Colonic fistula

　　1. Complete fistula

　　The intestinal lumen is completely inverted externally, exposing the abdominal wall, with all or most of the intestinal contents flowing out through the fistula.

　　2、管状瘘

　　可为病理性或手术后，尤其是腹腔引流管硬，压迫结肠所引起的肠壁坏死形成的瘘，管品小而瘘管长，肠内容物大部分流入瘘口远端的肠管内，仅小部分从瘘口流出体外。

　　2. Tubular fistula

　　It can be pathological or postoperative, especially when the abdominal drainage tube is hard and compresses the colon, causing necrosis of the intestinal wall and forming a fistula. The tube is small but the fistula is long, with most of the intestinal contents flowing into the distal intestinal tract of the fistula, and only a small part flowing out through the fistula.

　　What complications are easily caused by colonic fistula?

　　After colonic injury, inflammation, or tumor, and after colonic repair or resection and anastomosis, if there is leakage at the anastomosis site, it often occurs 4 to 5 days after surgery. The pain in the abdomen initially decreases after surgery, but then becomes more severe and persistent. It is often accompanied by sepsis, such as fever, abdominal tenderness, rebound pain, and increased muscle tension in the abdomen. At this time, it should first consider abdominal infection or the possibility of forming an intestinal fistula. The presence of intestinal contents flowing out of the abdominal incision or drainage hole is a reliable evidence of an intestinal fistula. However, it is relatively difficult to accurately judge the location of the fistula orifice. Generally, the exudate from an ileal fistula is often yellow rice gruel-like or thin paste-like, while the exudate from a colonic fistula is semi-formed or unformed feces.

　　First, Prevention

　　In the surgical treatment of the intestines, attention should be paid to the management of wounds to prevent the formation of fistulas. In daily life, attention should also be paid to:

　　1. Establish a normal dietary habit;

　　2. Prevent constipation and diarrhea;

　　3. Develop good defecation habits.

　　Second, Nursing

　　1. Psychological care: For patients who need a permanent artificial anus on the abdominal wall, psychological trauma exceeds physical trauma. Before surgery, it should be explained in detail the necessity of the artificial anus for treatment, noting that the process is not complex and will not affect daily life and work. This helps patients face reality and accept the fact, and build the confidence to live bravely.

　　2. Stoma care: In the short term after surgery (within 24 hours), clean the stoma, apply gauze soaked in normal saline externally, and use a stoma bag after 72 hours. During this period, attention should be paid to the blood circulation of the intestinal mucosa at the stoma, whether the stoma has retracted, bled, or necrotized. After using the stoma bag, observe the color, nature, and amount of fluid in the stoma bag. If there is gas and excrement in the stoma bag, it indicates that intestinal peristalsis has recovered, and it can begin to consume liquid food. In addition, it is also necessary to protect the skin around the stoma, reduce the stimulation of intestinal fluid to prevent the occurrence of eczema, and use zinc oxide ointment or anti-leakage cream to protect the skin.

　　3. Health guidance: Patients should pay attention to dietary hygiene.

　　1. Taking oral activated carbon powder or injecting methylene blue solution through a gastric tube, if the wound exudes carbon powder or blue liquid, it confirms the existence of an intestinal fistula. The time from taking or injecting the drug to excretion through the fistula can also help determine the location of the fistula orifice.

　　2、X线检查复查腹腔立位平片，可见膈下游离气体增加，也可证明有肠瘘存在的可能，（膈下在手术后可残渣余孽存积气，但应逐渐减少）。

　　2. X-ray examination: the re-examination of the abdominal upright film can show an increase in free gas under the diaphragm, which can also prove the possibility of the existence of an intestinal fistula (subdiaphragmatic residue can accumulate gas after surgery, but it should gradually decrease).

　　3. Fistula angiography: if there is a fistula, a catheter can be inserted into the fistula and contrast agent can be injected to help understand whether the intestinal fistula exists and its location, size, the direction of fistula passage, and the condition of surrounding intestinal tract, etc.

　　4. Gastrointestinal barium meal examination can help understand the location, size of the fistula, and whether there is obstruction at the distal end of the fistula.

　　Many foods can have unexpected harmful effects on our intestines, so we should pay more attention to them in daily intake to avoid negative health effects caused by imbalance. These foods mainly include:

　　1. Meat

　　There is no fiber rich in fiber. If the meat is not fully chewed, it is not easy to digest, leading to the proliferation of intestinal bacteria. Statistics show that in meat-consuming countries, the incidence of colorectal cancer is rising continuously.

　　2. Saturated fats

　　Saturated fats refer to animal fats and artificial fat cream. The accumulation of saturated fats changes the intestinal flora, increasing the content of bacteria that promote the conversion of bile acids into carcinogens.

