Enteric Fistulas: Causes, Treatment, and Recovery Insights

Intestinal fistula!! So painful?

Hello Dr.
Ke: Please help me! Save me! I need to undergo in vitro fertilization, and there is a myoma in my uterus.
A renowned physician at Chang Gung Memorial Hospital said it could be resolved with laparoscopy (I have been seeing this physician for 6 years, and he previously performed three abdominal surgeries on me due to endometriosis).
Therefore, I had surgery on July 12 this year.
The doctor said everything was handled well, and I could eat after the procedure since I had not passed gas that day.
However, on July 13, I developed acute peritonitis and required another surgery.
The surgeon stated that during the laparoscopy, they cauterized a 0.5 x 0.5 cm area of the ileum, resulting in burnt tissue, and subsequently removed 15 cm of the ileum and performed an end-to-end anastomosis (she mentioned that the anastomosis site was 15-20 cm from the ileocecal valve).

When I had my stitches removed on July 21, it was discovered that there was leakage of intestinal fluid, and the attending surgeon noted that she saw the anastomosis line had loosened.
Consequently, I was put on a fasting regimen and received total parenteral nutrition for nearly two months, but I still have not healed.
I then started to resume eating.
On September 11, the doctor advised us to go home and recuperate, and if healing did not occur, further surgery would be necessary.
She even mentioned that they would need to remove 50 cm of my healthy colon on the right side and perform anastomosis again, believing it would heal better??? Why sacrifice healthy colon tissue? Currently, there is still leakage of intestinal fluid, sometimes over 100 cc and sometimes less than 20 cc.
Will it heal on its own? I have normal bowel movements and urination! What dietary precautions should I take? If healing is not possible, when would be the best time for surgery? What difficulties might arise during the surgery? If the ileocecal valve (50 cm of the cecum) is removed, what effects could that have? Please help me!!!! I am truly suffering!!!!!
Hello Dr.
Ke: I have more questions! I apologize!!!! Why has this fistula developed? Is it due to the surgeon's poor anastomosis? Additionally, there is a purulent wound forming a hole at the incision site.
The doctor said it just needs a dressing change (moist dressing with shallow packing)? But after healing, it became purulent again.
Why is this happening?

Pei, 30~39 year old female. Ask Date: 2004/10/27

Dr. Ke Fangxu reply Surgery

Hello, in response to your question...
Generally speaking, if a uterine adenomyoma is asymptomatic (without bleeding or severe abdominal pain), surgical removal is not recommended unless the location of the adenomyoma is unusual.
It is also unrelated to in vitro fertilization (IVF).
Laparoscopic surgery is typically not an issue; however, if you have undergone three previous open abdominal surgeries, laparoscopic surgery is not advisable due to the potential adhesions from prior surgeries, which can complicate the laparoscopic procedure.
This is the source of your current difficulties.
After three abdominal surgeries, the risk of inadvertently injuring other organs during laparoscopic surgery significantly increases, which is the reason for the ileal cauterization.

Ileal injury is generally not a major concern.
If the cauterized area is indeed only 0.5 × 0.5 cm, simple repair is sufficient, and there is no need for resection, nor will there be a risk of anastomotic dehiscence.
If anastomotic dehiscence occurs, there are two management options: one is to perform an open surgery for repair and create an ileostomy, waiting for the anastomosis to heal before closing the ileostomy; the other option is to provide total parenteral nutrition while expecting the dehiscence to heal on its own.
Both approaches have their pros and cons; the former requires surgery but ensures healing, while the latter avoids surgery but carries the risk of developing a enterocutaneous fistula.
An enterocutaneous fistula refers to a connection between the intestinal lumen and the skin, allowing intestinal contents to leak out onto the skin surface.
The more you eat, the more it leaks.
If it does not heal spontaneously, surgical intervention is necessary.
The surgical approach will depend on the characteristics of the fistula.
Typically, a fistulogram is performed before surgery to determine where the skin opening leads.
Usually, it suffices to resect a small segment of the intestine and reconnect it, unless the affected area is extensive, in which case a large resection would not be performed.
In young patients, efforts are generally made to preserve the ileocecal valve during intestinal surgery.
Although resection of the ileocecal valve does not significantly affect function, it can impair the absorption of B vitamins.
Given the current situation, I recommend that you carefully evaluate the condition of the enterocutaneous fistula and consider undergoing closure surgery as soon as possible.

Keelung Hospital, Department of Health, Executive Yuan
Dr.
Feng-Hsu Ke

Reply Date: 2004/10/27

More Info

Understanding enteric fistulas can be quite complex, especially in the context of surgical procedures and complications that arise from them. An enteric fistula is an abnormal connection that forms between the intestine and another organ or the skin, often resulting from surgical complications, inflammatory diseases, or trauma. In your case, it seems that the fistula developed following a laparoscopic surgery aimed at addressing a uterine adenomyoma, which subsequently led to complications including acute peritonitis and resection of a segment of the ileum.

Causes of Enteric Fistulas
1. Surgical Complications: The most common cause of enteric fistulas is surgical intervention. In your situation, the laparoscopic procedure may have inadvertently caused damage to the intestinal tissue, leading to leakage and the formation of a fistula. Factors such as poor blood supply to the area, infection, or tension at the surgical site can contribute to this complication.

