65 year old gentleman, co-morbidities - chronic liver disease, coronary artery disease, previous angioplasty, NIDDM, CVA 15 yrs ago - fully recovered, was diagnosed with Periampullary carcinoma. CT - no local invasion or metastases. Classical Whipple's performed. Histology - All margins clear. 3 out 15 lymph nodes positive.
Patient clinically well post-op, however had a controlled PJ leak. Was given octreotide injections. He was discharged with a drain (approx. 150 ml per day). Re-admitted 5 days later with wound infection. Drain output around 50 to 100 ml per day now (3 weeks post-op). On FJ feeds. Absorbing well.
We follow medical fistula management: Assuming you have verified the anastomosis is intact but has a leak (not completely separated) (1) Bowel rest (feeding tube placed distal to fistula orifice; octreotide as long as it seems to be decreasing volume of effluent) (2) Nutritional support that meets his metabolic needs in light of effluent lost and wound healing (often underestimated). (3) Manage infections. (4) Contain effluent and protect peri-fistula skin (so pouch the fistula site; remove any drain tube which only acts as a foreign body and delays healing of the tract). (5) Avoid re-operation for at least 3 months following the initial surgical procedure. Allow at least 3 months possibly 6 months for healing to occur; should see slow decline in effluent volume. Do you have an ostomy care nurse to facilitate the pouching for you? These can be tricky to pouch but ideally the pouch would adhere for at least 48 hours especially if the output is only 100 cc per 24 hours. The key ingredient is patience, nourishment and don't reopen the belly while it is in this postop inflammatory state. the attached article may be of interest to you also.
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