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58
K. Kooragayala and M. Moore
• Meckel’s diverticulum→diverticulectomy or segmental
resection of wide based lesion
• Ladd’s procedure: Primarily performed in newborns
found to have malrotation with midgut volvulus
– Detorsion of volvulus in counter clockwise fashion
(“Turn back the hands of time”)
– Division of brous bands overlying duodenum
– Placement of small bowel in right abdomen, colon on
left abdomen
– Appendectomy
Common Curveballs
• Patient presents with malrotation without signs of obstruction or volvulus
• Incidentally found Meckel’s diverticulum in an adult
• Post-operative short gut syndrome after large segment of
small bowel resection
• The patient will be a post bariatric surgery patient and
you’ll be asked how to manage the associated mesenteric
defects
Summary
Midgut volvulus is a rare nding that is often described
in newborns in the setting of malrotation, but can also be
found in adults. Patients can present with peritonitis or
more indolent symptoms. Management includes detorsion of the involved bowel with resection of ischemic
segments.
Words ofWisdom
Do not wait until the next morning to evaluate the patient
with a swirl on a CT scan. Furthermore, do not hesitate to
convert from a laparoscopic approach to an open one if necessary to ensure safe detorsion. In a bariatric patient, start
from the terminal ileum and work backwards to help understand the bariatric anatomy.
Clean Kills
• Bilious emesis in newborn that does not trigger a STAT
upper GI study
• Patient hemodynamically unstable but taken for laparoscopy
• Non-operative management in patient with acute obstruction
Meckel’s Diverticulum
M.VirginiaButchy, JohnWilliamson,
andDanicaN.Giugliano
20
Meckel’s Diverticulum
• A true diverticulum, containing all three layers of the
abdominal wall.
• Typically found on the antimesenteric side of the bowel,
approximately 100cm (2feet) from the ileocecal valve.
• Heterotopic tissue can be found in the diverticulum, commonly pancreatic or gastric. This tissue can be hormonally active and/or the source of complications.
• Clinical symptoms are typically related to inammation,
hemorrhage or obstruction.
– Meckel’s diverticulitis is inammation of the tissue
caused by enzymes secreted by the active ectopic gastric/pancreatic tissue, impaction or torsion of the diverticulum. When the mucosa becomes inamed, bleeding
can occur and typically presents as painless lower GI
bleeding.
– Obstruction can also be caused when adhesions
develop from the inamed diverticulum to the abdominal wall or if the diverticulum acts as a lead point for
intussusception.
• “The Rule of 2s”—Diverticulum can be found in 2% of
the population, 2feet from the ileocecal valve, 2:1 male to
female predominance, 2 types of ectopic mucosa (gastric
and pancreatic), incidence of complication (2%), Typical
Age of presentation (2years), 2inches in length.
• Diagnosis can be made with umbilical ultrasound or a
99m-Tc-pertechnetate radioisotope scan (Technetium 99m scan or Meckel scan) which detects the presence of
gastric mucosa.
M. V. Butchy · J. Williamson
Department of Surgery, Cooper University Hospital,
Camden, NJ, USA
e-mail: butchy-margaret@cooperhealth.edu
D. N. Giugliano (
Division of Colon and Rectal Surgery, Department of Surgery,
Cooper University Hospital, Camden, NJ, USA
Cooper Medical School of Rowan University, Camden, NJ, USA
e-mail: giuliano-danica@cooperhealth.edu
*)
– 99m-Tc-pertechnetate radioisotope scan detects gas-
tric mucosa
– The accuracy of this study can be improved with the
administration of pentagastrin which increases gastric
mucosa uptake, and H2 blockers that inhibit excretion
into the bowel lumen
– Placing a foley can be helpful because it will drain the
isotope collecting in the bladder and potentially
obscuring the Meckel diverticulum
• Symptomatic Meckel Diverticulum is treated with segmental ileal resection at the base of the diverticulum.
Primary end-to-end anastomosis is the gold standard.
