Surgical treatment of external pancreatic fistulas

Fistulas at the site of a surgical suture are a rare but unpleasant complication associated with non-compliance with the rules of asepsis and antisepsis and the use of non-absorbable threads. If a patient develops a ligature fistula after surgery, it should be treated by a highly qualified surgeon in a specialized center to prevent relapse. It should be noted that strict adherence to the sanitary and epidemiological regime and the use of modern suture material during operations at the Igor Medvedev Center reduces complications such as ligature fistulas to zero. Our specialists also successfully treat complications of operations performed in other medical institutions.

Ligature fistulas

A ligature is a thread used to tie a vessel, restoring the integrity of organs and skin. A fistula is a reaction of the tissues around the thread, leading to their melting, failure of the suture, divergence of the edges of the wound, bleeding, etc.

Symptoms of ligature fistula

The development of a postoperative fistula occurs according to the following scenario:

• Within a few days after the operation, the wound area thickens, swells slightly, and becomes painful. The skin around it turns red and becomes hotter to the touch than other areas.
• After 6-7 days, when pressure is applied, serous fluid and pus emerge from under the suture.
• The general body temperature rises to subfebrile values ​​(37.5-38°).
• The fistula can close spontaneously and later open again.
• Recovery is possible only after repeated surgery.

Complications arising from the appearance of a postoperative fistula

• An abscess is a cavity filled with pus;
• Cellulitis – inclusion of subcutaneous fat in the inflammatory process;
• Eventration – loss of internal organs due to purulent melting of tissues;
• Sepsis - the spread of purulent contents in the cavity of the chest, skull, and abdominal cavity;
• Toxic-resorptive fever is pronounced hyperthermia as a reaction of the body.

Publications in the media

Subdiaphragmatic abscess is an abscess localized in the peritoneal cavity under the diaphragm (usually on the right) and arising as a complication of acute inflammatory diseases, injuries or surgical interventions on the abdominal organs.

Risk factors • Surgery • Chronic diseases - liver cirrhosis, chronic renal failure (CRF), nutritional disorders • Use of GCs • Chemotherapy • Radiation therapy.

Clinical picture • Pain in the hypochondrium, increasing with deep inspiration, radiating to the scapula or shoulder girdle • Pain in the chest, usually on the right. When the abscess is located close to the anterior abdominal wall, the pain syndrome is more pronounced • Nausea, hiccups • Forced position of the patient on the back, on the side or half-sitting • The temperature curve is hectic in nature • Chills, sweating • With a long course - pasty skin, bulging of intercostal spaces in the area localization of the abscess (usually IX–XI on the right) • Tachycardia • Shortness of breath • On palpation - rigidity of the muscles of the upper abdominal wall and pain along the intercostal spaces • Symptoms of peritoneal irritation, as a rule, are absent.

Research methods • Analysis of peripheral blood - neutrophilic leukocytosis, shift of the leukocyte formula to the left, increase in ESR • Blood culture for sterility • X-ray examination of the organs of the chest and abdominal cavities •• High standing and limited mobility of the dome of the diaphragm •• The presence of a fluid level under the diaphragm, displacement of neighboring organs •• In the lungs - atelectasis, pneumonic foci in the lower segments •• Effusion in the pleural cavity on the affected side • CT, ultrasound, radioisotope scanning using 67Ga.

Differential diagnosis • Other abdominal abscesses • Acute cholecystitis.

TREATMENT. The main method of treatment is surgical (adequate drainage of the abscess by percutaneous puncture and/or surgery); at the same time, antibacterial therapy is prescribed: broad-spectrum antibiotics, depending on the results of bacteriological examination and determination of the sensitivity of microorganisms to antibiotics.

Observation • Constant monitoring for 6 weeks after resolution of the process • Regular blood tests • Periodic X-ray examination of the chest organs until the patient’s condition normalizes.

Complications • Recurrence of abscess • Bleeding • Intestinal obstruction • Pneumonia • Pleural empyema • Multiple organ failure • Sepsis • Opening of abscess into the abdominal or pleural cavity • Fistula.

