How I do it: gastrointestinal cutaneous fistulas.

Area of Science:

• Surgical Gastroenterology
• Abdominal Wall Reconstruction
• Fistula Management

Background:

• Gastrointestinal cutaneous fistulas present significant surgical challenges with high mortality rates.
• Early recognition and diagnosis, often via fistulagram, are crucial, especially in the absence of sepsis.
• Nonoperative closure is unlikely after 5-6 weeks, necessitating surgical intervention.

Purpose of the Study:

• To outline principles for the recognition and management of gastrointestinal cutaneous fistulas.
• To describe a technical surgical approach to minimize complications and improve outcomes.
• To present a series demonstrating the efficacy of the described operative principles.

Main Methods:

• Careful abdominal entry to avoid further enterotomies, often requiring 1.5-2 hours.
• Lateral to medial dissection to address adhesions from previous incisions.
• Resection of limited bowel segments (12-18 inches) with end-to-end anastomosis.
• Native abdominal wall closure techniques (component separation or Abrahamson-type) or layered Vicryl closure.
• Adjunctive gastrostomy and catheter jejunostomy.

Main Results:

• The described operative approach successfully managed complex fistulas.
• Zero mortality was achieved in the last 50 cases within the personal series.
• The technique focuses on minimizing bowel resection and achieving secure abdominal wall closure.

Conclusions:

• A systematic approach to surgical repair of gastrointestinal fistulas can lead to successful outcomes.
• Meticulous surgical technique, including careful dissection and abdominal wall reconstruction, is key to minimizing morbidity and mortality.
• The described principles provide a framework for managing these complex surgical conditions effectively.