• V-shaped diverticulectomy is an acceptable alternative
technique with a transverse closure of the ileum.
• Stapling across the base of the diverticulum, taking care
not to narrow the lumen of the adjacent bowel is also
described in pediatric literature. This would be a surgical
option in a patient with a long diverticulum with a narrow
base and no abnormalities of the base or adjacent small
bowel.
• A hernia containing a Meckel Diverticulum is called a
Littre Hernia (typically an inguinal hernia).
A 2-year-old boy presents with 3h of bright red blood per
rectum. Dad reports that the patient was born healthy at
39-weeks and has had no signicant past medical history. He
had been eating, drinking, voiding, and acting normally until
the bleeding started. Since the bleeding started, dad has not
noted that the patient has been in any discomfort.
Based on the patient scenario, what is your differential
diagnosis?
• Anal ssure, intussusception, Meckel Diverticulum, hemorrhoids
What labs and imaging would you like to acquire?
• Due to the patient’s age and symptomatology, there
should be high suspicion for Meckel diverticulum.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_20
59
60
M. V. Butchy et al.
• Recommend acquisition of 99m-Tc-pertechnetate radioisotope scan, to detect gastric mucosa.
• Placing a foley can be helpful because it will drain the
isotope collecting in the bladder and potentially obscuring the Meckel diverticulum.
• The accuracy of this study can be improved with the
administration of pentagastrin which increases gastric
mucosa uptake, and H2 blockers that inhibit excretion
into the bowel lumen.
• 99m-Tc-pertechnetate radioisotope scans are 95% sensitive and 85% specic in pediatric patients (less in adults),
false positives can be seen with intestinal duplication,
obstruction, vascular malformations or cancers.
What is the treatment and what is the rationale?
• The gold standard treatment of a symptomatic Meckel
Diverticulum is a segmental ileal resection at the base of
the diverticulum with a primary end-to-end
anastomosis.
• Motivation for a segmental resection is that the bleeding ulcer may be on the mesenteric margin or from the
segment of small bowel from which the diverticula
originates. A simple diverticulectomy would remove
the hormonally active tissue but leave the ulcer
behind.
• Bowel resection should be chosen over a diverticulectomy if the patient has a broad neck of the diverticulum
(>2cm), a palpable abnormality of the base of the diverticulum, if the lumen of the bowel is narrowed or if the
tissue is unhealthy.
Describe a laparoscopic segmental ileal resection with
primary end to end anastomosis
• Place Foley catheter and nasogastric tube.
• Gain abdominal access and induce pneumoperitoneum
(Hassan, Veress, Optiview).
• Place trocars, it is likely best to place an umbilical port
rst for the laparoscope and use the camera to visualize
the abdomen. Attempt to triangulate the pathology with
your other ports.
– One option is to place trocars in a typical appendiceal
conguration with an umbilical, left lower quadrant
and suprapubic port sites.
– Another option is to place a supraumbilical port, left
and right midclavicular line ports (approximately
6–7cm from umbilical port).
• Explore the abdomen, lyse adhesions and locate the
Meckel Diverticulum.
• Identify the segment of resection.
• At this point: One could bring this portion of the bowel up
out of one of the port sites for direct manipulation or if the
surgeon is comfortable resecting and resting anastomoses
laparoscopically, one could perform these steps
intra-abdominally.
• Make a window in the mesentery at the resection margins.
• Transect the ileum at the resection margins using a GI
stapler.
• Divide the mesentery.
• Restore bowel continuity and close the mesenteric defect.
• Close the fascial defects of large, midline ports.
• Close wounds.
Alternate Scenario
You have taken a 12-year-old boy to the OR for acute appendicitis. After entry into the abdomen, you see an acutely
inamed appendix with surrounding murky uid. You also
see a 2-inches, blind end Meckel’s diverticulum located
2feet from the ileocecal valve with no evidence of inammation or adhesion.
What is your management strategy for an incidentally
found, asymptomatic Meckel diverticulum?
