Managing Intestinal Fistula After Sigmoid Colon Tumor Surgery

Intestinal fistula following colorectal surgery accounts for more than 90% of all fistula cases, making it one of the most severe complications in abdominal surgery. Although advancements in parenteral nutrition and intensive care have significantly improved our understanding of the pathophysiological changes associated with fistulas, the mortality rate still remains around 20%. Therefore, early detection and proper management are crucial once a fistula is suspected.

Steps to Take When Suspecting an Intestinal Fistula

1. Confirm the Diagnosis: A clear external fistula typically presents with a persistent wound on the abdominal wall that discharges gas or intestinal fluid, making diagnosis relatively straightforward. However, smaller fistulas or those directed inward toward the intestinal lumen can be more difficult to detect. It's also important to determine the underlying cause of the fistula, its type, number, location, and anatomical course. Additionally, it's essential to assess whether there is distal obstruction or other concurrent diseases, and whether intra-abdominal abscesses are present.

2. Provide Nutritional Support

Nutritional support, particularly total parenteral nutrition (TPN), plays a vital role in managing intestinal fistulas. Before the 1960s, the mortality rate for fistula patients was as high as 40%–50%, with malnutrition contributing to nearly 48% of these deaths. Since the 1970s, TPN has become a cornerstone of treatment, shifting the focus from primarily surgical intervention to conservative management. By maintaining adequate nutrition, the body can better support wound healing and immune function, improving outcomes.

3. Utilize Somatostatin Therapy

Somatostatin or its analogs are key in the treatment of intestinal fistulas. Research indicates that when TPN is used alone, fistula healing rates range from 16% to 80%, with healing times typically between 20 and 35 days. However, when somatostatin is added to the treatment regimen, healing rates jump to 82%, and healing time is significantly reduced to just 1–14 days. This highlights the effectiveness of combining hormonal therapy with nutritional support.

4. Control Infection and Preserve Organ Function

Infection control is a critical component in reducing mortality among fistula patients. Effective strategies include identifying and draining infected areas promptly, as well as using targeted antibiotic therapy based on culture results. Maintaining organ function through supportive care and early intervention can prevent complications such as sepsis and multi-organ failure.

5. Consider Surgical Intervention When Appropriate

While conservative treatment is often the first approach, timely surgical intervention may be necessary depending on the patient's condition. The current surgical principle involves waiting until the patient's nutritional status has improved and the fistula output has decreased. However, for smaller fistulas, early surgical revision with drainage placement may be considered. In cases where conservative treatment fails or when the fistula is large, prompt surgical correction is essential to prevent further complications.