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Tactical Decisions in High-Output Small Bowel Fistula
Tactical Decisions in High-Output Small Bowel Fistula ROBERT I. OLIVER, M.D.* JAMES D. HARDY, M.D., F.A.C.S. **
Most operations are routine and the patient promptly goes home to recuperate. Yet, there are a few patients whose structural and functional defects require the mobilization of all the resources, ingenuity, and dedication available to achieve a successful outcome. This article tells about such a case. The patient had a severe high-output small bowel fistula.
CASE REPORT The Initial Injury J. W., a 23 year old white male, received a 30-30 caliber gunshot wound of the lower abdomen on August 22, 1967. The wound was inflicted during a service station brawl which was the result of an old family feud. The patient was first taken to his local hospital where physical examination revealed a wound of entrance in the right lower quadrant and a wound of exit in the left lower quadrant. The blood pressure was 80/0 and the pulse rate 120. Lactated Ringer's solution, whole blood, and antibiotics were administered, and at operation he was found to have multiple perforations of the small bowel without injury to the colon or urinary tract. A large part of the lower portion of the rectus abdominus muscle had been blown away. Two segments of traumatized small bowel were resected, and multiple less severe perforations were sutured. The abdomen was drained and closed. The postoperative period was uneventful until the third postoperative day when excessive drainage emerged from the right lower quadrant. Oral liquid intake increased the drainage, and on September 7 the patient was transferred to the University Medical Center for evaluation and treatment of a small bowel fistula. '''Assistant Instructor, Department of Surgery, University Hospital, University of Mississippi Medical Center, Jackson, Mississippi '''''Professor and Chairman, Department of Surgery; Surgeon-in-Chief to the University Hospital, University of Mississippi Medical Center, Jackson, Mississippi Surgical Clinics of North America- Vol. 50, No. 5, October, 1970
1141
1142
RoBERT
I.
OLIVER, JAMES
D.
HARDY
Evaluation at University Medical Center He was quite ill, and severe excoriation of the skin of the abdominal wall had developed. Weight loss was apparent, and dehydration had resulted from the high output small bowel fistula or fistulas. Sepsis was not particularly in evidence. Effective intravenous fluid replacement was initiated on the basis of the apparent degree of dehydration and the profile of the plasma electrolyte concentrations. Multiple transfusions of blood and plasma were administered and broad spectrum antibiotic coverage was continued. The skin was moderately well protected by aluminum paste and catheter suction at the drainage sites on the anterior abdominal wall, since it was not feasible to apply a bag (Fig. 1). He required almost continuous nurse and physician attention.
First Operation After careful study and appraisal of the patient's total condition, we decided on operative intervention, which was performed on September 18, 1967. Because of extensive skin contamination, excoriation, and infection from the high-output fistula below, the abdomen was entered through a left subcostal incision. The plan was to do as little as possible, a simple bypass of the fistulous bowel being considered acceptable. On entering the peritoneal cavity, however, we encountered widespread active peritoneal inflammation with marked fibrinous adhesions and many loculated collections of pus. The entire small bowel was markedly thickened and edematous. It was found to be remarkably foreshortened, after it had been sufficiently freed up to permit reasonably certain identification of the anatomic and functional changes-an
Figure 1. Multiple fistulous openings on the anterior wall rendered skin protection difficult.
TACTICAL DECISIONS IN HIGH-OUTPUT SMALL BOWEL FISTULA
1143
Figure 2. The presence of the MillerAbbott tube facilitated differentiation of bowel proximal to the fistula from that distal.
identification which was considerably facilitated by the presence of a long Miller-Abbott tube (Fig. 2). All things considered, it appeared reasonable to resect the 30 em. of upper ileum involved in the fistulous area, since any anastomosis would be made through somewhat friable and diseased bowel, even if a bypass were employed. Furthermore, if the anastomosis held, the fistula would be cured, in contrast to the situation which would exist were the fistula to be bypassed. Certainly, there was no choice but to attempt to restore a portion of the small bowel for alimentation to reverse the patient's steadily downhill course. Thus, mid small bowel continuity was re-established with an end-to-end anastomosis. The Miller-Abbott tube was then advanced to the ileocecal valve, and the abdomen drained and closed. The immediate postoperative period was uneventful. However, on the fourth postoperative day drainage consistent with a small bowel fistula again developed. It was hoped that this represented a side fistula and that, with intestinal continuity re-established, the bowel would heal. Unfortunately, the amount of drainage increased and the problems of water, electrolyte, and nutritional losses, as well as skin excoriation, became magnified. The patient was given oral nutrients, and with blood and plasma supplements he remained relatively stable. Drainage from the fistula ranged from 1500 to 4000 ml. per day. Attempts were made to collect this drainage from the proximal fistula and to re-instill it into the distal fistula, but collection and administration systems were grossly inadequate. With the large volume of drainage, the skin of the anterior
RoBERT
1144
I.