• Resection of an incidentally found Meckel diverticulum during surgery is controversial. Any surgeon presented with this problem should weigh the risks and
benets.
• Diverticula are associated with inammation, obstruction,
and even GI malignancy so there is benet to prophylactic
resection; however resection is not without risk. In this
scenario, you could choose to scrub out and discuss the
risks and benets of resection with the patient’s guardian.
– Length >2 cm, palpable abnormality or brous bands
would be anatomic risk factors associated with future
complication and would be a good reason to resect the
diverticulum.
– In general, one should probably avoid resection of an
incidentally found Meckel diverticulum in an older
patient, with multiple comorbidities, to whom the risk
of a bowel resection outweighs the benet of a prophylactic resection.
• An incidentally found, asymptomatic Meckel diverticulum seen on imaging should not be resected. If there is an
associated mass, it should be electively resected because
of the association between Meckel diverticulum and GI
malignancy.
What would you do differently if you found that the appen-
dix appeared normal and the meckel diverticulum appeared
inamed?
• Proceed with a segmental ileal resection at the base of the
diverticulum and primary end-to-end anastomosis.
(described above).
20 Meckel’s Diverticulum
61
• Similar to the situation discussed above, this is a controversial topic and surgeons should weigh the risks and the
benets. In young patients with suspicious appendiceal
ndings (mass or adhesions) or whom you feel would be
difcult to re-operate on—it is likely benecial to perform an appendectomy. Older patients with comorbidities
may be unlikely to benet from a prophylactic appendectomy and are at high risk for complications.
Clean Kills
• Failing to obtain a Tech-99m scan in a child with painless
GI bleeding
Words ofWisdom
• Meckel’s diverticulum will be seen in approximately 2%
of the population and is likely to be seen in the operating
room, either incidentally or due to symptoms. It is important to be up-to-date with management of Meckel’s diverticulum, as it will most likely be seen during your time in
practice as a surgeon.
Bibliography
Hoballah J, etal. Operative dictations in general and vascular surgery.
2nd ed. Springer; 2012.
Score. https://www.surgicalcore.org.
Steele SR, et al. The ASCRS manual of colon and rectal surgery.
NewYork, NY: Springer; 2019.
Townsend CM Jr, etal. Sabiston textbook of surgery. 20th ed. Elsevier—
Health Sciences Division; 2016.
Colon Cancer
LeahSteinmetz andDanicaN.Giugliano
21
Colon Cancer
• Colon cancer is the third most common cancer in the
United States.
• Clinical presentation may be asymptomatic (seen on
screening colonoscopy) or symptoms including rectal
bleeding, iron-deciency anemia, abdominal pain, or
change in bowel habits.
• 20–25% of colon cancer present with metastatic disease
at the time of diagnosis.
• The etiology of colon adenocarcinoma can be sporadic,
hereditary, or familial.
– Sporadic: usually occur as solitary lesions in older
individuals (60–80years of age)
– Hereditary: usually in younger individuals with a fam-
ily history of colorectal cancers and associated with
other specic tumors and defects (genetic mutations
tend to be throughout the body, rather than limited to
the tumors themselves)
– Familial: no hereditary syndrome is identied, BUT
history of colorectal cancers among young (<50years
of age), close relative (rst-degree), or multiple family
members
• Surgical resection depends on the location of the tumor
and if surgery is elective or emergent.
• Adjuvant chemotherapy is recommended for patients
with stage III disease or high-risk stage II disease.
A 76-year-old woman presents to your ofce as a referral
after her most recent screening colonoscopy demonstrated a
large adenomatous polyp. Upon further investigation, she
reveals she has had weight loss, abdominal pain and has a sister
with a history of cancer at age 40. What workup is required?
