Colorectal Episode 5 UL CRS

Welcome back Behind the Knife listeners. Today I have my team, Drs. Kavalukas, Wolszynski, and Galandiak with me to go through several case scenarios surrounding the prevention and management of enterocutaneous fistulas. To review, an enterocutaneous, or EC, fistula is an abnormal connection between the gastrointestinal tract and skin.

Considering most EC fistulas result from surgery, this is a dreaded complication and a postoperative issue common to most surgeons. Today, we'll focus discussion on prevention and management of postoperative EC fistulas. Let's use a complicated case to highlight important tips and tricks. Alright, so let's say that you have a 64 year old man who presented to the hospital and you did a urgent small bowel obstruction due to a closed loop stricture or closed loop obstruction in the setting of prior radiation that the patient had maybe gotten 10 years ago.

So you see him back in clinic, it's his two week follow up,

and he says he's not doing so hot, he has some fevers, chills, and abdominal pain. And when you look at his abdominal exam, he has some erythema, swelling, and tenderness over his abdominal wall. So you're concerned and you admit the patient to the hospital for further workup.

So, Dr. Bulszynski, it's two weeks out, what do you think, are you, do you think this guy should go back to the OR, or what kind of things, how do you think you're going to manage this, this patient? Yes, this is a incredibly challenging problem that all abdominal visceral surgeons face, not only colorectal surgeons.

I certainly tell many trainees and that was what I've been taught that we should avoid going back from day 12 to week 12. And so I'm very dogmatic about this. And I try to optimize and investigate patients promptly, promptly so that we get to a point of diagnosis before day 12. But exceptions do occur.

Obviously, necrotic

bowel is one exception where you may need to take a patient back. Hemorrhage may be another. Inability to obtain appropriate drainage of sepsis is a third. I guess, generally speaking in relation to sepsis, so, the inflammation that occurs at about day 15 tends to obliterate the peritoneal cavity.

And so, I don't think a patient can get generalized peritonitis as such, and so localized abscesses that do evolve tend to be able to be drained under IR. Two examples that come to mind and have challenged the sort of day 12 to week 12 dogma that I follow. Were one case of mine where there was a patient who underwent what I thought was a fantastic laparoscopic left hemicolectomy with a hand sewn end to end anastomosis.

And after about day 20, the patient developed a very high grade small bowel obstruction from what turned out to be an internal fissure. the transverse mesentery

defect and I did end up taking him back and I found that the adhesions were much more friendly than I expected. And certainly I think perhaps with more MIS surgery, the dogma of day 12 may change to an extent.

Because I think there probably is less adhesions and less inflammation. Another case that comes to mind referred to me from an outside hospital was a patient who presented with hemoperitoneum in the right colon mesentery somewhere. On the background of enteric Crohn's disease and a division of adhesions that was performed about five weeks prior.

Unfortunately that operation, I don't think was the correct operation as nothing was resected. And so the patient presented with this active bleed, no obvious blush on CT and was an extremist. And we had to take him for an urgent laparotomy. And to my very pleasant surprise, again, the adhesions were not as horrendous as I expected.

And I do wonder if Patients who are on systemic steroids

tend to not develop as aggressive and acute inflammatory process post laparotomy as others. And this is where maybe Dr. Galandiak has a lot more experience about this. I've often noticed that to be the case, but not always, but many times. I do agree, I've had to take some internal hernias back at that time, but I wonder if because the root of that problem is more, you know, anatomic and less infectious or inflammatory.

If that would affect it or not, or I, I agree what you're saying it, when I've done it laparoscopically, I'm like, you know, this bowel peaked out into that internal hernia and we can try to pull it back in versus something clearly went wrong here. The suture line broke down, it's starting to get inflamed and necessitate towards somewhere, be it, you know, an intra abdominal abscess or the midline fascia.

I wonder if it would be a different scenario, but I guess.

Fortunately, unfortunately, there's no randomized controlled trials we can do for that. So, and we'll embrace surgeries definitely change this. So what are some other factors that could have potentially been addressed preoperatively in this patient to prevent this complication?

Right. So I guess in broad terms we can look at patient factors such as, say, smoking, nutrition, obesity, distal obstruction. Then we have disease factors such as IBD or in, In this case that we're discussing radiation, and there's also technical factors, so anastomotic technique, inadvertent enterotomies equipment limitations, limitations of the surgeon when faced with equipment limitations so lack of patience sometimes now, I guess one of the things in terms of the technical factors that I think is important is whether you use sharp dissection or not when dividing adhesions.