OLIVER, JAMES
D.
HARDY
abdominal wall became raw and tender. The most satisfactory means of control in this case was effected with aluminum paste and sump drains. Unfortunately, the patient's condition deteriorated steadily and the decision to re-operate was made as the only means of saving his life.
Second Operation Once again, the plan was simply to identify proximal and distal bowel and then to bypass the fistula. Laparotomy was performed on October 8, 1967, through a right subcostal incision. The peritoneal cavity still showed evidence of active peritonitis and the edematous and friable small bowel was held fast by adhesions. After unavoidable mobilization of the entire small bowel, approximately 60 em. of distal jejunum and proximal ileum were resected. Following completion of the anastomosis a Miller-Abbott tube was passed to the ileocecal valve. The immediate postoperative period was complicated by hypotension. This was treated with lactated Ringer's solution and whole blood. In fact, over a period of 12 hours, the patient received a total of twenty units of whole blood and 3000 ml. of other fluids. Since this bloody drainage persisted, and because of its arterial appearance, the patient was re-explored on November 9, 1967. The source of bleeding, which was found to be a very small mesenteric artery, was ligated. The small bowel had become even more edematous. The abdomen was closed with wire and drained. The immediate postoperative period was complicated by prompt recurrence of the fistulous drainage, and jaundice which was probably due to massive blood transfusion. It would be difficult to describe the amount of care this patient subsequently received from the medical center staff. During the ensuing 6 weeks, he required frequent blood and plasma supplements in addition to intravenous fluids. The continuous need for an intravenous pathway, to infuse from 4 to 7 liters of fluid each 24 hours, soon
120
WEIGHT
CHART
100
cri
a
.5 ......
3:
60
40
x =Operation
20 Aug.l967 Figure 3.
1968
1969
Body weight declined to 76lbs. (34.5 kg.) at one point.
TACTICAL DECISIONS IN HIGH-OUTPUT SMALL BoWEL FISTULA
1145
exhausted the usual veins of choice, and in the course of time five different cutdowns were done. The ever-present fistulous drainage was handled as before, but there was one favorable new circumstance: now at least a portion of his oral intake traversed the entire alimentary tract, for he began to have bowel movements. His weight declined to a low of 76 lbs. (Fig. 3), and his abdomen, although partially protected by the aluminum paste, remained raw and a constant source of discomfort. During the second week in December, 1967, he finally began to take sufficient calories by mouth to sustain himself, and his weight gradually increased to 90 lbs. by January, 1968. It was felt that he should not be subjected to another operation at this time, so he was discharged to be followed in the out-patient clinic. At home his weight stabilized at 100 lbs., and although the fistulous drainage persisted he was able to maintain and care for himself on an out-patient basis. However, most of the time he lay on a couch so that the drainage would run into a pan beneath. As may be seen in the photograph, the ileostomy bag would not fit the multiple skin surface drainage sites.
Third Operation On September 3, 1968 he was re-admitted for evaluation. Roentgen studies were all normal except for the small bowel fistula, believed to be located 3 to 4 feet from the ligament of Treitz. It was believed that sufficient time had passed for the peritonitis to subside and for the fistulous tract to have matured. Re-operation was decided upon and a Miller-Abbott tube was again passed. On September 18, 1968 he was explored through a midline incision. On entering the abdomen a moderate number of loose adhesions were encountered, but there was no active peritonitis, and the stomach and proximal small bowel were easily identified. The Miller-Abbott tube was then traced to the fistula. The jejunum was transected just proximal to this point, 3 1/2 feet from the ligament of Treitz. The ascending colon could not be mobilized because of dense adhesions, so it was necessary to use the right transverse colon for the jejuno-transverse colostomy (Fig. 4).
Figure 4. J ejunocolic anastomosis to bypass the fistula.