• Take a complete history and perform a physical
examination
– History includes risk factors (family history, inam-
matory bowel disease, previous polyps), change in
bowel habits, blood in stool, weight loss, abdominal
pain, screening/colonoscopy history
– Physical examination may show a palpable abdominal
mass, lymphadenopathy, or blood with digital rectal exam
• Diagnostic tests
– Usual laboratory tests including CEA level and liver
function tests
CEA is important in surveillance after surgical
resection and may indicate local recurrence or metastatic disease
– CT chest, abdomen, pelvis, with oral and IV contrast
for clinical staging
MRI abdomen used if CT scan shows liver lesion
and unclear if metastatic disease
– Colonoscopic biopsy of tumor
Diagnostic colonoscopy best to rule out synchronous lesions
Alternate Scenario
A 67-year-old female presents to you for surgical evaluation
of an adenocarcinoma of the descending colon recently diagnosed on exible sigmoidoscopy. What is the appropriate
next step in management?
L. Steinmetz
Department of Surgery, Cooper University Hospital,
Camden, NJ, USA
D. N. Giugliano (
Division of Colon and Rectal Surgery, Department of Surgery,
Cooper University Hospital, Camden, NJ, USA
Cooper Medical School of Rowan University, Camden, NJ, USA
e-mail: giuliano-danica@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_21
*)
• Preoperative complete colonoscopy to assess for synchronous lesion
– Synchronous lesions in colon cancer are not uncom-
mon (rate: 3–5%).
– It is important that complete evaluation of the colon be
performed before any operative intervention is
planned.
63
64
L. Steinmetz and D. N. Giugliano
A 54-year-old man with no PMH, PSH, or family history
of cancer presents to your ofce with a recent history of iron
deciency anemia. What is the recommended screening for
this patient?
• Average risk patient:
– Age 45years or older
– No history of adenoma, sessile serrated polyps, or
colorectal cancer
– No history of inammatory bowel disease
– No family history of colorectal cancer or conrmed
advanced adenoma (high-grade dysplasia, ≥1cm, or
villous or tubulovillous histology)
• Screening recommendations for average risk patients:
– Colonoscopy every 10years if no adenomas are seen,
bowel preparation if adequate, and colonoscopy is
complete
If low-risk adenoma (<2 polyps, <1cm)→Repeat
colonoscopy in 5 years, then in 10 years if
negative.
High-risk or multiple polyps (traditional serrated
polyps, 3–10 adenomatous polyps or sessile serrated polyps, hyperplastic polyp of ≥1 cm, polyp
that contains high-grade dysplasia or sessile serrated polyp with dysplasia, or any polyp with villous or tubulovillous histology), then repeat
colonoscopy in 3years, then in 5years if negative.
If more than 10 cumulative polyps, consider a polyposis syndrome and screen accordingly (as with
hereditary syndromes).
– Flexible sigmoidoscopy every 5years
40% of colon cancers are proximal to areas that can
be visualized by a exible sigmoidoscope.
If positive, colonoscopy is indicated.
– Fecal immunochemical test (FIT) every year or FIT-
DNA test every 3years.
If positive, colonoscopy is indicated.
– Any rst-degree relative with colon cancer
– Any rst-degree relative with an advanced adenoma
(high-grade dysplasia, ≥ 1cm, villous or tubulovillous
histology)
Lynch Syndrome/HNPCC
• Autosomal dominant
• Mutations associated with mismatch repair genes: MLH1,
MSH2, MSH6, PMS2
• Usually adenomatous, ~10, right sided polyps
• Risk of colon cancer is almost 75% by age 75
• High risk patients identied via Amsterdam criteria
screening
– At least one colon or HNPCC related cancer diagnosis
prior to age 50
– Two or more generations affected
– Three or more relatives have colorectal or HNPCC
related cancers. Of them, one relative is rst-degree of
the other two
– Familial adenomatous polyposis must be excluded
• Colonoscopy should be performed every 1–2years beginning at age 20–25years OR 10years before the age of the
youngest person in the family who received a colorectal
cancer diagnosis.
