A person underwent laparotomy for Crohn's disease with melena. A 15 cm segment of ileum was found to be diseased. Segmental resection with healthy margins and end-to-end anastomosis was done. On 7th postoperative day, the patient developed anastomotic leak. He continued to have 150-200 ml fistula output for the next 7 days. There was no collection of fluid in the abdomen and now patient is stable. The ideal management is:
Ans. a. Continue conservative management and expect the fistula to heal In the patient there was no collection of fluid in the abdomen and patient is stable. The ideal management is continuing conservative management and expects the fistula to heal. "Most of enterocutaneous fistulas heal spontaneously within 4-6 weeks of conservative managementQ. If closure is not accomplished after this time, surgery is indicated Treatment of Enterocutaneous Fistula Successful management 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 adequate nutritionQ. When sepsis has been controlled and nutritional therapy has been instituted, a course of conservative managementQ should be followed. Most of these fistulas heal spontaneously within 4-6 weeks of conservative managementQ. If closure is not accomplished after this time, surgery is indicated This period of conservative management not only allows those fistulas to heal spontaneously but also allows optimization of nutritional status and control of the wound and fistula sites0. Also, a reasonable delay permits the peritoneal reaction and inflammation to subside, thus making a second operation easier and saferQ Preferred operation: Fistula tract excision and segmental resection of the involved segment of intestine and reanastomosisQ. Simple closure of the fistula after removing the fistula tract almost always results in a recurrence of the fistula. If an unexpected abscess is encountered or if the bowel wall is rigid and distended over a long distance, thus making
Continue conservative management and expect the fistula to heal
Laparotomy and revision of the fistula, if margins are healthy
Laparotomy with dismantling of fistula and exteriorization
Laparotomy and assessment. If lateral leak is present, only lavage and drainage