1146
ROBERT
I. OLIVER, JAMES D. HARDY
Figure 5. Patient following injury.
rehabilitated
15
months
The patient's immediate postoperative course was gratifying. His lower abdomen rapidly healed and he began passing flatus per rectum on the third postoperative day. His oral intake was begun on the fifth postoperative day and was well tolerated. The only real problem now was the rapid transit of food from mouth to anus. He had from 6 to 10 bowel movements per day and complained of rectal pain and perianal excoriation. Nevertheless, for the most part his symptoms were controlled with supportive therapy, and he was discharged from the hospital on October 3, 1968. His out-patient course remained stable, and his anterior abdominal wall healed nicely (Fig. 5). His weight returned to 120 lbs., approximately the normal value, and bowel movements decreased to 2 stools a day. He was allowed to return to work. It was felt that, if necessary, the excluded portion of the ileum could be restored to the functional alimentary tract by another operation in the future.
DISCUSSION The severe high-output small bowel fistula represents a surgical and metabolic problem of the highest magnitude. Intensive local and supportive measures must be combined with judicious, well planned surgical intervention in order to effect a significant alteration in the inordinately high morbidity and mortality associated with these cases.
TACTICAL DECISIONS IN HIGH-OUTPUT SMALL BOWEL FISTULA
1147
The majority of high-output small bowel fistulas are secondary to operation or other trauma, but there are often contributing factors such as infection, neoplasia, or other defects of the gastrointestinal tract. A high-output external or cutaneous small bowel fistula is defined as one from which a volume of fluid in excess of 500 ml. is lost each 24 hours. As a practical matter, however, a fluid loss of 1000 ml. or less is readily tolerated by most adults. The factors which determine the severity of fistulas are (1) level and volume, (2) associated injuries, (3) the amount of sepsis, and (4) the location of the external fistula. In general, the higher the fistula the greater the fluid loss, because less intestinal absorptive surface is available. A small bowel fistula without associated injuries or disease is usually easily handled. On the other hand, when the lesion is complicated by injury to surrounding organ systems, management can be very difficult. Associated peritonitis is also a serious circumstance. Indeed, infection may range from mild inflammation of the surrounding skin with associated pyogenic granulomas to widespread peritonitis, pelvic abscesses, subphrenic abscesses, and abscesses at other sites in the abdomen or elsewhere in the body. The location and the nature of the external fistula are also important factors in determining morbidity and mortality. In view of the fact that most fistulas are related to operation, it follows that most extemal fistulas occur in areas of operative incisions or operative drainage sites. The smaller the external opening, the easier it is to control and collect the drainage. The topographical location and number of fistulous openings are also important. The diagnosis of small bowel fistula is seldom a problem, because of the distinctive characteristics of the drainage. Initially the drainage may be confused with serum, blood, or even an abscess before it assumes the typical color of small bowel contents. If there is any doubt, indigo carmine, methylene blue, or charcoal may be given by mouth and the drainage tract inspected for appearance of the dye. A barium meal followed by frequent x-rays and fluoroscopy is often helpful in determining the level of the fistula. Injection of radiopaque medium into the extemal fistula may also yield useful information. If the fistula is from the first portion of the jejunum it will contain a greenish bile, while drainage from a more distal portion of the small bowel will yield yellowish or brownish material.
Nonoperative Management Treatment of small bowel fistula is nonoperative and operative. Nonoperative treatment includes (1) nutritional therapy, (2) fluid and electrolyte replacement, (3) control of sepsis, and (4) management of the fistulous drainage and the surrounding skin. NUTRITIONAL THERAPY. From the very beginning the best possible nutritional intake should be achieved by all available means. With a low small bowel fistula or a small side fistula, adequate nutrition may be obtained by the oral route. High-output fistulas, especially if located in the proximal small bowel, are more difficult to treat.
