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And we'll just go through one of the cases. Um So perfect. So this case that we're going to run through sort of touches on a lot of things that we've spoken about already. And again, like I said, I just want you to think about whether these decisions would be the things that decisions you would be making. Um and or how different you may act. So firstly, the in this case here, the registrar that's turned up for the night shift, but a 35 year old usually fit and well male. It has been seen by a colleague admitted, but for theater handed over act shows for appendicitis, they're already on the table. They've done the brief. You've just got to turn up to theater and, and deal with them. No. So in theater you find there's a mass um viable tissues. We've all been there, difficult dissection, but you've performed some find the appendix uh managed to immobilize it, resect it, leave a drain because of all the the uh contamination around and uh and send it back to the ward and on the third day, postoperative, these are somewhat tender in the abdomen. Um as expected postoperatively. Um, the whites all started to come down. Um CRP is still high but that's relatively static. Um, and it's noted that the drain output is a little bit mucky. It's a bit dirty probably from the wash that you did during the procedure. There's no major concerns noted from the ward round and only about 30 mils in the drain in total for 24 hours. So that's the decision is taken to take that drain out. And the following day the patient now has worsening abdominal pain on examination. He's got peritonism. The obs are worse, tachycardic. He's now got a temperature as well. Nurses are concerned about him saying he's not looking very well and his white cell count. Shut up. The question is a leading one. I'm hoping everyone would say would do act at this point. Hang on a minute. Aren't they supposed to answer that question? Um Yeah, they were supposed to, but I was hoping that everyone would. Well, we don't know, do we? We haven't asked them, have we? That is true. We've lost it. Would anyone do anything other than aci have to go back to? I'd like to know what they would do. That's why we put the question in there, Suzy, if you don't mind. Sorry, I give them the, you get the slides back up, right? Who has the guts to say anything other than act? Yeah, after that. Sorry. Yes, sir. Yeah. There you go. There you. Good. Go straight back in. Yeah, I, and see how that number is. By the end of the day. Can I ask you a question? Do we never do? I see. See you. I couldn't hear you assume we never assume. Why not? Assumptions are the mother of all cops? Say again? Because assumptions are the mother of all CS way. One way of saying it another reason it makes an ass out of you and me never assume. OK? So that's your first lesson. OK. So you'd give fluids, antibiotics, painkillers. OK. Operate CT scan. She asked for a show of hands, Suzie, do you think? Yeah, absolutely. So for a CT scan, if everyone put their hands up? OK. And then f reoperate is that one? Do not put his hand up now? No, you might do. OK? Right. What happened then? But they had act have we got those slides fractured? Thank you. So the patient went for acc scan and there was a collection of the rale fossa and raising suspicion of a, a leak from the stumper. The decision was for conservative management at this point. Um And an IR drainage was discussed with your friendly radiologist, but unfortunately, the CT was deranged and therefore he was unable to have the drain that day. So, so just to come up to that is that, you know, this is already alarming, right? Because you got a young patient who's basically had an appendicectomy. I assume no previous medical history of and on. No, I'm just saying, like I declare no comorbidities of not. Ok. Um, and, um, we'll do it and has deranged clotting a few days after an operation. So it's probably more septic than we, than, than we think they are. Right. You know, the younger they are, the more overt the, the, the, the classical sign of sepsis may not be present unless you look for them. So, the fact that the clotting is the range is probably not a good sign. Just by the way, New Zealand, where they invented the inside system, the commonest cause of intestinal failure in New Zealand is appendicitis. Share that with you. Thank you. So, POSTOP day six worsening sepsis, things are not getting any better either. The bloods are clinically, the drain wasn't done for two days. In fact, because of the clotting, it's now been corrected and the drain is inserted, the patient comes back to the ward and there is small bowel content in the drainage bag. Question to you, is this alarming? Are you going to do anything different? We do sad clot for two days. The clotting needed correcting. That's why I was waiting two days worsening. Would you not be, er, that's my question to you. The, we take him to theater at which point, uh, at the point when his thing was worsening inside the drain and he was clinically getting worse do. And what would your purpose be of taking him to theater to see what's going on. Why is he getting septic or? You've