And so whilst I

do use energy for hemostasis sometimes, I certainly am very strict in that I only divide adhesions with with sharp dissection. And I believe that For my cases, it eliminates the potential delayed enterotomy due to an inadvertent burn. And that reduces the potential diagnostic uncertainty when I'm faced with patients who, you know, who are evolving into something concerning a few days after a complex division of adhesions.

My last point on the matter I guess, for colorectal surgery or particularly revisional surgery, I think it's like playing a game of chess. In that it is very important to think several steps ahead. For example, overwhelmingly for small bowel, I perform an end to end hand sewn anastomosis.

And so, I've started placing a Weck clip on the mesenteric edge of the anastomosis to ensure that that is easier to find radiologically if I am ever

to do a post operative scan. Interestingly, we had a discussion about this with the Leahy group at one of the DCI journal clubs and I've adopted that from them.

Alright, so let's say that your patient is admitted and undergoes a CT scan with contrasts and they note a lower abdominal wall collection with oral contrasts that is extravasated into this collection. It's walled off, there's surrounding loops of small bowel. It does say it's concerning for developing an ercutaneous fistula.

Your labs show a Y count of 16, a creatinine of 2 some other electrolyte derangements. They're a little bit tachycardic but their blood pressure is stable. I think it's really important for all listeners that we review a lot of the main key management tenets of EC fistula care. With the obvious hope to close the fistula or if we can't close a fistula, optimize the patient or fistula take down in the future.

So the first

tenet that I always like to consider is the control of sepsis. So, This patient has an intra abdominal fluid collection that we are presuming to be an infection. So, the patient should be started on antibiotics and a drain placement whether that be CT guided or if the patient were to be in more extremis.

Such as high fevers, rigors, rigors, sorry hypotension that may necessitate someone going back to the OR for control of their sepsis and placement of a drain. You want to make sure you collect or correct any fluid electrolyte imbalances, which can happen if it's a high output fistula more often than low output fistula that we'll talk about later on.

And so get the patient started on IV fluids and once they're stabilized, consider. Nutrition for them, whether it be parental, if it's a low output fistula, or it needs to be sorry, if it's a high output fistula parental, or if they're able to eat enteral nutrition

consider potentially refeeding the fistula if you're able to figure out the distal portion of it.

And of course, watch out for that central line sepsis if someone started on TPN. I think the other, you know, medications that you can try to sort of, if it's a high output to try to decrease the output is, you know, proton pump inhibitors to try to reduce the gastric secretions trietide and other somatostatin analogs have very mixed data.

I don't think it's harmful to, Try it. I've seen it work in some instances and not make a difference in other instances, but it's it's available for use. And then other anti motility drugs such as loperamide or codeine can also be used to decrease the fistula output. I think that, further to that, the preparation of the drug sometimes is helpful.

So with loperamide, opening up the capsules tends to absorb them better. And I've actually noticed

that locally we have liparamide, which is sublingually absorbed now, which again, arguably would be much more efficacious for these cases. So crush the pills or, or make them more effective in absorption.

Dr. Galandiak, can you tell us a little bit about the standard of care imaging to map a fistula? Well, it depends sort of what what the previous surgeon has done. I mean, if you know they've had done an oocolic anastomosis and that's what's fistulized, I don't think there's there's really a lot of need to do studies for it.

But if you have an unclear situation, then a lot of times it's useful to do a gastrograph and study either through an NG tube or through the fistula itself, just to figure out where it's at. So, you know, roughly how much fluid output you're going to be expecting from it. And to make sure that there's not distal, the important thing is to make sure that there's not distal obstruction.

It's

keeping it open. And for most of at least our patients that we take care of here in Louisville I know we rely incredibly heavily on our wound care ostomy nurses. Do you have any particular tips and tricks that you rely on Dr. Glandiac? Well, I think in many cases having a vac on these patients or either just official appliance is very helpful in terms of.

Just cleanliness and keeping things in order and the biggest I think advance in terms of getting things to seal is using you can ring type devices around the fistula, especially if fistulas are in areas of creases where they don't seal real well, having taking an econ ring which are those little round Disc like things that people put around stomas, cutting

them and using them to line the edges of the wounds will help seal and get good, a good seal, whether you're using a wound collector type of appliance, or whether you're trying to put a vac onto a low output fistula to get it to heal.

And for kind of our younger listeners, I think it's just important to. For us to review that there are some favorable characteristics that you want to look out for in those fistula grams defects that are smaller than 1 centimeter. Those that have longer tracks tend to heal spontaneously rather than needing a future surgery.