Prognosis • Mortality from 10 to 90% with inadequate treatment (abscess not drained, source of infection not removed).

ICD-10. K65.0 Acute peritonitis

Diagnostics

The primary diagnosis of a ligature fistula is carried out in the dressing room during a visual examination of the wound by a surgeon. To clarify the location of the fistula, the presence or absence of complications (abscess, purulent leaks), an ultrasound scan of the surgical wound is performed.

If the fistula is located deep in the tissue and its diagnosis is difficult, fistulography is used. During the examination, a contrast agent is injected into the fistula tract and radiography is performed. As a result of such manipulation, the fistula tract will be clearly visible on the x-ray.

Treatment of ligature fistula

The vast majority of cases of ligature fistula can only be resolved through surgery. The longer a postoperative fistula exists, the more difficult it is to cure. Complex therapy using medications is used for treatment.

Groups of drugs used to treat fistula:

• Local antiseptics - water-soluble ointments (Levosin, Levomekol, Trimistan), fine powders (Gentaxan, Tyrozur, Baneocin);
• Antibacterial agents – Ampicillin, Norfloxacin, Ceftriaxone, Levofloxacin;
• Enzymes for the destruction of dead tissue - Trypsin, Chymotrypsin.

Since the drugs retain their effect for several hours, they are injected into the fistula tract and distributed throughout the tissues surrounding the wound several times a day.

Fat-based ointments (Synthomycin ointment, Vishnevsky ointment) prevent the outflow of pus, so they are not used in the presence of extensive purulent discharge.

In addition to surgical and drug treatment, physiotherapy is used:

• quartzization of the wound surface;
• UHF therapy.

As a result of the use of UHF therapy, microcirculation of blood and lymph improves, which leads to a decrease in swelling and stops the spread of infection. Quartz treatment has a detrimental effect on pathogenic bacteria, promoting stable remission of the process, although not guaranteeing complete recovery.

The “gold standard” for treating a ligature fistula is an operation that eliminates the problem completely.

Progress of the operation to eliminate the ligature fistula:

• Three-time treatment of the surgical field with an antiseptic in the form of an alcohol solution of iodine.
• Injection of an anesthetic solution into the tissue around the surgical wound and under it (Lidocaine - 2% solution, Novocaine - 5% solution).
• Injection of dye into the fistula tract in order to completely examine it (“green paint” and hydrogen peroxide).
• Dissection of the fistula, removal of the ligature completely.
• Removal of the cause of the fistula along with revision of the surrounding tissues.
• Stop possible bleeding with an electrocoagulator or hydrogen peroxide 3%, since suturing a blood vessel can provoke the appearance of a new fistula.
• Wash the wound with antiseptics (Dekasan, 70% alcohol, Chlorhexidine).
• Closing the wound with sutures again with the installation of active drainage.

After the operation, the patient needs dressings and drainage rinsing. If the purulent discharge is not fixed, the drainage is removed.

Medicines used in the presence of complications (phlegmonous inflammation of the tissue, purulent leaks):

• Antibacterial agents;
• Non-steroidal anti-inflammatory drugs (NSAIDs) – nimesil, diclofenac, dikloberl;
• Ointments for tissue regeneration - troxevasin and methyluracil ointment;
• Herbal preparations with vitamin E (aloe, sea buckthorn oil).

Local revision of inflamed tissues with wide dissection of the fistula is a classic form of surgical treatment of postoperative fistula. Most minimally invasive techniques are ineffective in treating this complication.

Self-medication of a ligature scar will not bring recovery, because only surgery and subsequent debridement of the wound can save the patient from complications. When attempting self-treatment, precious time will be lost.

How can a fistula on the gum be cured?

Of course, we treat it, we deal with it, we work for it. In order to cure a fistula on the gum, first of all, we should eliminate the reason due to which the fistula occurred. We should not
fight the pimple itself, smear it with various ointments and lotions, but must eliminate the cause of its occurrence.
We must
eliminate the chronic inflammation itself that led to this fistula.

