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Thanks to do so for inviting me here in midst of a very great program. I am going to speak on what can be done in any setting. So I'm not going to spend that much time talking about what is done in the tertiary if units, but more about how can we actually prevent it and how can we manage it in the setting of even the DGH and a non specialist unit. Um First of all, what's if it, it's a barn door thing, but it's basically where your gut doesn't work enough and you need intravenous supplements, be that uh preenter fluids, be that parenteral nutrition and that can be caused by a variety of reasons. Um There's a functional classification. So type one, if is self limiting, we will all see this, your postoperative ileus is basically type one if it's self limiting and in general doesn't come within the remit of an if F unit. Once you kind of get beyond 28 days, you start talking about type two. If that's prolonged, those are mostly actual complications, fistulation, ongoing abdominal sepsis. And then unfortunately, there's a group of patients who progressed to type three if so, that's long term irreversible in inverted commas, intrasinal failure or short bowel syndrome, chronic obstruction and intrasinal dismotility. Uh you can look at pathophysiology as well. There are five major groups of conditions which can cause if so the short bowel and the short bowel and uh mechanical obstruction. So, blockage symptoms and then extensive small bowel mucosal disease such as Crohn's uh radiation enteropathy. Um and, and similar, the the the these numbers are underrepresentation, probably of actual, if numbers, he's looking at numbers of patients on BN. So two per three per million in Europe to uh probably slightly more in the UK um and varying numbers uh indicating prevalence. So the question of course is, well, ok, if that's intestinal failure, what's normal, the normal small bowel that is hugely variable, right? From about 2.5 to 8.5 m and even beyond in general, we say that if you've got less than 2 m of small bowel, you probably have short bowel and at risk of having a form of insufficiency or failure critically. Um If you, you know, if you only have about a meter of small bowel ending in a jejunostomy or a fistula, uh that's probably gonna cause you trouble. Uh that, that critical length of small bowel can be less the more colon you still have connected to it. The colon is really important in slowing things down and absorbing fluids. If you look at the category of short bowel. You've got three types of short bowel. So you've got the category of having a hidrogeno toomy or high fistula. Those patients will normally get quite often nutrition and fluid balance issues and need parental support. Uh patients who have that, but with go in circuits depending also, of course, on how much golden is, the circuit will usually maintain fluid balance, but we probably still need nutritional support because obviously they still have a short length of small bowel to absorb calories over. And then the patients who've had a mid small bowel resection, so have a gal ileal or ileo ay anastomosis rarely develop major issues, causes a short bowel. There are lots of causes the main ones massive intestinal resections such as due to thromboembolic events, repeated small bowel resections for surgical complications for Crohn's OCS fistulae which cause high output post bariatric surgery is quite a big group as well. And then in the pediatric population, necrotizing enterocolitis, which I won't focus on in, in this talk, as everybody probably knows, fistulation is a major challenge with significant costs and still even now, fairly high mortality, not as high as it was, you know, a few decades ago, but still particularly high sepsis is the main driver for mortality in fistulation. The other diers being the underlying disease, you know, if you've got malignant fistulation and obviously, that will determine your prognosis. Some patients get a lot of bleeding, electrolyte, imbalances, malnutrition um, the causes are varied. There are surgical causes such as anastomotic leaks or inadvertent bowel injuries. Uh The technique of abdominal closure distal obstructions, uh, per management. There are some, uh I wouldn't call it evidence, but there's some data which may suggest that the, the slightly more aggressive bowel prep regimens which are used can, can, that can be associated with fistulation rates. Of course, abdominal sepsis, patient factors such as smoking, poor diabetic control all contribute to all of this. And of course underlying disease, patients with Crohn's will be more prone to have fistulation, especially if they have small bowel Crohn's intraabdominal malignancy, diverticular disease and radiation damage. Um Like I said, there is still quite high mortality rates associated with fistulation. And interestingly, there's more data coming out that if you got high fistula outputs, your mortality risk increases probably has to do with, you know, the, the electrolyte imbalances and the malnutrition rates. Now, not as we said that that it's a bad thing to have. What can we do to try to prevent it? Um I'm just going to give some key topics. You can have a whole symposium on just this topic. So go into detail. But basically, there are few things I think we can all do be very critical about this tendency to just have another look. The planned 2nd, 3rd, 4th, 5th Relook, I had a patient referred to me the other day who has fly after 10 rel looks, all of which were planned. That's probably nine, too many, maybe even 10, too many. Um, and you know, the whole thing about, I'll just have a look under the hood. Um, is, is I think a bit obsolete or should be obsolete. Definitely have a very high threshold about going in after 10 days after your last laparotomy also. Um, the other thing, so we were talking about relook