　　3. Gluten

　　Gluten can form a paste-like sticky substance, adhering to the inner wall of the intestines.

　　I. Treatment principles of colonic fistula

　　1. Ensure the maintenance of overall nutrition and electrolyte balance, and improve the self-healing ability of the intestinal fistula.

　　2. Administer a large amount of antibiotics to control abdominal infection and thoroughly drain at an appropriate time.

　　3. Try to understand the location and size of the fistula.

　　4. Protect the skin around the external fistula.

　　5. Try to find the cause of the intestinal fistula and treat it according to the symptoms.

　　6. Intractable intestinal external fistulas should be surgically treated at an appropriate time.

　　II. Intestinal fistula

　　Treatment should be given according to the different stages:

　　1. In the first stage (from 7th to 10th day after the fistula occurs), the patient is in the unstable period of the fistula and the initial stage of infection. The abdominal infection is severe, with local inflammation and edema. Surgical repair of the intestinal fistula often fails and may lead to the spread of infection; the patient should be fasting, gastrointestinal decompression, and receive parenteral nutrition to correct the general condition; antibiotics should be administered, the abdominal infection focus should be thoroughly drained, and the intestinal contents should be completely drained out of the abdominal cavity (the wound should be cleared in time or a catheter should be inserted for drainage).

　　2. In the second stage (from 10th to 30th day), after the 1st stage of treatment, the patient gradually recovers, and the fistula, after drainage or treatment, has become a 'controlled' fistula. Infection remains severe or continues to spread and develop, so it is necessary to actively control infection and strengthen nutrition. Especially, total parenteral nutrition is a necessary means to provide calories and nitrogen sources.

　　3. In the third stage (from 1st to 3rd month), after the 1st and 2nd stages of treatment, the fistulas with good effects have healed or stabilized. Since the influence of intestinal fistulas on nutrition is relatively low, but when the fistula does not heal, it is necessary to timely understand the factors causing the non-healing, common reasons include:

　　(1) There is an obstruction at the distal end of the fistula;

　　(2) The tissue of the fistula has been epithelialized;

　　(3) The colon mucosa has healed with the abdominal wall, making the fistula appear lip-shaped;

　　(4) There are foreign bodies in the fistula opening;

　　(5) There is poor drainage of abscesses near the fistula opening;

　　(6) Special infection or tumor exists.

　　During this period, the focus is to find the cause of the unhealed fistula, control abdominal infection, especially intestinal wall interstitial abscesses, and timely laparotomy and drainage of abscesses when highly suspected. Of course, if B-ultrasound can be confirmed, puncture and aspiration of pus can be performed under its guidance, and antibiotics can be injected to alleviate concerns about widespread adhesions in the abdominal cavity during surgery that are easy to damage the intestinal tract.

　　For patients with unhealed intestinal fistula in the fourth stage, control abdominal infection, and if the local condition of the fistula opening is good, elective surgery can be considered to remove the cause and close the fistula. If there is distal obstruction of the fistula opening, it should be relieved before repairing the fistula opening; for simple lipoma fistula or tubular fistula, the fistula can be turned towards the intestinal lumen without excessive exploration of the abdominal cavity. Of course, when there is special infection or tumor locally, the lesion should be resected and anastomosed.

　　3. Perioperative management

　　1. For acute patients, correct electrolyte imbalance and shock in a timely manner to prevent prolonged ischemia of the intestinal wall. Correct anemia and malnutrition after surgery.

　　2. Elective surgery, solve malnutrition, and if necessary, intravenous nutrition can be provided to improve the plasma protein, hemoglobin, and vitamin C content of blood before and after surgery, and do a good job of intestinal preparation before surgery.

　　4. Matters needing attention during the operation

　　1. When performing intestinal resection and anastomosis, the tissue clamped with vascular forceps at the distal end of the intestinal resection should be cut off. For intestinal stenosis caused by intestinal lesions, intestinal torsion, intussusception, or mesenteric vascular injury, thrombosis, etc., when performing intestinal resection and anastomosis, it is better to resect more to ensure the normal tissue of the intestinal ends. Generally, the distal end of the intestinal segment is at least 3-5 cm away from the necrotic intestinal tract (or the lesioned intestinal tract).

　　2. Ensure good blood circulation at the anastomotic end of the intestine. When resecting the intestinal tract, resect more on the contralateral side of the mesentery to ensure blood supply. When separating the mesentery, do not do too much and do not exceed 1 cm from the intestinal end. During suturing, the mesenteric side should carry some avascular mesentery to ensure blood supply without damaging the supplying vessels.

　　3. When performing intestinal resection and anastomosis, there should be no infection or hematoma locally. The suture must invert the intestinal mucosa to ensure complete serosal-to-serosal healing of the intestinal ends.