an apparently solitary distal small-bowel injury is treated

Discussion in 'MRCS Forum' started by Lona., Dec 22, 2007.

  1. Lona.

    Lona. Guest

    A 22-yrs-old man sustains a gunshot 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
    b- Board-spectrum antibiotics
    c- Total parenteral nutrition
    d- Somatostatin to lower fistula output
    e- Loperamide to inhibit gut motility
  2. Lona.

    Lona. Guest

    Answer: c. (Schwartz, 7/e, pp 1181-1182) Most enterocutaneous fistulas result from trauma sustained during surgical procedures. Irradiated, obstructed and inflamed intestine is prone to fistulization. Complications of fistulas include fluid and electrolyte depletion, skin necrosis and malnutrition. Fistulas are classified according to their location and the volume of output, because these factors influence prognosis and treatment. When the patient is stable, a barium swallow is obtained to determine (1) the location of the fistula, (2) the relation of the fistula to other hollow intra-abdominal organs, and (3) whether there is distal obstruction. Proximal small-bowel fistulas tend to produce a high output of intestinal fluid and are less likely to close with conservative management than are distal, low-output fistulas. Small-bowel fistulas that communicate with other organs, particularly the ureter and bladder, may need aggressive surgical repair because of the risk of associated infections. The presence of obstruction distal to the fistula (e.g. an anastomotic stricture) can be diagnosed by barium contrast study and mandates correction of the obstruction. When these poor prognostic factors for stabilization and spontaneous closure are observed, early surgical intervention must be undertaken. The patient in the question, however, appears to have a low-output, distal enterocutaneous fistula. Control of the fistulous drainage should be provided by percutaneous intubation of the tract with a soft catheter. This is usually accomplished under fluoroscopic guidance. Antispasmodic drugs have not been proved effective; somatostatin has been used with mixed success in the setting of high-output (greater than 500 ml/day) fistulas. There is no indication for antibiotics in the absence of sepsis. Total parenteral nutrition (TPN) is given to maintain or restore the patient’s nutritional balance while minimizing the quantity of dietary fluids and endogenous secretions in the gastrointestinal tract. A period of 4 to 6 weeks of TPN therapy is warranted to allow for spontaneous closure of a low-output distal fistula. Should conservative management fail, surgical closure of the fistula is performed.

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