the other thing, open abdomens. Um Bogota bags or Bogota bags have saved lives undoubtedly in the ischemia setting in the trauma setting. Um it shouldn't really have a role in the abdominal sepsis setting if you are gonna leave an abdomen open and that's still a big if but if you do do it in a way that you're thinking ahead about how to get that abdomen closed again. And a Bogota bag is not, is not a temporary closure, it's a temporary covering and that's all it is. And actually there's guidance out there. You know, the ACP GBI guidance on emergency surgery very clearly states that one should try a dynamic closure technique and the dynamic closure technique of choice in the guidance is mesh mediated facial traction with negative pressure wound therapy. There will be a video of that signposted in one of the other presentations in this session as well. So leaving the abdomen open, like I said, damage control, the concept of damage control laparotomy comes from the trauma and ischemia setting and it's absolutely valid. Right. But a, a laparotomy for abdominal sepsis is not a damage control laparotomy. There's no damage to control. There's a source to control, which is different from damage. So this whole hit and run thing quickly, get in, get out and run away. It doesn't really apply to most of these patients. The whole concept of planned relook in the abdominal sepsis patients is probably not valid for most of them. And actually, there's a randomized controlled trial from the Netherlands, the relapse trial, which randomized patients who came with uh abdominal sepsis to either a Rook on demand strategy or a planned Relook strategy. Once source control was achieved in the index laparotomy. Uh And that actually showed that there was higher mortality rates and higher major morbidity rates in the Planned Rook patients. Um And again, brother said, if you leave an abdomen open, have a do it with a plan in place um to, to, to plan for early closure. And you know, there's a lot of data out there showing that early closure of an open abdomen is associated with significantly decreased mortality rates for these patients. So you're actually doing them a massive favor. This is an overview published a few years ago as well. It looks at various methods of closure or non closure. Bogota bag is there as well and looking at things like, like, you know, ultimate closure rates, fistulation rates and mortality rates, you can, you can kind of see that a static closure technique like Bogota bag probably has is one of the least favorable options. Um And again, like I said, the our own guidelines on emergency surgery and also the world's emergency surgery guidelines say that if you do leave an abdomen open in that index, laparotomy, um at the very start your neck, depression, wound therapy, uh there are commercial devices on the on the market, there are non commercial devices which you can kind of make yourself the key thing in that is the visceral protection sheet because what you want to do in that first laparotomy is avoid the intrasinal cocoon from adhering to your parietal peritoneum because that leaves your options open. If you are gonna, if you are gonna come back uh to get that closed, the moment your bowel starts sticking to everything it becomes very difficult to do. Um And then when you are going to get to closure, if you can't just close primarily, then a combination of negative pressure wound therapy and mesh mediated facial traction, avoid putting in bridging mess depending on the mesh you use. If it's a vitral mesh or a biologic mesh, that's basically a static closure technique, not really closure but whatever and definitely synthetic, even these so called safe measures, you know, the composite measures should not be used in these scenarios. Um The other thing about prevention is uh you know, know when not to make joints. Um So, for instance, in man, our patients in the presence of ischemia, there's very little points joining two ischemic bits about together. Uh but also next to active sepsis, if you've got balance, which you've kind of been marinating in this pool of badness for a few days or a few weeks trying to join them up is like, you know, stitching together two bits of wet newspaper. It's probably not gonna hold. Um And yes, that means that there will be patients where you, you are gonna be given if, but that's more controlled, if you know, by bringing out a high stoma, that's probably better than it all falling apart and then becoming very unwell or fistulated. At least this is a controlled situation. The other thing is like I said before, don't use non absorbable mesh next to pri bowel. And also, although you probably won't find this in a lot of guidance. Yeah. Fine. Don't V directly on the ball, I think that's a no brainer but also don't VAC on top of an absorbable bridging mesh. Right. There's, there's this tendency and nine times out of the 10 will go fine. Right. But that one time out of 10, you get this guy, um who basically they, his abdominal wall after an A B resection. Um and they had to do something to his stoma. They couldn't get him close. They put the bridging biologic mesh in and back on top of that was sent home and about four months later he pitched up in A&E because he saw some weird green stuff in his back canister and they took it down and that's, that's, that's what it looked like, kind of. Um, so, you know, be very careful about how you deal with these wounds when you have, once you have got closure or coverage. Um, the other key thing, even if you forget everything else, I've said, please don't. But if you do, this thing is really important, don't operate in the wrong window and the window is kind of 10 days to six months. You know, d don't keep on going in, definitely try not to go in beyond 10 days. Um, and again, if you look at, you know, the timing of definitive, I have surgery like