The first treatment option for a fistula is endodontic

For such treatment, we provide the patient with high-quality endodontic treatment under a microscope when:

• the tooth canal itself is visible,
• its branches are visible
• and you can see if there are cracks in the tooth canal.

Our doctors perform minimally invasive treatment procedures under a microscope at a high level. Treatment of processes that led to a fistula, to a fistulous tract on the gum, to complications of various periodontitis. In the video - endodontist of the Scientific Research Center, winner of many international competitions in endodontics and dental restoration Melikov Azer:

In the clinics of the German Implantology Center, special materials are used that seal the apical part very well and for a long period, which are biocompatible with the tissues surrounding the tooth and which give a very good result.

That is, we have a therapeutic method of treatment - this time

. When highly qualified endodontists, using microscopes, special equipment and special materials, carry out canal therapy and eliminate the cause of the fistula.

The second treatment option for fistula is mixed

Second method

- This is a mixed treatment, when treatment is carried out jointly by a therapist and a surgeon. If the lesion is already quite strong, lysis of a certain part of the root apex has occurred, when the process has already been going on for quite a long time, then the therapist cleans the canals:

seals the apical part of the root with a special material, and the surgeon opens, makes surgical access and polishes the apical part of the tooth root.

We do not perform dental resections when the tooth is cut down in half. You often think, I often have patients come to me who have had a resection and you think the person has had ⅔ of the root cut off and this tooth is no longer tenable, it can barely hold on, and why did it have to be done? We do it minimally invasively. We polish the apical part of the root with special ultrasonic tips after the therapist has carried out the treatment, and we get very good long-term results.

The third treatment option is surgery.

There is also a surgical method - this is the third method

treatment when the inflammation is already chronic according to the principle “No tooth - no caries, no periodontitis, no nothing.”
That is, the tooth is removed
, the source of inflammation is removed:

and an implant is placed

:

Subsequent rehabilitation of the patient takes place on the implant.

The fourth treatment option is autotransplantation.

Autotransplantation is a type of third, surgical treatment option. But the patient’s own donor tooth acts as an implant. As a rule, wisdom teeth, which are not involved in the process of chewing food and are actually the body’s reserve for such cases, are excellent for this role. Wisdom teeth transplantation is suitable for posterior teeth and premolars (fourth, fifth, sixth and seventh teeth).

Advantage

This method of treatment is that the patient’s own tooth is transplanted, the patient’s own tissue, which is not foreign to the body, even in conditions of the inflammatory process with a fistula, significantly reduces the risk of tooth-implant rejection.
The specialists of the German Implantology Center have accumulated many years of clinical experience in such operations. You can see how the autotransplantation operation takes place in the following video. There, at the end of the film, the patient shares his impressions of the dental transplant (this is a review 1 year after
the transplant operation):

Prognosis and prevention

In cases where the body rejects surgical sutures made of any material, the prognosis for the operation is unfavorable. The situation is the same with self-medication - in this case it is very difficult to make a forecast.

It is impossible to take preventive measures for the appearance of a fistula, since even with strict adherence to antiseptics, infection can penetrate into the surgical wound and rejection of the suture material.

Author of the article:

Volkov Dmitry Sergeevich |
Ph.D. surgeon, phlebologist Education: Moscow State Medical and Dental University (1996). In 2003, he received a diploma from the educational and scientific medical center for the administration of the President of the Russian Federation. Our authors

Surgery to remove rectal fistula

To better prepare for surgery, your doctor may prescribe antibiotics and topical pain relievers. During the operation to remove a rectal fistula, the following manipulations are performed: excision of the rectal fistula, opening and cleaning of purulent pockets, suturing the sphincter, moving the rectal mucosa to eliminate the internal hole.

1 Surgery to remove rectal fistula

2 Surgery to remove rectal fistula

3 Surgery to remove rectal fistula

The choice of surgical treatment method depends on the type of fistula, its location, the degree of scarring, the presence of ulcers and infiltrates.