done act scan? You've shown an abscess? Yeah. Uh, concerned about a stump leak. Well, you know about the stump leak. What's your concern? Whether we can sort it? And an operation is your method of sorting it out. That's what you're telling me in a nutshell. Get the drain for two days. Yeah. Mm. I mean, first of the, one of the things to challenge of course, is this whole thing about waiting two days because of the range clotting, you can, you can under range clotting, right? You can also just say, well, listen, if the alternative is an operation with the same deranged clotting, maybe you should go for the drainage first and we can always do the operation. There are ways of challenging this. So, you know, I wouldn't necessarily say, well, therefore we should do an operation. I would say that the deranged clotting in and of itself should not be a reason not to intervene, right? You can, you can correct it to a certain degree I think. Did that make sense to you all in the room? What Mr Me, what Akash just said? Yeah, it's not so much. The deranged clotting has clouded the issue, hasn't it? What does he need doing? What's the question in your head? What treatment does he need? However, you do it drain the sepsis? That's the answer, isn't it? And Akash is absolutely right in that the deranged clotting is because he's poorly, isn't it? So you can do something about that. You gotta drain the sepsis. And that's the first letter of what word anz up if you've ever heard of Snap. Ok. Hans Down. Thank you. Be honest. Hands up. If you've never heard of Snap. If you have not heard of Snap. Ok. Hands up. If you can spell it, it honest, nobody else tells spells snap. Anyone like to have a go. No. And then your closest and lucky you can sometimes you add an extra s or an extra P for skin. How do you spell? I keep forgetting to do, bring it back. SN AP, either SN Ap or SN Ap. Yeah. So me and Akash and Lisa, we spell it. Ssssssss ssss and then take a nap. It. Right. That's how we spell it cos what do people forget to do? Brain, the sepsis. Yeah. Yeah. Yeah. It's obvious on the CT scan, but we're making it very obvious. So. Sepsis. Ok, Suzie. Ok. Yep. So if we get back to the slides, please. Oh, yeah. We haven't decided what we're gonna do. Yeah, we haven't actually decided yet. No, we, with the small bowel content. So what people want to do about that? We're not operating, we might have operated sooner but we're not gonna operate. Are we gonna operate now? We gonna operate now? Oh, ok. Who's that now. Blood a good lady. Yeah. What you gonna do with IV, fluids, IV, antibiotics. With any luck, we'll develop a controlled fistula with any luck. What year reg are you finished being a registrar? Very good. Congratulations. You run out of luck. Now, this is when the rest of your life starts. There's no luck. Your luck is just used to, I mean, to be devil's advocate. Right. Um, I know most of my per was about operating is bad and everything, but this is, you know, the slightly, except, well, for me, slightly exceptional situation where you can get to a problem within that 10 day window, you know. Um, so it's not, it, I don't feel it would be unreasonable for those of you to say, listen, I'll go in because now I've got established leak from somewhere, you know, the, well, well in the drain. Um, and it's within six days, it is not unreasonable to say, ok, I'm going to go in, you know, in particular in the presence of a patient who we've said has been septic unwell. We're worried about them. She didn't say operate though, did she, I'm sorry, did you go to say something? No, we, we were saying maybe it may, it was not unreasonable to decide to operate on day four, day five with small bowel content in a septic patient. She didn't say that though. Did she? She said, what did you say drip IV antibiotics? I mean. Yes, potentially. So, of course, none of this is, is, you know, just a binary answer, right? If you have a patient in this situation, a drain and, you know, the first day or so, there's a bit of small out and then it kind of dries up or it's very low volume patient becomes better, you know, crucially. Um, there, there's a, there's a case to make you just wait it out. Absolutely. Yeah, if they're not improving or if it's just really bow content, it keeps on coming out, you know, and it doesn't really stop within, within the 10 day window. You could make a case to just go in and try to sort the, to try, try to fix the problem, try fix the problem, fix the problem, you come in and sort and fix the problem. Control the source. OK. Right. Sorry Lisa. You on, you know, II just, I just said control, II think we're not. Ok. Definitely. Didn't say fix. You'd agree control. You'd agree with me. Control is the word we would use. Ok. Control. Great. Yes, sir. Did you try b rest and keep your head still, bar, bar, rest and TPM. Rest and TPN. What do we think of that up there? What, what, what goal in mind? See if the fistula will dry out otherwise you're gonna head for a right hemicolectomy. So does a fistula dry out because the gut, which has been, which has evolved to be used, doesn't get used. Sorry. That's a very leading question. Did you understand that