fistula repair, uh, surgery, the longer we wait, the lower, um, the, the rate of recurrence of fistulation. And if you pool a lot of data from various papers together, then you can see a definite trend towards lower mortality, the longer one waits, but also lower fiscal of recurrence rates, the longer one waits, right. So, in general, our cut off is about six months, but even beyond six months, the longer one waits, the better it gets now, uh, pre-optive period. So this is pre I surgery period. Um, you know, patient, these patients have been through a lot and the team has been through a lot. They've been in the hospital for months on end. Um, quite often for various reasons. They've been confined to beds also for various reasons, which most of them are not valid. They've been kept nil by mouth. Um, quite often in an attempt to dry up the fistula. You know, if the fistula hasn't dried up in a few weeks, it's probably not going to dry up. Right. You just have to accept that. And I don't know if anybody's ever tried remaining no by mouth. It's really hard and it's really difficult and it's really horrible for patients. So at some point you just need to give in and let them eat. Um, they'll have a high output stoma or fistula. Uh, they'll have had multiple operations, maybe even some failed attempts to repair things. You know, we are surgeons. We like fixing problems, even like fixing our own problems and sometimes that's not the right thing to do. Um, it'll be a bit septic because of pockets here and there. They want something done. The family want something done. The, the, the, the team wants something done. They've had maybe repeated infections. Their liver is going off a bit and they're depressed. I think every patient who has ever come to the IU at ST Mark's and that's not because of ST Mark's, but just because of what they have will have a degree of depression or PTSD. Maybe it is in Marks. I don't know. Um, they say Mons, gosh. Um, now So, in general, when they come to us, I, you know, and this is where I'm, I'm always, um, there are multiple reasons why I'm glad that I'm a surgeon. But one of the things is that I actually don't have to do all that much in those early stages. Right. It's about draining sepsis. I think stomach care, stomach care, of course does is more than just stomas but also complex wounds and fistulas and everything. And then I kind of say, get the medical bit sorted and then I kind of take a step back and then let the gastroenterologist do their magic again. Like I said, let them eat crucial, get them out of bed crucial, um, site support, not as needed but definitely needed. And then also very rarely, it is vanishingly rare that we would offer definitive surgery in that admission post transfer across to us. It's about getting them home. And quite often when I tell them that I said, listen, you're not going to have an operation in this admission. The plan is for you to go home. The first thing I hear is a big sigh of relief. They've been in the hospital for months and they want to go home. Um, and they don't, the last thing they want is yet just another big operation. Spend many more months in the hospital. So they actually are relieved when we tell them that, uh, you will have all heard or seen this pneumonic at some point snap, it's short, it's snappy. Um, ironically it is, um, not a complete story, you know, uh, sepsis, nutrition, anatomy and plan. It's, it's a, it's a, it's a concept but actually there's far more to it. So you've got the immediate phase where sepsis is the main important thing, but also early wound management, pain control. Um, then the early stages where I gained maintenance, fluids, thinking about nutrition and refeeding in those early stages and engaging with psychosocial support, engaging with physiotherapy is crucial as well. And then you got the late stage of management where you start thinking more about the anatomy, you start thinking ahead about your operation and again, crucially plan, it's a planned procedure minimum six months from the last laparotomy quite often, even longer than that sepsis, important, very important, try to try to drain it without the need for surgery. Sometimes you need to do surgery just to drain sepsis quite often, you know, pockets in the paracolic gutters or whatever, if you can't get it with. Ir you could sometimes very carefully, you know, kind of think about the risks and benefits of going in surgically, try not to disrupt the sinal cocoon. It's about getting access to that pocket and then draining that. Mostly I must say IR nowadays has become so good that they can drain most things. Um Something about nutrition and electrolytes, the concept of bowel rest, um is probably no longer the standard of care or it shouldn't be. So this thing about, oh, well, let's keep the no by mouth or just on tips or something. Um And just the end, uh for months on end is not really the standard of care anymore. Use the gut, the gut is there to be used even if it's only 50 centimeters of gut, use it. Um And if it's accessible and possible and accessible is, of course, more than just you think, right? And you can access guts via a fistula, you can access gut via a mucous fistula or a loop stoma or a double bowel stoma or whatever. So that's where the concept of distal lymph feeding comes in. Um And you know that that's basically involves infusion of either feed or stoma outputs into out of circuit guts. It promotes intestinal adaptation. Certainly, when bowel has been out of circuit for a long time in some patients, especially patients with high fistulas or high stomas, it may even replace or reduce the need for prevent nutrition because you activate your intestinal break. So it slows your output down. But also you're making use of all that absorptive capacity which is out of circuits. Um And that's what I said. So it may also reduce your, your stone