A patient of Crohn's Disease, underwent resection anastomosis. Now presents on 7th post-op day with anastomotic site leak from a fistula. Everyday leakage volume adds up to 150-200m1. There is no intraabdominal collection and the patient is stable without any complaints. What will be the next line of management?
Ans is 'a' i.e. Do conservative treatment and leave him and hope for the spontaneous resolution Conservative management to promote spontaneous resolution is the treatment of choice for intestinal fistulas. Surgery is done if the fisula fails to resolve and consists of resection of the fistulous tract together with the segment of the intestine from which it originates. Schwaz writes- "The overall objectives are to increase the probability of spontaneous closure. Most surgeons would pursue 2 to 3 months of conservative therapy before considering surgical intervention. This approach is based on evidence that 90% of fistulas that are going to close, close within a 5-week interval, and also that surgical interventions after this time period are associated with better outcomes and lower morbidity. If the fistula fails to resolve during this period, surgery may be required during which the fistula tract, together with the segment of intestine from which it originates, should be resected." Conservative management consists of Fluid and electrolyte resuscitation Nutrition, usually through TPN; TPN allows bowel to rest Control of sepsis with antibiotics and drainage of abscesses Treatment with 1-12 antagonists or proton pump inhibitors or Somatostatin analogues (Octreotide) decreases fistula output. Factors inhibiting spontaneous closure: Malnutrition Foreign body within the fistula tract Radiation enteritis Malignant fistula Inflammatory bowel disease Local inflammation and sepsis High output fistula Sho fistulous tract (<2 cm) Epithelialization of the fistula tract Distal obstruction of the intestine Fistulas can be divided into 3 types according to 'output' - low output (<200 mL/24 hr), - moderate output (200-500 mL/24 hr), and high output (>500 mL/24 hr).
Do conservative treatment and leave him and hope for the spontaneous resolution
Perform Laparotomy and check for leakage site and healthy margins
Perform Laparotomy and completely exteriorize the fistula
Perform Laparotomy and place lateral drains and leave