How I do it: gastrointestinal cutaneous fistulas.

INTRODUCTION: Gastrointestinal cutaneous fistulas are among the more complex surgical conditions, with mortalities in the current series between 6% and 20%, and in some non-U.S. series, up to 40%. The series of principles of recognition, preparation of the abdominal wall, enteral and parenteral nutrition, and support, is outlined. Diagnosis in the absence of signs of sepsis is usually obtained by a fistulagram done by collaboration between the senior surgeon and the senior radiologist and followed to make certain that there is no intestinal obstruction. If spontaneous (nonoperative) closure does not occur in 5 to 6 weeks, it is unlikely to occur and an operation will be required. In our experience, obliterative peritonitis does not subside until a minimum of 4 months, and so an elective operative approach should take place when required after 4 months since the previous operation (when the fistula occurred).
METHODS: A technical approach to operation is described. Avoiding enterotomies is critical. The abdomen should be entered in a fresh area, either by an extended incision, or in a virgin area transversely, if the previous incision was vertical and occupied the entire length of the abdomen. It often takes between 1.5 and 2 h to get into the abdomen without making additional enterotomies. The goal is to dissect laterally in one area until one enters a free lateral space which is free of adhesions. One then proceeds from lateral to medial to take down the adhesions from the previous incisions. When one is finished taking down these adhesions, it is usual that only 12 to 18 in. of bowel of the fistula and the surrounding enterotomies requires resection. An end-to-end anastomosis should be performed. Our practice is a two-layer silk-interrupted anastamosis. Adjunctive steps following the operation usually include a gastrostomy and a catheter jejunostomy. In order to be successful, the best results are obtained with a native abdominal wall closure with either component separation or an Abrahamson-type closure. If this cannot be achieved, multiple layers of vicryl are used, which usually enables the fistula to heal; a hernia usually results, but that can be dealt with at some future time. Using these principles, the last 50 cases at our personal series have been done without mortality.