1148
ROBERT
I. OLIVER, JAMES D. HARDY
Intravenous caloric supplementation can be useful. Some of the different compounds available for intravenous administration are (1) dextrose (1 liter of 5 per cent dextrose, 50 gm. carbohydrate, 200 calories), (2) alcohol (approximately 7 calories per gm.), and (3) protein hydrolysate (protein, 4 calories per gm.). In the past, administration of large amounts of protein hydrolysates and carbohydrates have led to considerable spillage into the urine with a resultant tendency to dehydration. Recently Dudrick, Wilmore, Vars, and Rhoads have worked out a program of hyperalimentation which is quite promising. In some cases the fistulous drainage can be collected and introduced into the small bowel distal to the fistula, by one means or another. This limits not only the caloric loss but also fluid and electrolyte depletion. In theory this might appear simple, but in actual application it is difficult to effect. The presence of peritonitis, distal obstruction, associated pathologic conditions, and multiple fistulas all complicate the picture. FLUID AND ELECTROLYTE THERAPY. Correct administration of intravenous electrolytes and blood is the most urgent single immediate problem associated with high-output small bowel fistula. Careful records of fluid intake and output from all sources must be recorded in order to effect balanced corrective therapy. It is essential to follow daily body weights, as well as blood pressure, pulse rate, urine volume, and skin turgor, as helpful clinical guides to fluid volume replacement. Electrolyte requirements are determined by probable losses in addition to frequent measurements of serum sodium, chloride, bicarbonate, and potassium levels. If the illness is prolonged, calcium and magnesium deficits may develop. A significant decline in the sodium and chloride levels can lead to water intoxication, which may be treated with an administration of 3 per cent sodium chloride solution. Low potassium levels are treated with potassium chloride (1 gm. KCl= 13.6 mEq. K). The onset of tetany may represent hypomagnesemia or hypocalcemia. Decrease in magnesium may be treated with magnesium sulfate (1 gm. · MgSO. = 8.10 mEq. Mg), while decreased calcium may be treated with calcium gluconate (10 mi. calcium gluconate = 1 gm. Ca). MANAGEMENT OF FISTULOUS DRAINAGE Of the many problems associated with small bowel fistulas, collection of the drainage and care of the surrounding skin are among the most frustrating. If a single small external opening exists, an ileostomy bag, a nipple, or a sump arrangement is usually effective in collecting the drainage and holds skin excoriation to a minimum. When there is a large fistula or multiple fistulas, all collection systems may prove grossly inadequate, and the surrounding skin is then exposed to an outpouring of the highly caustic small bowel contents. The surrounding skin may also be protected by keeping it as dry as possible with the aid of a heat lamp. Application of karaya powder is sometimes helpful, as is dehydrated Amphogel. Aluminum paste is messy and is not looked on favorably by the nursing service or the hospital laundry, but in some cases, such as the one presented here, it is very beneficial.
TACTICAL DECISIONS IN HIGH-OUTPUT SMALL BoWEL FISTULA
1149
Operative Management Operative management may be divided into two categories: (1) emergency control, and (2) definitive or staged control. Following the discovery of a high-output small bowel fistula there is usually a period of observation during which the physician studies the various parameters of the problem and assesses the total situation and prognosis. Some fistulas will close spontaneously, but others persist, and the conditions which dictate surgical intervention are the following: (1) distal intestinal obstruction which, because it prohibits free flow along the intestinal tract, will not permit the fistula to heal, (2) massive fluid loss despite control of infection and adequate nutritional intake, (3) the presence of an intraperitoneal abscess which must be drained, (4) declining general condition of the patient from all causes combined. Once the patient's condition has stabilized and the fistula has matured, one can begin to plan a surgical attack aimed at control. The most important factors here are control of the peritonitis and the achievement of a positive nitrogen balance. The operative maneuvers available are essentially three: (1) The fistulous opening itself may be exposed and closed with sutures. This is appealing but not usually effective, and is not recommended. (2) The fistulous portion of the bowel may be exposed and excised, with bowel continuity re-established by an end-toend anastomosis. (3) In complicated cases, such as the one presented here, it is often necessary to perform an anastomosis around the fistulous opening. After creation of such a bypass, remarkably little drainage may appear through the fistula. Moreover, it is often surprising how rapidly the patient's general nutritional status improves once the massive external fluid loss is controlled. A second operation may be needed at a later time for total correction. Each case must be individualized.
REFERENCES 1. Bowlin, J. W., Hardy, J. D., and Conn, J. H.: External alimentary fistulas. Analysis of
seventy-nine cases with notes on management. Amer. J. Surgery, 103:6, 1962. 2. Chapman, R., Foran, R., and Dunphy, J. E.: Management of intestinal fistulas. Amer. J. Surg., 108:157, 1964. 3. Dudrick, S. J., Wilmore, D. W., Vars, H. H. M., and Rhoads, J. E.: Long-term intravenous hyperalimentation. Fed. Proc., 27:486, 1968. 4. Edmunds, L. H., Jr., Williams, G. M., and Welch, C.: External fistulas arising from the gastrointestinal tract. Ann. Surg., 152:445, 1960. 5. Firme, C. N., and Paine, J. R.: An improved sump suction drain for the management of gastric and intestinal fistulas. Surg., 47:436, 1960. 6. Miller, H. I., and Barry, C. D.: Postoperative gastrointestinal fistulas. Amer. J. Surg., 115:382, 1968. 7. Rice, C. 0., Orr, B., and Enquist, I.: Parenteral nutrition in the surgical patient as provided from glucose, amino acids and alcohol. Ann. Surg., 131:289, 1950. 8. Welch, C. E., and Edmunds, L. H.: Gastrointestinal fistulas. SURGICAL CLIN. N. AMER., 42:1311, 1962. University Hospital 2500 N. State Street Jackson, Mississippi 39216
Most operations are routine and the patient promptly goes home to recuperate. Yet, there are a few patients whose structural and functional defects require the mobilization of all the resources, ingenuity, and dedication available to achieve a successful outcome. This article tells about such a case. The patient had a severe high-output small bowel fistula.
