Fistulas

By Meg Marinis, Director of Medical Research Dec 02, 2010
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Who knows the three rules of surgery?

1. Eat when you can.
2. Sleep when you can.
3. Don't f*** with the pancreas.

So the importance of the first rules should be pretty clear. And here's a fairly thorough explanation of the third rule: "Surgerizing the pancreas is like trying to remodel a house full of gasoline. And the house is made of Jell-O. And sits on top of a kindergarten. And it's on fire. And filled with bees. Don't f*** with the pancreas."

Also, here is another reason to leave it alone...

So. Let me guess. You want to know what the heck a fistula is?

Good question. A fistula is an abnormal opening between one or more hollow organs inside the body. They may develop between the esophagus and the windpipe, or the bowel and the vagina. They can also develop between two blood vessels such as between an artery and a vein, or between two arteries. But over the past few episodes, Dr. Bailey has declared war on post-operative pancreatic fistulas. Whew. That's a mouthful.

Remember back in 708 when the Chief was busy with the State Department flooding his ER? Well, since he was so busy, the Chief tasked Bailey with overseeing his previous patient, Mrs. Louise Cortez? He had recently operated on Louise for her chronic pancreatitis, yet she was readmitted to the hospital with a complication. And yep. That complication was a pancreatic fistula. Shortly after Louise's surgery, the repair inside her abdomen sprung a leak (a fistula), causing pancreatic fluid to be in places it should not be. Pancreatic fluid (sometimes referred to as "pancreatic juice") possesses digestive enzymes, so as soon as it is released into the abdomen, it starts to digest... tissue and other organs. Important things that Louise needs. So basically, a fistula is a leak, and that leak ain't good.

How do you get one of these things?

So, a pancreatic fistula is usually a complication of acute or chronic pancreatitis. It can also occur postoperatively, especially after pancreatic resections, or after abdominal trauma. Affected patients can present with fever, abdominal swelling, abdominal pain, shortness of breath, a cough, and weight loss. Also, after a patient receives surgery for pancreatic disease, their surgeons will insert a drain to help remove any excess fluid inside the abdomen. When this drain empties out fluid of an abnormal color (pancreatic fluid should be clear) or if lab results show a high amylase level, doctors will leave the drain in place longer than usual to avoid more serious complications.

And how do you treat them?

Traditionally, doctors prefer conservative and non-operative treatment for pancreatic fistulas. Initially, patients should be put on pancreatic rest and monitored—for example, a very specific diet will be assigned and certain medications will be stopped in hope that if the pancreas' job is limited, less fluid will leak, and perhaps the opening may close. However, this treatment tends to require a costly and lengthy hospital admission, and often surgeons turn to endoscopic and surgical intervention, especially if the abdominal tissues and organs have been seriously injured from the fistula.

But Bailey doesn't want to treat them... She wants to PREVENT them!

After losing Louise and realizing that too many patients suffer this complication, Bailey becomes determined to bring those numbers down. All over the world, doctors struggle with increasing post-operative complications, desperate to find the right combination of care and recovery to prevent their patients from getting worse, or even dying.

In Episode 710, "Adrift and at Peace," Jackson, Lexie, and April (all assigned to Bailey's service) compete to see which one of their protocols succeeds with eliminating the occurrence of fistulas. Jackson's protocol includes a "fast-track recovery" plan. He believes that the sooner he has his patients up out of bed and walking around? The fewer complications they will endure. Other components consistent with this protocol include early nutrition, regionalized anesthesia, and early catheter removal.

April decides to see whether or not adding a medication to her patients' drug regimens will improve the recovery process. April starts adding the drug octreotide, which works to reduce secretion of fluids by the pancreas and small intestine.

And last but not least, Lexie works with a standard post-op protocol with a checklist that she developed for accountability. These checklists manage post-operative factors such as post-op care, post-op gastric tubes, intraabdominal drains, post-op feedings (fluids and solids), first mobilization out of bed, and the combination of medications.

And who wins? Eli. The insanely handsome nurse. Standard protocol was to pull out these drains after five days. However, Eli notices that his patients who got them pulled at three days? Did better. So he does whatever he can to get his patients' drains pulled in three days, like he did with Lexie's patient...

For more information on fistulas, please visit:

http://www.nlm.nih.gov/medlineplus/fistulas.html

And for more information on the pancreas, in general:

http://pathology.jhu.edu/pancreas/BasicOverview1.php?area=ba