• Extracolonic cancers associated with HNPCC:
– Gastric cancer (1–13% lifetime risk)
– HPB cancer (1–4% lifetime risk)
– Urinary tract (1–18% lifetime risk)
– Small bowel (1–6% lifetime risk)
– Endometrial cancer (15–60% lifetime risk)
– Ovarian cancer (1–38% lifetime risk)
Familial Adenomatous Polyposis (FAP) Syndrome
A 54-year-old man with a sister with colon cancer diagnosed at age 40 presents to your ofce with a recent history
of iron deciency anemia. What is the recommended screening for this patient?
High risk patient includes the following:
• Personal history of adenoma
• Personal history of colorectal cancer
• Personal history of inammatory bowel disease (ulcer-
ative colitis, Crohn disease)
• Hereditary syndromes
– Lynch syndrome or hereditary nonpolyposis colon
cancer (HNPCC)
– Familial adenomatous polyposis (FAP)
• Family history
• Adenomatous polyps (100–1000s of polyps throughout
the colon)
• Gene mutation: APC
• Associated with duodenal tumors and desmoid tumors
• Extracolonic manifestations:
– Osteomas
– Dental abnormalities
– Congenital hypertrophy of pigmented retinal
epithelium
• Surgical management is a total proctocolectomy with
ileal pouch-anal anastomosis followed by endoscopic surveillance every 2years
– 12–29% risk of cancer developing in the rectal stump
within 20–25years if opt for ileo-rectal anastomosis
instead
21 Colon Cancer
65
– Proctocolectomy with ileal pouch–anal anastomosis
avoids the possibility of subsequent development of
rectal cancer
– Colectomy with ileorectal anastomosis may be appro-
priate, especially for patients with mild polyposis or
attenuated FAP. However, these patients should be
counseled that they remain at elevated risk for developing rectal cancer after this procedure and should
undergo endoscopic surveillance every 2years.
General Principles ofSurgical Resection
• Patient should have mechanical/antibiotic bowel preparation unless patient has obstructive symptoms
• Consider preoperative ureteral stents for large/bulky/xed
tumor
• Resection includes the involved segment of colon along
with its draining lymphatics and accompanying segmental blood supply both at their points of origin
– High ligation of vessels
– Minimum 12 lymph nodes
– Margins should be at least 5cm
• For tumors of the cecum, ascending colon, and proximal
transverse colon: perform a right hemicolectomy
– Ligation of ileocolic, right colic, right branch of mid-
dle colic, removal of 5–8 cm of ileum to proximal
transverse colon
• For tumors of the distal transverse colon: perform an
extended right hemicolectomy
– Ligation of ileocolic artery, right colic artery, middle
colic artery
– Anastomosis between ileum and descending colon
• For tumors of the splenic exure: perform an extended
right hemicolectomy, left hemicolectomy, or partial resection with high ligation of left colic artery and left branch
of the middle colic artery
• For tumors of the descending colon: perform a left
hemicolectomy
– Ligation of left colic artery and inferior mesenteric artery
– Anastomosis of transverse to rectum
• For tumors of the sigmoid and rectosigmoid: perform sigmoid colectomy
– Ligation of inferior mesenteric artery distal to takeoff
of left colic
– Anastomosis between descending colon and upper
rectum
• For synchronous or metachronous cancers: perform a
subtotal colectomy with ileorectal anastomosis
• For a tumor invading into adjacent organs: perform an en
bloc resection
– This does not preclude resection for cure or marking
margins of resection with clips for postoperative
radiotherapy
Malignant Bowel Obstruction
• For any obstructing lesion, clinical conversion of obstruction to near obstruction through NGT, intravenous uid
(IVF), and bowel rest should be attempted. If accomplished, pre- pare the bowel and perform the indicated
segmental resection.