outputs. There are various ways of doing that that you won't go into detail, you know, various routes. What are the goals? Um You know, you can feed with different stuff basically continuous or bolus feeding. And there are a lot of different tubes that one can use for all of that. And again, that's a different symposium altogether. But basically, this is somebody who's doing bolus feeding with a bit of vital 1.5. So just a bit of uh nutrition. And actually, this man had a high, this is actually a fistula. So this was a high loop type fistula at about 60 centimeters from DJ. And he did this about five times a day and was able to come off PN altogether prior to surgery. Um And then this is another chap. I don't know if these videos are going to work. Um But it basically shows this is a commercial device called the insides pump, which basically um dri is a driver to drive the stoma effluent from the proximal limb of a stoma or a fistula into the distal limb without the patient having to manually kind of, you know, aspirate it and, and, and, and um put it down the distal limb. So it's quite patient friendly. Ok. Yeah. And then the other one kind of shows the same thing. Um And that works quite well. Uh Yeah. So in general, when to feed, when not to feed in the acute setting, when the patient is just fistulated, and the patient is quite often septic um treat sepsis, that's what you need to do. First drain collections, correct your fluid and electrolyte balances and it is probably, you, you find once when they're septic and spiking and everything to avoid PN in lines in those 1st 24 to 48 hours. But once the sepsis is controlled, start thinking about nutrition. PN probably in that very early stage. Once you have an established fistula, um, 1 to 2 weeks, maybe even sooner, start oral or enteral feeding, um, and distal feeding where, where possible. So again, in this stage where you've got a developing fistula, so you basically don't have a fistula yet, but you've got like a cavity which is going to break through once that's an established fistula. Think about enteric feeding, maybe with fistula classes or enteral classes. If you still have a partially mature tract with still a cavity in the middle, probably p until that's all settled down and then through enteral feeding, this whole process probably is a matter of days rather than weeks or months, right? So this whole concept of months of just PN probably doesn't fit anymore. Um What w when they do have either short bow or high put stone or he put fistula, um, it's, it's about what to eat and drink and then what volumes, right? So it's not about not eating, it's definitely not about not eating, but it's also not about, oh, are you having all these losses or drink more? That's also the wrong thing to say, right. So they can definitely eat in general solid food, low fiber high salt junk food. They love it when I say you can have that. Um, our new S mark site has got a mcdonald's just across the road, which is brilliant. It works really well. Uh, for these patients, not for the patients who want to rehabilitate for other types of surgery, but I know um, fluid allowance. So again, like I said, don't just tell patients to drink more. It's about what to drink, right. Hypotonic fluids will drive asoma output. So you can paradoxically dehydrate yourself by drinking more. It's about what to drink. So limit your hypotonic fluids to about a liter a day. As long as you also have a glucose saline solution like Cinar mix or something similar for another liter a day. And then um you know, a combination of drugs. So, anti motility agents quite often you have to give loperamide and codeine in conjunction, you can give quite good dosages and they work best if you take them together half an hour before food. So not with food just before anti secretory agents, protein pump inhibitors, you know, lansoprazole and everything are the standards octreotide. There is actually not a lot of evidence for ret in non pancreatic fistulae. Definitely not that it is better than all the other meds and it is more expensive and because it's injections, it's actually a bit uncomfortable for patients. Um So we don't really support using octreotide in the majority of these patients and then drug therapy, not in the early stages. But ultimately, you know, there's the growth factors coming on the market or on the market, which are probably going to be a huge game changer in all of this. What is not helpful in the treatment of high output stomas are things like Creon Golos and everything, right? They are not the mainstay treatment of, of this problem. Again, electrolyte solutions, there are different ones we go for S Marks mix because a it doesn't, it, it actually gives you good sodium input. Uh That's why it taste so horrible because it's salt. It's basically seawater, but it also doesn't have potassium. Whereas double strand diorite, which is the other big alternative used in the country, you need to make sure you need to check your potassium every once in a while because there's actually quite a lot of potassium in double strength or a light by double strength. I mean, if you follow the manufacturer's instructions, it is still a hypotonic solution. You have to double it. It's 10 sachets in a liter. Um And again, all these sports drinks which everybody keeps going on about are also hypotonic. Even if you add some salt to it, it's still hypotonic. So they still don't really help with all of this. Um This is the same guy, you know, the, the chap who had this this afternoon with the VAC and everything. This is him in my clinic a few months after discharge managing this himself because of input from the stoma nurses who just told him how to do it himself and he was doing this himself. So that's great. Again, the other things also and that starts very early on. Think about risk factors, diabetic control, smoking, obesity, you