An enterocutaneous fistula arising from the small bowel and draining spontaneously through the abdominal incision may be managed successfully with medical therapy. Therapy should include nasogastric decompression, replacement of intravenous ﬂuids as well as TPN, and appropriate antibiotics to treat an associated mixed bacterial infection. If the infection is under control and there are no other signs of peritonitis, the surgeon may consider allowing potential resolution of the fistula over a period of up to 2 weeks. Some authors suggested the use of somatostatin to decrease intestinal tract secretion and allow earlier healing of the fistula. In some cases, the fistula will close spontaneously with this mode of management. If the enterocutaneous fistula does not close with conservative medical management, surgical correction with resection, bypass, or reanastomosis will be necessary.
A rectovaginal fistula that occurs following gynecologic surgery is usually the result of surgical trauma that may have been aggravated by the presence of extensive adhesions and scarring in the rectovaginal septum associated with endometriosis, pelvic inﬂammatory disease, or pelvic malignancy. A small rectovaginal fistula may be managed with a conservative medical approach, in the hope that decreasing the fecal stream will allow closure of the fistula.
A small fistula that allows continence except for an occasional leak of ﬂatus may be managed conservatively until the inﬂammatory process in the pelvis resolves. At that point, usually several months later, correction of the fistula is appropriate. Large rectovaginal fistulas for which there is no hope of spontaneous closure are best managed by performing an initial diverting colostomy followed by repair of the fistula after inﬂammation resolves. After the fistula closure is healed and deemed successful, the colostomy can be reversed.
Risk Factors Deep venous thrombosis and pulmonary embolism are largely preventable, yet significant complications in postoperative patients. The magnitude of this problem is relevant to the
Table 22.11 Thromboembolism Risk Stratification
Age <40 years with other risk factorsa and major surgery
History of deep venous thrombosis or pulmonary embolism
Age >60 and cancer or history of venous thromboembolism aRisk factors: obesity, varicose veins, history of deep venous thrombosis or pulmonary embolism, current estrogen, tamoxifen, or oral contraceptive use.
gynecologist, because 40% of all deaths following gynecologic surgery are directly attributed to pulmonary emboli, and it is the most frequent cause of postoperative death in patients with uterine or cervical carcinoma (125,126).
The causal factors of venous thrombosis were first proposed by Virchow in 1858 and include a hypercoagulable state, venous stasis, and vessel endothelial injury. Risk factors include major surgery; advanced age; nonwhite race; malignancy; history of deep venous thrombosis, lower extremity edema, or venous stasis changes; presence of varicose veins; being overweight; a history of radiation therapy; and hypercoagulable states, such as factor V Lieden, pregnancy, and use of oral contraceptives, estrogens, or tamoxifen. Intraoperative factors associated with postoperative deep venous thrombosis include increased anesthesia time, increased blood loss, and the need for transfusion in the operating room. It is important to recognize these risk factors and to provide the appropriate level of venous thrombosis prophylaxis (127,128). The levels of thromboembolism risk are listed in Table 22.11.