• Obstructing right-sided lesions: segmental resection with
primary anastomosis
• Obstructing left-sided lesions: diverting colostomy ± segmental resection
• Subtotal colectomy may be needed if colon has nonviable
areas due to distention
• Stoma depends on patient factors and integrity of bowel
• Colonic stenting is a treatment option for obstructing leftsided lesions prior to denitive operative management
Perforated Lesions
• Treatment should include oncologic resection
• Perforated left colon cancer: segmental resection with end
colostomy (Hartmann procedure) versus primary anastomosis with ileostomy
• Perforated right colon cancer: right hemicolectomy with
ileostomy or primary anastomosis ± diverting stoma
• Perforated cecum secondary to obstructing left colon
cancer:
– If stable, then perform subtotal colectomy with pri-
mary ileorectal anastomosis
– If unstable, then perform colectomy, ileostomy (with
mucous stula if primary tumor unable to be removed
or patient remains unstable)
Adjuvant Treatment
• Indicated for positive lymph nodes (stage III patients),
tumors with high-risk features, invasion into other organs,
or distal metastases
• FOLFOX is the treatment of choice for high- risk stage II
and stage III disease
• Always consider adjuvant therapy in colon cancer patients
with bowel obstruction, perforation, high-grade lymphovascular involvement, and inadequate resection of
regional lymph nodes
Clean Kills
• Forgetting colonoscopy to rule out synchronous lesions
• Not performing preoperative staging workup
• Not performing the correct surgical resection
66
L. Steinmetz and D. N. Giugliano
• Not performing en bloc resection when cancer has spread
to adjacent organs
Bonus Points
• Patients presenting with metastatic disease.
– Symptomatic patients (bleeding or obstruction) should
undergo resection prior to starting systemic
chemotherapy
– Asymptomatic patients in good performance status
should rst start systemic chemotherapy
Words ofWisdom
The denitive treatment for colon cancer is surgical resection. It is important to know the operative details of various
segmentectomies because staging and adjuvant chemothera-
peutic treatment options are dependent on adequate lymphovascular resection. The extent of segmental resection with or
without anastomosis/stoma creation depends on the presentation of the tumor. Surgical resection is the most effective
therapy for patients who present with obstruction, and perforated cancers should be treated with oncologic resection.
Resection of liver metastases must be considered in patients
without any identiable extrahepatic tumors.
Bibliography
Score. https://www.surgicalcore.org
Steele SR, etal., editors. The ASCRS manual of colon and rectal sur-
gery. NewYork, NY: Springer; 2019.
Enterocutaneous Fistulas
PatrickMurphy
Introduction
An enterocutaneous stula (ECF) is an abnormal connection between the gastrointestinal tract and the skin, allowing
contents from the bowel to leak externally. Like other stulas, ECFs connect two epithelialized surfaces, in this case
the large bowel (colon/rectum) or small bowel (duodenum,
jejunum, ileum), and the skin. This denition typically
excludes stulas formed by the stomach/esophagus and stula-in-ano. While anatomically similar, they do not have
the same natural progression and this chapter will focus on
the diagnosis, acute and chronic management of classically
described ECFs. Additional terminology should be claried—enteroatmospheric stulas (EAF) are a subclass of
ECFs where the enteric portion of the stula directly communicates with the outside world. This is the same as an
ileostomy, colostomy, or mucous stula except EAFs are
not intentionally created (Fig.22.1).
ECFs cause substantial morbidity and mortality with
complications including sepsis, uid and electrolyte abnormalities, and malnutrition. Management requires a nuanced,
multidisciplinary approach accounting for anatomy, output
volume, underlying etiology, nutrition, and sepsis control.
Denitive surgical management in non-healing ECFs is successful in well over 50% of cases.
P. Murphy (*)
Department of Surgery, Divisions of Trauma and Acute Care
Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
e-mail: pmurphy@mcw.edu
22
Fig. 22.1 Enterocutaneous stula
Etiology andPathophysiology
Enterocutaneous stulas are typically iatrogenic in nature
(>75%) from missed injuries, failed repairs and anastomotic
leaks. Patient factors inuence the risk of ECF formation in
each of these circumstances—steroid use, malnutrition,
malignancy, and inammatory bowel disease (IBD). A
minority of ECFs are not related to surgical intervention but
instead are related to IBD (particularly Crohn’s disease),
radiation, diverticulitis, malignancy, trauma, or ischemia.