CASE REPORT The Initial Injury J. W., a 23 year old white male, received a 30-30 caliber gunshot wound of the lower abdomen on August 22, 1967. The wound was inflicted during a service station brawl which was the result of an old family feud. The patient was first taken to his local hospital where physical examination revealed a wound of entrance in the right lower quadrant and a wound of exit in the left lower quadrant. The blood pressure was 80/0 and the pulse rate 120. Lactated Ringer's solution, whole blood, and antibiotics were administered, and at operation he was found to have multiple perforations of the small bowel without injury to the colon or urinary tract. A large part of the lower portion of the rectus abdominus muscle had been blown away. Two segments of traumatized small bowel were resected, and multiple less severe perforations were sutured. The abdomen was drained and closed. The postoperative period was uneventful until the third postoperative day when excessive drainage emerged from the right lower quadrant. Oral liquid intake increased the drainage, and on September 7 the patient was transferred to the University Medical Center for evaluation and treatment of a small bowel fistula. '''Assistant Instructor, Department of Surgery, University Hospital, University of Mississippi Medical Center, Jackson, Mississippi '''''Professor and Chairman, Department of Surgery; Surgeon-in-Chief to the University Hospital, University of Mississippi Medical Center, Jackson, Mississippi Surgical Clinics of North America- Vol. 50, No. 5, October, 1970
1141
1142
RoBERT
I.
OLIVER, JAMES
D.
HARDY
Evaluation at University Medical Center He was quite ill, and severe excoriation of the skin of the abdominal wall had developed. Weight loss was apparent, and dehydration had resulted from the high output small bowel fistula or fistulas. Sepsis was not particularly in evidence. Effective intravenous fluid replacement was initiated on the basis of the apparent degree of dehydration and the profile of the plasma electrolyte concentrations. Multiple transfusions of blood and plasma were administered and broad spectrum antibiotic coverage was continued. The skin was moderately well protected by aluminum paste and catheter suction at the drainage sites on the anterior abdominal wall, since it was not feasible to apply a bag (Fig. 1). He required almost continuous nurse and physician attention.
First Operation After careful study and appraisal of the patient's total condition, we decided on operative intervention, which was performed on September 18, 1967. Because of extensive skin contamination, excoriation, and infection from the high-output fistula below, the abdomen was entered through a left subcostal incision. The plan was to do as little as possible, a simple bypass of the fistulous bowel being considered acceptable. On entering the peritoneal cavity, however, we encountered widespread active peritoneal inflammation with marked fibrinous adhesions and many loculated collections of pus. The entire small bowel was markedly thickened and edematous. It was found to be remarkably foreshortened, after it had been sufficiently freed up to permit reasonably certain identification of the anatomic and functional changes-an
Figure 1. Multiple fistulous openings on the anterior wall rendered skin protection difficult.
TACTICAL DECISIONS IN HIGH-OUTPUT SMALL BOWEL FISTULA
1143
Figure 2. The presence of the MillerAbbott tube facilitated differentiation of bowel proximal to the fistula from that distal.
identification which was considerably facilitated by the presence of a long Miller-Abbott tube (Fig. 2). All things considered, it appeared reasonable to resect the 30 em. of upper ileum involved in the fistulous area, since any anastomosis would be made through somewhat friable and diseased bowel, even if a bypass were employed. Furthermore, if the anastomosis held, the fistula would be cured, in contrast to the situation which would exist were the fistula to be bypassed. Certainly, there was no choice but to attempt to restore a portion of the small bowel for alimentation to reverse the patient's steadily downhill course. Thus, mid small bowel continuity was re-established with an end-to-end anastomosis. The Miller-Abbott tube was then advanced to the ileocecal valve, and the abdomen drained and closed. The immediate postoperative period was uneventful. However, on the fourth postoperative day drainage consistent with a small bowel fistula again developed. It was hoped that this represented a side fistula and that, with intestinal continuity re-established, the bowel would heal. Unfortunately, the amount of drainage increased and the problems of water, electrolyte, and nutritional losses, as well as skin excoriation, became magnified. The patient was given oral nutrients, and with blood and plasma supplements he remained relatively stable. Drainage from the fistula ranged from 1500 to 4000 ml. per day. Attempts were made to collect this drainage from the proximal fistula and to re-instill it into the distal fistula, but collection and administration systems were grossly inadequate. With the large volume of drainage, the skin of the anterior
RoBERT
1144
I.
