin B12 deficiency. In the case of postoperative enterocutaneous fistula after distal gastrectomy, macrocytic hypochromic anemia due to B12 deficiency will appear earlier and more severely. This should also be actively monitored preoperatively and corrected by subcutaneous vitamin B12 injection if necessary.
Exercise capacity is also an important indicator to evaluate the patient’s ability to undergo definitive surgery [1]. Prolonged bed rest itself is an important catabolic factor, while exercise is an anabolic factor. Prolonged bed rest, despite nutritional support, can be combined with skeletal muscle atrophy, subcutaneous fat accumulation, and decreased tissue healing and resistance to infection. Prolonged bed rest can also be combined with crushing pneumonia and lung infection, which in turn affects lung function. Based on our experience of operating on a large number of patients with intestinal fistulas over the years, there is a clear conclusion that prolonged bed rest and inability to get out of bed is one of the contraindications to definitive surgery. Forced surgery is extremely risky.
It has been reported in the literature that the risk of surgery in cardiac patients can be evaluated by 6 min walking distance and maximum oxygen consumption for a certain exercise power [2]. We use stair climbing to facilitate the recovery of the patient’s general condition in our daily work in the treatment of enterocutaneous fistula and also by this means to evaluate whether the patient’s general state can tolerate surgery. The smoothest recovery from surgery in the average adult patient with intestinal fistula is to climb 16 flights of stairs in about 6 min. Even in patients over 80 years of age with enterocutaneous fistula, those who can climb 4-6 flights of stairs before surgery have an excellent postoperative recovery.
Exercise is an important “treatment” for bedridden patients with intestinal fistulas. The ability to get out of bed is the starting point for recovery. It is no less important than any pharmacological treatment. The assessment of exercise capacity is no less important than any laboratory test for determining the timing of surgery. More recently, it has been confirmed in the literature that exercise also promotes the synthesis of hepatic autogastrin [3]. However, the timing and intensity of exercise in patients with more severe disease, especially to derive some better quantitative indicators, deserve to be studied in depth.
Before definitive surgery, patients should also be helped to overcome some bad habits or reactions that affect wound healing, such as abdominal coughing and erratic reflux after gastric tube placement. Before surgery, patients can be repeatedly trained to reduce the intensity of coughing, especially abdominal coughing intensity. For patients who do experience recurrent eructations after gastric tube placement, percutaneous endoscopic gastrostomy (PEG) can be performed before surgery for enteral nutrition support, and postoperative gastrointestinal decompression can be left in place to avoid postoperative gastric tube placement and the many discomforts caused.
The surgeon must think repeatedly before the operation of enterocutaneous fistula and have a mature surgical plan, with at least three sets of upper, middle and lower surgical plans for patients with complex parenteral fistula. It is important to have a plan for various intraoperative situations that may arise. The surgical team discusses the options repeatedly before surgery to ensure that everything is foolproof. Only when these are done can we say that the time is ripe for definitive surgery. One cannot expect to get on the operating table and open the stomach and then look at it. This is because sometimes, for patients who have had one, three or more surgeries, the belly may not open at all, or when it is opened and seen, one cannot remember what to do with it.
Medical development today, the improvement of intestinal anastomosis technology, the application of effective antibiotics, the maturity of enteral and parenteral nutrition support methods. the popularity of ICU, and the emergence of pro-synthetic drugs have made early definitive surgery possible. Through animal experiments, we found that in patients with small intestinal fistulas without organ dysfunction, where the abdominal inflammation is mild and the adhesions can be safely separated, it is possible to achieve successful surgery within 2 weeks after surgery. However, this is provided that the aforementioned conditions are fully met.
The question of when a patient with intestinal fistula can be operated is easy to ask. But it is really difficult to answer. It is even more difficult to operate in clinical practice. But the principle is clear: the patient must be in the best possible health to undergo the operation, and the surgeon must be in the best possible state of mind and psychology to perform the operation.
References
[1] Enrigt PL, McBurnie M A, Bittner V, et al. The 6-min walk test: a quick measure of functional status in elderly adults [J].
[2] Takigawa N, Tada A, Soda R, et al. Distance and oxygen desaturation in 6min walk test predict prognosis in COPD patients [J].Respir Med,2007, 101( 3): 561-567.
[3] Pupim LB, Flakoll PJ, Ikizler TA. Exercise improves albumin fractional synthetic rate in chronic hemodialysis patients [ J].Eur ,J Clin Nutr,2007, 61( 5):686-689.