Post-operative Fistula

Question 1

A 30 year old woman had a resection of part of the ileum for Crohn’s disease. Five days later she has a fever (38.5) and a discharge of brownish offensive material from the lower end of the abdominal wound. How would you assess and manage her?

Answer 1

Impression
My impression is that this woman has developed an enter-cutaneous fistula given the likely faecalant discharge.

Differentials

• post-op wound infection
• Necrotising soft-tissue infection
• wound dehiscence
• infected wound seroma

Goals

• rule out serious DDx/ peritonism, assess for any HD isntability and provide immediate resuscitative measures whilst calling for senior help
• Targeted Hx/Ex/Ix
• definitive management with conservative +/- surgical intervention in setting of enter-cutaneous fistula + IV antibiotics if indicated by systemic signs of infection.

Question 2

Post-operative fistula - Assessment

Answer 2

Assessment

• Rule out HD instability, call for senior help, begin A to E assessment
• focus on ensuring stable airway then circulation, E for evidence of peritonism and fever (complicated fistula/infection)

Question 3

Post-operative fistula - History

Answer 3

History

• read the surgical notes, ?difficult anastomosis/bowel tears, method of closure, etc (look for risk factors for anastomotic leak), passing wind/going to toilet? Urinary/bowel changes.
• sx: fevers, malaise, lethargy, confusion (evidence of systemic infection).
• volume of output, suppuration? evidence of wound infection, any pain?
• Crohn’s disease history
• medications: steroids can impair wound healing

Question 4

Post-operative fistula - Examination

Answer 4

Examination

• vitals
• hydration status assessment
• abdominal examination: peritonitis, wound infection
• PV exam for ?enterovaginal fistula.

Question 5

Post-operative fistula - Investigations

Answer 5

Investigations

• Bedside: Wound swab + MCS, septic screen
• bloods: FBC, UEC, LFT cultures if septic, CRP/ESR,
• imaging: CT abdomen with IV and oral contrast, fistulogram

Question 6

Post-operative fistula - Management

Answer 6

Management
- call for senior help, ideally inform surgical registrar on call/Gen surg reg and treat fistula according to SSNAP (sepsis, skin, nutritional support, anatomy, definitive procedures:

Sepsis

• managed in resus if present
• empirical ABx IV plus other relevant supportive

Skin

• protection of the skin of the abdo wall
• consider stoma-bag if mod-high output fistula
• consider lowering steroids to promote wound healing, however would need to be in consultation with gastro re ongoing Crohn’s disease

Nutritional support

• fluids
• electrolytes
• consider TPN
• reduce oral intake to limit stoma output, consider loperamide

Anatomy
- relevant investigations imaging to determine the course and origin of fistula to assist in any relevant surgical planning.

Procedure

• most fistula’s will close by themselves with conservative management in 6 weeks
• Hence, delay surgery unless indicated, avoid repair of anastomosis and consider end ileostomy/colostomy for subsequent re-anastomosis in the future.