leading question? OK. Sometimes it does sometimes. Is that enough? In a case, I've seen it. It did it worked. If it was you in that position, would you be OK with that sometimes? Would you be happy? Oh, the alternative would be a right hemicolectomy alternative is a right hemicolectomy. Mm. Ok. Is it, why can I challenge that? Why, why do you say right hemicolectomy if it's a stump blowout? So you're assuming it's a stump blowout? Oh What do we never do? Well, it Yeah. And do I really the first thing you do that thing? I'm not sure that I talk 35 year old patient fit in. Well, previously coming with Appendix toy. I think in, I'll, I'll take the criticism for that but I will do the laparoscope there and then, and when the drain cannot be done, I can see if it's collection, I can wash it out that there should be tissue blends and then if there is a fistula, then I can see there and then I think it would merit we look earlier rather than late. There are lots of different points in that particular comment I feel. But I think we've gone past the what we do gonna do when we can't do the drain business. I think we've decided we were going to drain pus one way or another way. So you do that laparoscopically we accept that we've, on this occasion it's been, uh, managed, er, with interventional radiology and now you got, um, stuff coming out. So they have got fistula possibly. Yeah, lots of hands going up now. Good repeat the CT. Oh, I was going to say that you don't actually know where the drain is. Mhm. What did he do? You assumed? What, what do we never do? Oh, so you're checking? Got you. I'm curious about the original note that said mass and then he cracked on with an appendicectomy. Was that a Phlegmon? Was that some suspicious cancer thing? That, in which case we're not expecting it to? Yeah, we, we're saying it's an inflammatory mass. Yes. So we're happy. There's no malignancy, um, there, but it was a mass that had to be picked apart to find the appendix at which point it was taken. Um, we're getting lots of questions kind of going back a little bit. We, which isn't really the purpose of, would you like to know what happens on the next day? I think I've got a question myself beforehand if I mind. But just on Ak's point, how many people in the room truly believe that if you have developed? And we come to the point that this is a, an enterocutaneous fistula that if you have got a patient with an cutaneous fist and it's just started as in this case, how many people truly believe that putting that patient nil by mouth is a good therapeutic maneuver. No, on E I love it. Love it, love it, love it. Love it. What's your name, sir? Where are you from? I'm working in Arrow Park. Um I wouldn't necessarily put them nil by mouth. I would probably let them drink water, but I think you can modify their diet and stop them having high fiber diet. You know why you could even put them on just ensures cos I think that's, that's gonna be residue that goes down to where they might have a stump leak. That's where the fistula might be. Oh OK. So a different way of asking the question is how many people think, think putting person nil by mouth, restricting their intake in terms of volume is gonna help heal the fistula. Does anybody think that no one? Do you think that Tom? So, so there's something to pick apart here, right? So what, what Dermott is not asking is how many people think fistulas don't heal on their own? That's not the question, right? The question is whether bowel rest is the way, is the way to increase your chances of a fistula healing well, without surgical intervention. Ok. Intra fistula in general, some of them heal without the need for further surgery. The classical data says about, I got to say 50% is 60 that's putting all the fly together and that's probably the wrong thing. A Crohn's fistula official distal obstruction probably won't heal no matter what you do. The concept of bowel rest. So giving the bowel nothing to do and PN does not push the patient into the category of the fistula healing. It makes the patient very unhappy. Hm. But it doesn't actually increase your chances of a fistula healing. If a fistula is gonna heal, it'll heal and what enables the fistulas to heal. What one therapeutic maneuver will definitely increase the chances of the fistula healing. I go nutrition, control sepsis, drain the sepsis. That's the one thing the other day I had someone come in who had a, a fistula from his small bowel to his perineum for six months. It was an abscess cavity. The only thing I did that was useful for him and he came from another hospital was stick a knife in and drain the sepsis. And the registrar who was on, well, when I say I did it, I don't do that at my level. Uh, the registrar who did it, uh, phoned me up on a Sunday afternoon to say you, this patient's on the list for drainage of his pelvic collection. And I said, yeah, he said, well, it's, he's got a fistula. I said, yeah, he said the small bowel is gonna end up all over his perineal. And I said, well, I hope so. Otherwise he hasn't got a fistula, has he? So, yes, that's exactly all what I want to happen. He goes, but you want me to do that rain. His sepsis. Oh, he's