DIAGNOSIS AND MANAGEMENT OF POSTOPERATIVE GASTROINTESTINAL FISTULA - A KINETIC-ANALYSIS

Gastrointestinal fistula is a major concern after extensive gastrointe stinal surgery. Thirty three gastrointestinal fistulas in 32 patients were retrospectively analyzed regarding the diagnosis of fistula and i ts management. Special attention was directed to the time intervals be tween surgery and the diagnostic or therapeutic intervention. Onset of fever occurred an average of 8 days after gastrointestinal surgery wh ile abdominal pain, leukocytosis and biliary-enteric drainage most fre quently developed at postoperative day 9. The definitive diagnosis was made on average at day 14 postoperatively and definitive treatment at day 19. Diagnosis was made by abdominal CT scan in 25% of patients, c ontrast enema in 25%, upper gastrointestinal radiologic series in 12%, and laparotomy in 35% of cases. Although percutaneous drainage was ut ilized in 18/32 (56%) of patients it was a definitive treatment in onl y 5 out of 18 (28%). Surgical drainage was required in 40% of the pati ents. A primary closure by plication of intestinal perforations was pe rformed in 63% of cases. In addition, forty percent of patients requir ed early or delayed construction of an ostomy. From this study the del ay in diagnosis was approximately 5 days and the delay in definitive t reatment approximately 10 days from the earliest clinical signs of fis tula formation. No conclusive recommendations regarding diagnosis emer ged from these data; rather, the simplest tests should be employed fir st. Early diagnosis and definitive surgical treatment resulted in an i mproved outcome as compared to late (after the tenth postoperative day ) interventions. An algorithm for fistula diagnosis and surgical treat ment that utilizes a kinetic approach to management was proposed.