can be obese and non nursed. I'm probably not the first one to tell you that. So that's important underlying conditions like Crohn's will need to be treated. If there are revascularization options in men ischemia, then look at those, deal with portal hypertension dips and stuff like that is all quite important. But also like I said, mobility. Um I, we've had patients come to us with flexion or contractures of their legs because they've just stayed in bed for no reason. There was nothing wrong with their legs to begin with. There was something wrong with her bowel and their belly to begin with, but not with the legs. Um Behavioral patterns again, same thing sometimes it's the patient who drives that, you know, II don't I don't feel like engaging with physio today. So send them away. Um And you need to kind of break through that pain management, the more pain relief, the more opiate somebody's on before big surgery, the more tricky it's gonna be manage their post surgical pain. So deal with that as well. And also dentition, you know, we can tell people to eat more solids if they don't have the teeth that's gonna be a bit tricky as well. Anatomy, a little thing. It's important to know about your anatomy. Um, and there are various ways of doing that are barn doors. A CT with IV and oral contrast, you can do a mesenteric phase. If the underlying problem was, was vascular, you can think about CT enterography or M small bowels if there's a Crohn's a pathology underlying it, and then all kinds of other tests which basically aim to having contrast opacification of every bit of the digestive tract in that patients, even the outer ones, right? So those could be 0 g done, stoma, there could be water. So contrast studies and in patients where you think you're going to be joining up a relatively short segment of small bowel to an incomplete colon, especially in female patients. Think about anorectal physiology and an ultrasound because you could actually make the quality of life a hell of a lot worse by doing that. Uh if they don't have uncontrollable, diarrhea, incontinence issues. So those are the page we may need to think about what may be bringing out an end colostomy as part of their operation. Uh This is an example of a CT with, with, with oral contrast. So you get good contrast ification um of the small bowel which then leads ultimately into a uh big XLA prostate type wound and a fistula in the mis there. So that, that's a, this is a decent contrast oac CT scan. This is an example of a different patient of a fistulogram uh where you can again see a decent length of small bowel, a pacifying distal to a fistula. This is a patient that we then set up on distal and feeding and A came off b nearly altogether. Um This is again, our chap uh who we met and even in this guy, you know, this all looks very kind of like, well, what the hell is going on here. But if you systematically map him, you can turn that into this. You know, there are various ways of documenting anatomy. This is something we've published on. So you can kind of get an idea in a glance how much bow they have left that there's actually not a lot of bowel between all these fistulas. So you don't really have to work to hard on preserving all those little bits of bowel and making 5 million anastomosis. Um And, but also thinking about, you know, the abdominal wall that the ureters may be troublesome because the small bowel stuck to them. So it, it's, it's a way of mapping, but it's important that you get an idea in your mind. Um What's going on with that patient for those left for short gut. Despite all our best intentions, there are, there are options intestinal letting procedures have been around for a while. Most of the data is from the pediatric population. The evidence for it in support in the adult population is very sparse, very bad quality. And it is not actually that frequently done in the UK, especially InterSim growth factors, like I said, are probably going to be a game changer. The combination of restoration of continuity where you can with intrasinal growth factors is probably going to get quite a few people off PN or maybe transition from parenteral nutrition to just parenteral fluids or a combination. And then of course, like Miss Amin said, there's a huge role for interstital transplant and again, early engagement, uh rather than once they failed and they, you know, the liver has gone off and they have no access anymore is is crucial in these patients. So, um in short, avoid this whole tendency to just reoperate with the best of intentions, right? We all want to fix problems, but maybe sometimes the best way to fix the problem is not creating more problems. Wait as long as you can and then even a bit longer feed the gut wherever you can. Don't just tell the patient to drink more aggressively look for and treat sepsis, but avoid laparotomies in doing so be standardized and systematic in your mapping and also the documentation of the mapping. And also crucially which I haven't said here but a plea that if you end up in the middle of the night doing an emergency operation where you resect bowel, nobody actually cares how much bowel you've removed, you know, patients proudly tell them proudly the guy who say, oh, so and so removed 3 m of bowel. Excellent. How much do you still have left? I don't know. And it's not in any up not, it's, it's nowhere there, right? Document how much bowel you leave behind. That would be one of the pleas I think. Um, if you want to know more about incidental failure, ST Mark's has the horizons course, which is annual, which is in October, both online and in person at the Royal College of Physicians. So please feel free to sign up. And then of course, I wouldn't be a surgeon if I wouldn't also just advertise our major flagship conference, which is free online for those who want to attend. And thank you very much.