OLIVER, JAMES
D.
HARDY
abdominal wall became raw and tender. The most satisfactory means of control in this case was effected with aluminum paste and sump drains. Unfortunately, the patient's condition deteriorated steadily and the decision to re-operate was made as the only means of saving his life.
Second Operation Once again, the plan was simply to identify proximal and distal bowel and then to bypass the fistula. Laparotomy was performed on October 8, 1967, through a right subcostal incision. The peritoneal cavity still showed evidence of active peritonitis and the edematous and friable small bowel was held fast by adhesions. After unavoidable mobilization of the entire small bowel, approximately 60 em. of distal jejunum and proximal ileum were resected. Following completion of the anastomosis a Miller-Abbott tube was passed to the ileocecal valve. The immediate postoperative period was complicated by hypotension. This was treated with lactated Ringer's solution and whole blood. In fact, over a period of 12 hours, the patient received a total of twenty units of whole blood and 3000 ml. of other fluids. Since this bloody drainage persisted, and because of its arterial appearance, the patient was re-explored on November 9, 1967. The source of bleeding, which was found to be a very small mesenteric artery, was ligated. The small bowel had become even more edematous. The abdomen was closed with wire and drained. The immediate postoperative period was complicated by prompt recurrence of the fistulous drainage, and jaundice which was probably due to massive blood transfusion. It would be difficult to describe the amount of care this patient subsequently received from the medical center staff. During the ensuing 6 weeks, he required frequent blood and plasma supplements in addition to intravenous fluids. The continuous need for an intravenous pathway, to infuse from 4 to 7 liters of fluid each 24 hours, soon
120
WEIGHT
CHART
100
cri
a
.5 ......
3:
60
40
x =Operation
20 Aug.l967 Figure 3.
1968
1969
Body weight declined to 76lbs. (34.5 kg.) at one point.
TACTICAL DECISIONS IN HIGH-OUTPUT SMALL BoWEL FISTULA
1145
exhausted the usual veins of choice, and in the course of time five different cutdowns were done. The ever-present fistulous drainage was handled as before, but there was one favorable new circumstance: now at least a portion of his oral intake traversed the entire alimentary tract, for he began to have bowel movements. His weight declined to a low of 76 lbs. (Fig. 3), and his abdomen, although partially protected by the aluminum paste, remained raw and a constant source of discomfort. During the second week in December, 1967, he finally began to take sufficient calories by mouth to sustain himself, and his weight gradually increased to 90 lbs. by January, 1968. It was felt that he should not be subjected to another operation at this time, so he was discharged to be followed in the out-patient clinic. At home his weight stabilized at 100 lbs., and although the fistulous drainage persisted he was able to maintain and care for himself on an out-patient basis. However, most of the time he lay on a couch so that the drainage would run into a pan beneath. As may be seen in the photograph, the ileostomy bag would not fit the multiple skin surface drainage sites.
Third Operation On September 3, 1968 he was re-admitted for evaluation. Roentgen studies were all normal except for the small bowel fistula, believed to be located 3 to 4 feet from the ligament of Treitz. It was believed that sufficient time had passed for the peritonitis to subside and for the fistulous tract to have matured. Re-operation was decided upon and a Miller-Abbott tube was again passed. On September 18, 1968 he was explored through a midline incision. On entering the abdomen a moderate number of loose adhesions were encountered, but there was no active peritonitis, and the stomach and proximal small bowel were easily identified. The Miller-Abbott tube was then traced to the fistula. The jejunum was transected just proximal to this point, 3 1/2 feet from the ligament of Treitz. The ascending colon could not be mobilized because of dense adhesions, so it was necessary to use the right transverse colon for the jejuno-transverse colostomy (Fig. 4).
Figure 4. J ejunocolic anastomosis to bypass the fistula.
1146
ROBERT
I. OLIVER, JAMES D. HARDY
Figure 5. Patient following injury.
rehabilitated
15
months
The patient's immediate postoperative course was gratifying. His lower abdomen rapidly healed and he began passing flatus per rectum on the third postoperative day. His oral intake was begun on the fifth postoperative day and was well tolerated. The only real problem now was the rapid transit of food from mouth to anus. He had from 6 to 10 bowel movements per day and complained of rectal pain and perianal excoriation. Nevertheless, for the most part his symptoms were controlled with supportive therapy, and he was discharged from the hospital on October 3, 1968. His out-patient course remained stable, and his anterior abdominal wall healed nicely (Fig. 5). His weight returned to 120 lbs., approximately the normal value, and bowel movements decreased to 2 stools a day. He was allowed to return to work. It was felt that, if necessary, the excluded portion of the ileum could be restored to the functional alimentary tract by another operation in the future.
