A 22-yrs-old man sustains a gunshot wound to the abdomen. At exploration, an apparently solitary distal small-bowel injury is treated with resection and primary anastomosis. On postoperative day 7, small-bowel fluid drains through the operative incision. The fascia remains intact. The fistula output is 300 mL/day and there is no evidence of intraabdominal sepsis. Correct treatment includes.
|A||Early reoperation to close the fistula tract|
|C||Total parenteral nutrition|
|D||Somatostatin to lower fistula output.|
a. Successful management of patients with intestinal fistulas requires establishment of controlled drainage, usually using a sump suction apparatus; management of sepsis; prevention of fluid and electrolyte depletion; protection of the skin; and provision of adequate nutrition.
b. The control of fistula output is most easily accomplished by intubation of the fistula tract with a drain.
c. Protection of the skin around the fistulous opening is important to prevent excoriation and destruction of the skin. This is most easily accomplished by using Stomahesive appliances with applications of zinc oxide, aluminum paste ointment, or karaya powder.
d. The suction catheter can be brought out through the end of the Stomahesive bag, which is cut to just fit the fistulous opening. This will allow for collection and accurate measurement of the output.
e. The use of TPN has been an important advance in the management of patients with enterocutaneous fistulas and significantly prevents the problems of malnutrition. A reasonable management plan would be to follow a conservative course for 4 to 6 weeks, at which time, if closure has not been obtained, surgical management should be considered.
f. This period of conservative management not only allows those fistulas to heal spontaneously but also allows for optimization of nutritional status and control of the wound and fistula sites. Also, a reasonable delay permits the peritoneal reaction and inflammation to subside, thus making a second operation easier and safer.