got a hole there already. It's draining. I said, yeah, make it bigger. Sunday afternoon. I wasn't on call, phone call for half an hour trying to persuade this fellow to just stick a knife in him. Drain pus anyway. Eventually he did. And the small bowel flooded all over his pads and that lasted a week and then it dried up and now he's gone home. No TPN, no additional nutrition, no nil by mouth. So there you go drain the sepsis. Simple as, let's see what actually happened with these patients. So, um, we have the, the slides back. Thank you the following day. You'll be pleased to know the sepsis was settling. His drain has worked. That's not the end of the story then. So the bloods are slightly improved. Everyone seems to be quite happy. Um Oh, it's not b I see. All right. Ok. Um, and the patient is made no, by mouth, by the registrar on the ward round and they have an NG placed any thoughts on that. Yeah. And then the following day, unfortunately, things get worse again. So obs go off, he now has further signs of sepsis, ongoing sepsis. His bloods have worsened. His CRP is now over 300 the decision is made that he needs an exploratory laparotomy. During this laparotomy, there is a healthy cecal base, the stump is intact and actually there's a small bowel leak from a suspected diathermy injury. And this is in the judging at about approximately 100 centimeters from the DJ. So the decision at the time of the operation is to resect that small bowel segment only about 6 to 7 centimeters taken. Um, and the nieces are worried. So this 35 year old who's normally fit and well is on inotropes at the end of the procedure. Um, decisions taken because of that information to staple both ends and the decision is then taken to leave a book bag. So what do you think of that as an outcome? So, first of all, going back to the whole assumption thing is, you know, everybody here assumed this was either a stump leak. I didn't think one colleague thought well, could it be the drain which had entered, which had been drained, inserted into the small bowel, right? This shows that it could, it could be something as simple as in the aic injury of the small bowel, right? So the whole thing about the patient need to write hemi, yes, if there were a stump leak potentially. But the whole concept of this is that you need to think about all the options in these cases. Two, yeah. And of course, I won't even say anything about the Bogota bag after my presentation. No, no, no, no. That was very interesting. That topic, I mean, that's, er, er, slightly, but that's what those guys need to know. Isn't it, cos they'll be faced with this, this, um, scenario may not be faced with having to reconstruct things, but you will be faced with the sick patient with an open abdomen, that's for sure. So, the, the thing because we've all had the situation right where the anus gets really upset during an operation as you are, you know, stirring up everything and you're draining and you're washing and you're whatever, uh, you get the septic shower. Um quite often you can still spend a few minutes doing a closure of the fascia. If you really can't, if there's a real concern, then putting a, a there or whatever whatever solution you have in your own trust and again, go away from this meeting and check what solution you have in your own trust, but whatever it is, it does not take longer than cutting open the big, you know, IV infusion bag and fashioning that into a Bogota bag. It does not take longer to do, but you say you, you, you preserve a lot of options to get this patient's abdomen closed within about two weeks with a Bogota bag. You will not. Ok. Uh You got the slides up again. Yeah. So we're just going to run through. Uh just, just stop that for one sec. So what was the main out of that operation? In one word? Two words, maybe fix the problem. Source control. Yeah. Yeah. Yeah. So we say drain the sepsis and I spell it with a million Ss and that's an operation where the purpose was to drain the sepsis, not to fix the problem, but to drain the sepsis. Source control if you like. Yeah. Yeah, great. So we're now on day 10 patients in Itu on maximum dose CYO Trippe and he's not getting any better. There's a plan look been booked, ischemic segment of small bowel. Um The decision is to resect that segment. The decision is then taken to anastomose those two ends and also to leave a bug to bag again, allowing for a planned Rook. Is this one of those pause moments, Orestes, should we ask them what they would do without the red writing? They get to the Relook Laparotomy and uh ischemic small bowel. Ok. Should we give them some options? Hands up, show of hands. Have you got time for that? We're running a little bit tight just to get through the whole case. I, no, if you want to talk about it, I don't want to talk. I want to ask. Well, the main, the main, I mean, I think there are a lot of things which you can say here about this, but let's go with the second point decision to an the remaining ends, right? Show of hands. Who would ANAs, ok, Chavan, who would have ANAs Mosed if they hadn't heard this session and, and, and they were faced with this problem last night. Oh, that's