2. Inflammatory Conditions: Conditions such as Crohn's disease or diverticulitis can lead to the formation of fistulas due to chronic inflammation and ulceration of the intestinal wall.

3. Radiation Therapy: Previous radiation treatment in the abdominal area can weaken the intestinal walls, making them more susceptible to fistula formation.

4. Trauma: Any significant injury to the abdomen can also result in the development of fistulas.

Treatment Options
1. Conservative Management: Initially, the treatment for an enteric fistula often involves conservative measures. This includes bowel rest (avoiding oral intake), nutritional support via total parenteral nutrition (TPN), and careful wound care to manage any leakage. The goal is to allow the fistula to close spontaneously.

2. Surgical Intervention: If conservative management fails, surgical intervention may be necessary. This could involve reoperation to repair the fistula, which may include resection of additional bowel segments if necessary. The decision to remove healthy bowel tissue, as mentioned in your case, is typically based on the surgeon's assessment of the tissue's viability and the likelihood of successful healing.

3. Wound Care: Managing the external wound where the fistula is leaking is crucial. Your physician's recommendation for moist wound healing techniques is standard practice to promote healing and prevent infection.

Recovery Insights
- Healing Time: The healing of enteric fistulas can vary significantly. Some may close within weeks, while others may take months. Factors influencing healing include the size of the fistula, the underlying cause, nutritional status, and overall health.

- Nutritional Considerations: Maintaining adequate nutrition is essential for healing. If oral intake is not possible, TPN can provide the necessary nutrients. Once you can resume eating, a low-residue diet may be recommended to minimize bowel movement and stress on the healing area.

- Monitoring for Complications: Regular follow-ups with your healthcare provider are crucial to monitor the fistula's status and manage any complications, such as infection or further leakage.

When to Consider Surgery
If the fistula does not show signs of healing after a reasonable period (usually several weeks to months), surgical intervention may be warranted. The timing of surgery can depend on various factors, including the patient's overall health, the presence of any complications, and the surgeon's assessment of the situation.

Potential Complications of Surgery
Surgical intervention carries risks, including infection, bleeding, and the possibility of further complications related to bowel function. Resection of the ileocecal area (the junction of the small intestine and the beginning of the large intestine) can lead to changes in bowel habits, such as diarrhea or malabsorption, depending on how much bowel is removed.

Conclusion
It is understandable to feel overwhelmed by the situation, especially with the complexities of your medical history and the current challenges you are facing. It is essential to maintain open communication with your healthcare team, express your concerns, and seek clarity on your treatment options. They can provide personalized advice based on your specific circumstances and help guide you through the recovery process. Remember, you are not alone in this, and there are resources available to support you through your healing journey.

Similar Q&A

Understanding Anal Fistulas: Symptoms, Treatment, and Recovery

Hello, I discovered frequent discharge on my underwear around October last year. The discharge was greenish-yellow and odorless. There was no pain or unusual symptoms during bowel movements. I delayed seeking treatment until February of this year when I visited Chi Mei Medical Ce...

Dr. Xu Kaixi reply Surgery
Dear Dr. Hsu Kai-Hsi of the Department of Surgery at Tainan Hospital, Ministry of Health and Welfare: We kindly request that you come to the outpatient clinic for an examination to clarify and address the issues you have described. Wishing you good health and safety from the Dep...

Post-Surgery Recovery: Understanding Anal Fistula Healing Process

Hello Dr. Ke, I had a bit of a lapse in memory around the end of June when I developed an "anal abscess" due to frequent wiping from diarrhea. Initially, I was unaware of the condition and visited a small clinic where I was prescribed painkillers and anti-inflammatory m...

Dr. Ke Fangxu reply Surgery
If an anal abscess is left untreated for too long, there is a higher chance that it will develop into a fistula. This type of fistula is generally more complex to manage and has a higher likelihood of recurrence. Currently, you have undergone drainage of the abscess and a fistulo...

Post-Surgery Complications of Anal Abscess in Adolescents: What to Expect

A 15-year-old boy has been experiencing diarrhea for the past six months. Two months ago, he underwent an endoscopy that revealed inflammation in the small intestine, suspected to be Crohn's disease. He was then referred to a teaching hospital, where the initial diagnosis wa...

Dr. Zhang Shuhao reply Surgery
After incision and drainage of an anal abscess, some cases may still develop into an anal fistula. Diarrhea can also exacerbate the symptoms of the fistula. Additionally, Crohn's disease is more likely to lead to fistula formation, and this condition requires long-term medic...

Understanding Rectovaginal Fistula: Causes, Symptoms, and Treatment Options

I underwent a vaginal-rectal fistula repair after giving birth to a son on March 20. The delivery involved a midline episiotomy, and the wound healing has not been satisfactory. I would like to present the following observations and questions for your assessment: 1. I was hospit...

Dr. Wei Fumao reply Obstetrics and Gynecology
I am more inclined to accept the treatment approach of placing the drain for two to three months, as the diameter of the fistula may decrease or it may heal, allowing for further management. Additionally, Escherichia coli is unlikely to cause an ascending pelvic infection.