Occasionally, an ECFs is intentionally created with the use
of a drain in an otherwise hostile abdomen. Similarly, initially purulent drains may develop to ECFs as the patient’s
course progresses. Examples include drains for perforated
appendicitis, complicated diverticulitis and pancreatitis. A
common language is needed when discussing ECFs and ve
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_22
67
68
P. Mu rph y
Table 22.1 Classication of enterocutaneous stulas
Cause Surgical Enterotomies,
Non-surgical Trauma, malignancy,
Internal location Proximal Duodenum, jejunum,
Distal Ileum (distal), colon,
External location Atmospheric Enteric mucosa
Supercial cutaneous Drains directly into
Deep cutaneous Drains into abdominal
Number of stulas Single Only 1 stula
Multiple Two of more stulas,
24-h output Low <200mL
Moderate 200–500mL
High >500mL
IBD inammatory bowel disease
Table 22.2 Pathophysiologic consequence of enterocutaneous stula
Intestinal failure Malabsorption Decreased surface area and
Malnutrition Calorie and macronutrient
Fluid/electrolyte
imbalances
Skin breakdown Chemical irritation Digestive enzymes cause
Sepsis Abscess formation Either deep or supercial.
Large uid losses Dehydration, hypotension,
Electrolyte losses Hyponatremia,
Chronic infection Bacterial contamination,
Bacterial
translocation
anastomotic leak,
missed injury
radiation, IBD,
controlled perforation
ileum (proximal)
rectum
visualized at skin level
cutaneous wound
cavity then to skin
wound
close or distant
bypassing of normal
digestive processes
decits (particularly
protein). May include
vitamin/mineral deciencies
fatigue
hypokalemia,
hypomagnesemia,
metabolic acidosis
irritation and ulceration
around stula site
acute and chronic
In the acute settings new
collections may form until
tract matures
Risk of bacteremia
nature of ECFs, these consequences can wax and wane as the
stula matures, or patient conditions change.
Presentation andDiagnosis
The hallmark feature of ECFs are enteric contents from a
cutaneous opening. Bilious or fecal drainage is typically
associated with other signs and symptoms such as abdominal
pain, distention, tachycardia, and fever and may be associated with peritonitis. Cellulitis surrounding the cutaneous
drainage, uid and electrolyte imbalances are common, particularly early in the course before the stula has matured.
Workup aims to dene stula anatomy and quantify output. Computed tomography provides the best initial study to
delineate anatomy. Contrast should be given both orally and
delayed images may need to be obtained depending on stula location. Specialized studies like CT stulogram or even
endoscopy can further clarify details if needed depending on
the location of the ECF.Labs should be obtained to evaluate
nutritional status, uid/electrolyte levels, and markers of
inammation.
Initial Management
Early management of ECF focuses on skin care, nutrition,
and infection/sepsis control.
Skin Care
Diversion of enteric contents away from skin is one of the
main objectives in ECF management. There are several strategies and an individualized approach based on ECF
characteristics and patient body habitus is required. In general, gentle mechanical cleansing should be used and like
any other irrigated skin, soap and water should be used and
harsh chemicals avoided. Topical skin products such as barrier lms/pastes may help protect skin from efuent.
Similarly, adhesives and ostomy pouches should be used as
much as possible to divert output away from the skin. These
also facilitate quantication of output.
key features are useful both in the management but also in
predicting spontaneous closure, Table22.1.
The pathophysiologic consequences of ECFs are predictable based on the criteria outlined in Table22.1. For example, patients with high-output stulas are more likely to
suffer from dehydration. There are four main consequences
of ECFs—intestinal failure, uid and electrolyte imbalances,
skin breakdown, and sepsis, Table 22.2. Given the chronic
Nutrition
Nutrition, particularly meeting protein goals, is paramount
is stula healing and for operative planning if the stula
does not close. The “best” way to meet nutrition goals is
with enteral nutrition. This is possible in a few scenarios.
First, it may be possible to place a feeding tube distal to the
stula opening (if very proximal) via nasojejunal tube.