impossible. To answer. Oh, and you got some more hands up there. So we've, we've changed some minds. That's good. Um Chauvin's who would not Amos leave the end in the abdomen and come back a few days later. Ok? Or, or, you know, one or two days or whatever. Ok. And Jovan who would not an exteriorize both the ends as a stoma and be done with it. Ok. Who would ask somebody else? Um, Disappointed to see. Not all your hands went up there as somebody else not to do it. Just a bit of a, you know, phone a friend kind of thing? No harm. Yeah. OK. Should we go back to the slides and see? So we've, I think we've mostly touched on most of the learning points already from the discussion. Uh Is there anything else you want to add about? No, no, we haven't really talked about media special. No, we've got a video I think so. There, there's a QR code on one of the slides so feel free to. It's, it's a very good video by the, by uh what David Layfield and Andy King are in Southampton. Um It's a very good video of me, media fashion traction. Just give you a second just to get those. Can we, you get that to play at all? We get the video to play, see if it will play with another click. Not Yeah. OK. OK. I don't think we're gonna be able to um have the video play, sorry about that. Um And now back to day 12, it's another couple of days have pass. We've got a fluctuating need for anatomic support. Now, um, and he goes back for his Planned Relook and you can't do it because all the specialties are in your way. So another two days pass, he's still on maximum inotropic support and he's unstable and he has a relic laparotomy at this point, there's an anastomotic leak from your joint. Um And the question is whether it's an ischemic leak. Um The anastomosis is resected a decision for a stoma. So a proximal end is brought out and the mucus fistula has brought out the distal end, but you're unable to perform the primary closure. We're now day 14 from his original surgery. Remember there's sheath retraction, the vacs um is unavailable to you and there's no, you have no experience in other systems that might be available in your hospital. Um So therefore the left abdomen is left open and a boat of bag is applied. Yeah, we'll just do the last time as well. So um there's a reducing need for inotropic sport at this point, blood seem to be improving. He has another planned relook er and the small is healthy. So there is a decision at this point not for any restoration of continuity. He remains with his uh Iost toy and mucus fistula. He has some degree of component separation and a primary closure. And this is another looking points the pause regarding the primary closure regarding the primary closure and the degree of some degree of separation. OK. What question do you want to ask them? Then? Akash, if so, did we see this regularly in a in an op note, right? That people have said partial component separation, perform some degree or whatever? Does anybody know what that means? Good. I either um let me put it differently. So let's say you have this situation where you got this retracted, she or whatever you feel, you want to close it all at day, whatever it was 16 or whatever it is. Um How many of you would actually do a component separation in at this setting in this scenario? Good. Excellent. There is you need to think about goals and priorities, right? In this situation, the goal of the operation is to save life, save bowel, right? It is not to do an abdominal wall extraction. Yes, if you can get it closed, great, right by all means. But if you can't, don't burn bridges for the future, because this patient is now in a sit is in a situation that they will need an operation at some point in the future. Probably. Um and part of that operation will undoubtedly be an abdo, you know, some form of repair, reconstruction of the abdominal wall if planes have already been opened and the component separation performed, that limits the possibilities for the future. Um It also is just an unnecessary insult in this operation. It makes the operation takes longer than it would than it would have had to take. Right? So it, it is so in general, I would say, don't embark on any proper abdominal wall repairs in this situation, don't start doing retrorectus dissections and everything like and component separations and things like that. Ok. That's good. Uh Are there any more slides there? Restless Summary. Yeah. Just the summary essentially so that the patient goes home, discharged with um high out the stoma mucus and goes home on PM home PM. OK. Home on a uh PN after an appendicectomy. Um-hum. Yeah. And probably in New Zealand it could well be from New Zealand. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Cause that's uh the commonest cause of intestinal failure. So um I think we have got time for any questions Suzy or last slide. Just the key learning points to take away from the discussion before we did that. Then should we ask for any questions? I'm keen to ask for questions. Sorry. Person who likes to ask if there's any questions? Yes, Tom from Outland. Thanks. Sorry. So can I be clear in intestinal fistulas? There is no situation where you give any degree of bowel rest. Is that what is that what we're saying? So what? No, in essence, actually, um I think there is a limited role in specific circumstances and I would say that potentially in the event where you do not have contained sepsis perhaps, but where you have uncontained sepsis, for example, an asthmatic leak into a collection that is then discharging out. Um Then I think there is some role very early for a short period of barrel rest and that's mainly to avoid in my mind, things like peas and carrots getting into this. Um And it is yes, just to to in the situation where you don't actually have fully control of the sepsis to try and limit its damage. So again, the girl of that bowel rest, which is days rather than weeks, right? Is not to make the fistula heal or make the bowel heal. It is again to not make the sepsis worse. This is all about sepsis, right? So this is my, one of, one of the diagrams are showed in my slide, you know, in the early stages, we got this evolving cavity, which is not yet a fistula or maybe a little fistula, but you still have a major cavity bn absolutely fine. The moment that fistula has become mature and you've got a proper track and you're confident it's all coming out and everything, get up to get start using that gut. So again, the goal of the bowel rest is not to make the fistula heal. It's it's to make sure the sepsis doesn't get worse. And both of those answers were very, very similar, uh did not chew your peas and carrots in Nottingham, then Lisa, the people just swallow peas and carrots in Nottingham. Do you never chew them then? No. Ok. So block off little holes and stuff. But yeah. Ok. So that's it. That's a very limited role in which, uh, in cases where you may be making an abscess worse. Uh, a guy called Professors Irving when I was, uh, what was called a house dog and back in the day in Manchester once drew me a fistula and I drew him a straight line and he drew a big abscess with a tiny hole at each end. And he said, that's how you treat. That's how you think about fistulas. They're all abscesses. So we do that final question and then kind of close. That's all right. There you go. Oh, sorry. Um, I just wanted to explain on the question earlier. Does it, does it not matter where the level of the fistula is? Would you not bowel rest any bowel even if it's, I'll answer that correct. It doesn't matter where the fistula is. If you have a proximal fistula and you eat and drink, your output will go up. But you can manage that by giving them more parenteral nutrition. If they're on parental nutrition, you can manage it by increasing your amount of constipating agents and stuff like that. What you don't do, of course, is never give octreotide if you think of giving octreotide, that's your, what's called your last throw of the dice. It means every other bit of your brain has imploded and you've completely run out of ideas and what you need to do if you're thinking of giving octreotide as your pen touches. Oh, no, you don't use pens anymore. Do you? Um, as you type, lay a word octreotide into your computer, you should stop and this is for people with fistulas. I'm not talking about neuroendocrine stuff. Stop yourself. Prescribing noot and phone. Either Lisa or Akash or me cos we'll give you the advice of what you should do next. That's my best advice about the use of octreotide in intestinal fistulas. I just hope any other questions? No. Oh yeah. Oh yeah. Thank you, sir. Well, people are asking about because we're always told that lower output fistula are more likely to heal. What, what do you say to that? So if, if the fistula output is 1 L plus, um and like listening to all these conversations in my mind, a liter going through a fistula is not going to allow it to heal. And that's why we're saying, II assume why that's why the registrar put down an NG tube and kept the patient no, by mouth to reduce the gastric contents going down the way and things like that. Um So is, is this sort of out, I mean, you know, foreign bodies prevent fistula healing, radiation, chronic inflammation. What about the output? Just because we're extremely tight with time. If we can, I just don't know, want to leave that an answer difference. Answer that in one word. Yeah. One stops fistula healing sepsis. What causes obstructions, fistulas, sepsis? Yeah. The reason, the fist and what causes a high fistula output sepsis? Say a bit louder sepsis. So if you sort out the sepsis, the output will go down. The reason is people don't, the only thing I would add to that, sorry or is add to that is that if you have a high out, then put in me measure in place to try to reduce the out bowel rest is not one of them. But these other things we just said about what to drink or not to drink, what to eat medication. Those are the, those are the, the, the measures. Yeah. You think they got the message about the sepsis? No hope so. Eventually sepsis. All right. Thank you very much. So, yeah, just drawing to a close this session. Thank you ever so much to our speakers. It's been an absolutely brilliant session. Um And obviously, uh if any further questions coming up, we'll try and answer them in the, in the breaks and things. Thank you guys. I