DISCUSSION The severe high-output small bowel fistula represents a surgical and metabolic problem of the highest magnitude. Intensive local and supportive measures must be combined with judicious, well planned surgical intervention in order to effect a significant alteration in the inordinately high morbidity and mortality associated with these cases.
TACTICAL DECISIONS IN HIGH-OUTPUT SMALL BOWEL FISTULA
1147
The majority of high-output small bowel fistulas are secondary to operation or other trauma, but there are often contributing factors such as infection, neoplasia, or other defects of the gastrointestinal tract. A high-output external or cutaneous small bowel fistula is defined as one from which a volume of fluid in excess of 500 ml. is lost each 24 hours. As a practical matter, however, a fluid loss of 1000 ml. or less is readily tolerated by most adults. The factors which determine the severity of fistulas are (1) level and volume, (2) associated injuries, (3) the amount of sepsis, and (4) the location of the external fistula. In general, the higher the fistula the greater the fluid loss, because less intestinal absorptive surface is available. A small bowel fistula without associated injuries or disease is usually easily handled. On the other hand, when the lesion is complicated by injury to surrounding organ systems, management can be very difficult. Associated peritonitis is also a serious circumstance. Indeed, infection may range from mild inflammation of the surrounding skin with associated pyogenic granulomas to widespread peritonitis, pelvic abscesses, subphrenic abscesses, and abscesses at other sites in the abdomen or elsewhere in the body. The location and the nature of the external fistula are also important factors in determining morbidity and mortality. In view of the fact that most fistulas are related to operation, it follows that most extemal fistulas occur in areas of operative incisions or operative drainage sites. The smaller the external opening, the easier it is to control and collect the drainage. The topographical location and number of fistulous openings are also important. The diagnosis of small bowel fistula is seldom a problem, because of the distinctive characteristics of the drainage. Initially the drainage may be confused with serum, blood, or even an abscess before it assumes the typical color of small bowel contents. If there is any doubt, indigo carmine, methylene blue, or charcoal may be given by mouth and the drainage tract inspected for appearance of the dye. A barium meal followed by frequent x-rays and fluoroscopy is often helpful in determining the level of the fistula. Injection of radiopaque medium into the extemal fistula may also yield useful information. If the fistula is from the first portion of the jejunum it will contain a greenish bile, while drainage from a more distal portion of the small bowel will yield yellowish or brownish material.
Nonoperative Management Treatment of small bowel fistula is nonoperative and operative. Nonoperative treatment includes (1) nutritional therapy, (2) fluid and electrolyte replacement, (3) control of sepsis, and (4) management of the fistulous drainage and the surrounding skin. NUTRITIONAL THERAPY. From the very beginning the best possible nutritional intake should be achieved by all available means. With a low small bowel fistula or a small side fistula, adequate nutrition may be obtained by the oral route. High-output fistulas, especially if located in the proximal small bowel, are more difficult to treat.
1148
ROBERT
I. OLIVER, JAMES D. HARDY
Intravenous caloric supplementation can be useful. Some of the different compounds available for intravenous administration are (1) dextrose (1 liter of 5 per cent dextrose, 50 gm. carbohydrate, 200 calories), (2) alcohol (approximately 7 calories per gm.), and (3) protein hydrolysate (protein, 4 calories per gm.). In the past, administration of large amounts of protein hydrolysates and carbohydrates have led to considerable spillage into the urine with a resultant tendency to dehydration. Recently Dudrick, Wilmore, Vars, and Rhoads have worked out a program of hyperalimentation which is quite promising. In some cases the fistulous drainage can be collected and introduced into the small bowel distal to the fistula, by one means or another. This limits not only the caloric loss but also fluid and electrolyte depletion. In theory this might appear simple, but in actual application it is difficult to effect. The presence of peritonitis, distal obstruction, associated pathologic conditions, and multiple fistulas all complicate the picture. FLUID AND ELECTROLYTE THERAPY. Correct administration of intravenous electrolytes and blood is the most urgent single immediate problem associated with high-output small bowel fistula. Careful records of fluid intake and output from all sources must be recorded in order to effect balanced corrective therapy. It is essential to follow daily body weights, as well as blood pressure, pulse rate, urine volume, and skin turgor, as helpful clinical guides to fluid volume replacement. Electrolyte requirements are determined by probable losses in addition to frequent measurements of serum sodium, chloride, bicarbonate, and potassium levels. If the illness is prolonged, calcium and magnesium deficits may develop. A significant decline in the sodium and chloride levels can lead to water intoxication, which may be treated with an administration of 3 per cent sodium chloride solution. Low potassium levels are treated with potassium chloride (1 gm. KCl= 13.6 mEq. K). The onset of tetany may represent hypomagnesemia or hypocalcemia. Decrease in magnesium may be treated with magnesium sulfate (1 gm. · MgSO. = 8.10 mEq. Mg), while decreased calcium may be treated with calcium gluconate (10 mi. calcium gluconate = 1 gm. Ca). MANAGEMENT OF FISTULOUS DRAINAGE Of the many problems associated with small bowel fistulas, collection of the drainage and care of the surrounding skin are among the most frustrating. If a single small external opening exists, an ileostomy bag, a nipple, or a sump arrangement is usually effective in collecting the drainage and holds skin excoriation to a minimum. When there is a large fistula or multiple fistulas, all collection systems may prove grossly inadequate, and the surrounding skin is then exposed to an outpouring of the highly caustic small bowel contents. The surrounding skin may also be protected by keeping it as dry as possible with the aid of a heat lamp. Application of karaya powder is sometimes helpful, as is dehydrated Amphogel. Aluminum paste is messy and is not looked on favorably by the nursing service or the hospital laundry, but in some cases, such as the one presented here, it is very beneficial.
TACTICAL DECISIONS IN HIGH-OUTPUT SMALL BoWEL FISTULA
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Operative Management Operative management may be divided into two categories: (1) emergency control, and (2) definitive or staged control. Following the discovery of a high-output small bowel fistula there is usually a period of observation during which the physician studies the various parameters of the problem and assesses the total situation and prognosis. Some fistulas will close spontaneously, but others persist, and the conditions which dictate surgical intervention are the following: (1) distal intestinal obstruction which, because it prohibits free flow along the intestinal tract, will not permit the fistula to heal, (2) massive fluid loss despite control of infection and adequate nutritional intake, (3) the presence of an intraperitoneal abscess which must be drained, (4) declining general condition of the patient from all causes combined. Once the patient's condition has stabilized and the fistula has matured, one can begin to plan a surgical attack aimed at control. The most important factors here are control of the peritonitis and the achievement of a positive nitrogen balance. The operative maneuvers available are essentially three: (1) The fistulous opening itself may be exposed and closed with sutures. This is appealing but not usually effective, and is not recommended. (2) The fistulous portion of the bowel may be exposed and excised, with bowel continuity re-established by an end-toend anastomosis. (3) In complicated cases, such as the one presented here, it is often necessary to perform an anastomosis around the fistulous opening. After creation of such a bypass, remarkably little drainage may appear through the fistula. Moreover, it is often surprising how rapidly the patient's general nutritional status improves once the massive external fluid loss is controlled. A second operation may be needed at a later time for total correction. Each case must be individualized.
REFERENCES 1. Bowlin, J. W., Hardy, J. D., and Conn, J. H.: External alimentary fistulas. Analysis of
seventy-nine cases with notes on management. Amer. J. Surgery, 103:6, 1962. 2. Chapman, R., Foran, R., and Dunphy, J. E.: Management of intestinal fistulas. Amer. J. Surg., 108:157, 1964. 3. Dudrick, S. J., Wilmore, D. W., Vars, H. H. M., and Rhoads, J. E.: Long-term intravenous hyperalimentation. Fed. Proc., 27:486, 1968. 4. Edmunds, L. H., Jr., Williams, G. M., and Welch, C.: External fistulas arising from the gastrointestinal tract. Ann. Surg., 152:445, 1960. 5. Firme, C. N., and Paine, J. R.: An improved sump suction drain for the management of gastric and intestinal fistulas. Surg., 47:436, 1960. 6. Miller, H. I., and Barry, C. D.: Postoperative gastrointestinal fistulas. Amer. J. Surg., 115:382, 1968. 7. Rice, C. 0., Orr, B., and Enquist, I.: Parenteral nutrition in the surgical patient as provided from glucose, amino acids and alcohol. Ann. Surg., 131:289, 1950. 8. Welch, C. E., and Edmunds, L. H.: Gastrointestinal fistulas. SURGICAL CLIN. N. AMER., 42:1311, 1962. University Hospital 2500 N. State Street Jackson, Mississippi 39216