And long tracks are defined as greater than 2 centimeters. However, and to be aware that, you know. Non gastric ligament of traits and ileal origin are more likely to spontaneously heal as well. And we're always looking to get a good pouch on fistulas to make sure that we get appropriate ins

and outs so we can better classify them as kind of low, moderate, or high, high output being greater than 500 cc's a day to kind of adjust and manage expectations with your patient as that's kind of a, a pretty important prognostic factor for someone's going to need a future surgery or not.

And conversely, what you often will see, or at least, unfortunately, I often see is entire end of the bowel in the wound. That's not going to close. So you might try to hope it's going to close. I think the other, you know, the, if we're, if we're listening to this for kind of outside prep. You know, it's certainly something that I also think about even when I'm preparing to close the intercutaneous fistula as you think of your friends mnemonic.

You think about foreign body radiation infection or inflammation, inflammatory bowel diseases are all your eyes. E is epithelialization of the, of the fistula

tract. neoplasms. And then the distal obstructions I really pay a lot of attention to. Some people advocate highly for to do a full lysis of adhesions because if you have anything very distal to your fistula tract and you just try to do a local fistula takedown, it's likely to recur if you don't go back and address anything that's further downstream.

So that's something You know, to think about either both for the fistula, but also something that may need to be dealt with when you go back for reoperative surgery and in terms of taking care of these patients, while enteric nutrition is always much to be favored over parenteral nutrition in many of these people have high fistulas.

That just isn't practical because if you give them, even if you're trying to give them elemental nutrition, it's just, you know, so increases your fistula output if they have a proximal fistula, that or there's just such a limited amount of GI tract available for absorption that you just have.

And if you have no access, good access to the distal part it just is parental is unfortunately a lot of times the way to go. And I think another point to make before we move on is just the importance of kind of a multidisciplinary team approach, like most things in surgery to, you know, if this is a complicated scenario to, you know, ask for help from your gastroenterology colleagues or talk directly with your interventional radiologist.

and review those images together befriend your wound ostomy, internal stoma therapist, get dietary involved, social work, and really those kind of mental health therapists are really important too because this ends up being, you know, months and months long problem and it carries a high risk for depression for both the patient and the family and the surgeon at times.

And the surgeon. And the surgeon. So, you know, don't forget to ask for help from all those specialists.

But I can't stress enough how many of the listeners may not know where they're going to be practicing or what resources they will have. It is so worthwhile going to spend time with your local wound ostomy nurse and just learning basic, tips and tricks of managing these kind of wounds.

You don't know what kind of resources you might have if you're still in training when you go out, and just knowing how to apply these things, I think, is a really important thing. Alright, so let's move on. So let's say, you know, we've taken care of his, of this patient's initial sepsis and presentation of the fistula, and he comes back two months later, continues to have a liter and a half of output from this lower midline fistula despite optimal medical management.

So, now we're starting to think about taking him to the operating room for

a take down of the fistula on an x lap and what, what kind of our, what's our tips and tricks and timing for taking down these fistulas. I'd like to just hit on the importance of differentiating between enterocutaneous and so called enteroatmospheric fistulas and, and Dr.

Glandiak touched upon it a little bit where you can see a loop of bowel protruding. So I guess when a fistula is mature, the bowel can protrude above the level of the abdominal wall. It almost looks like a stoma. And the skin. And I think it's important to also assess the, the flanks. And when the patients with mature fistulas are examined, their abdominal wall is quite lax and you can move the flanks.

as opposed to having this feeling of this, you know, woody cocoon which obviously would be far more hostile. And so I think such signs are subtle and, and they're acquired over a long period of time, but this probably speaks to the point of really these, these cases should be performed by.

By an experienced team with, you know, with gray hairs and in a catch 22, these cases will then cause more gray hairs.

But yeah Hey, I'm going to have gray hair. Oh, What was mentioned that the patient had one and a half liters and the decision despite optimal medical management and the decision was made to take the patient back. That shouldn't be the case. A thing to make the decision to take the patient back. You can have home IV fluids, you can have you know that that high output is not a reason to do an early closure.

You, you wanna wait to exactly what Dr. Hinky said, to have a palpably soft abdominal wall. Is your reason to take the patient back to close the fistula, not because they're having high output. Rod, what's your typical timeframe that you feel like you get to that nice. soft abdominal wall. Do you think it takes six months, a year?

What's, what do you, what do you typically

see with that physical exam finding? It varies. I also find that some of these patients, because their history is so complex they're not a very good historian. And so there's a lot of extra findings like infected mesh and things like that, that somehow arise.

But I certainly wouldn't touch anyone for at least six months. And then it depends. Some, some people longer. I don't. Try to hide from the cases, but they're very unique and apart from the rule of a minimum of six months I don't have any anything else to say. Dr. Glandiak, say you've waited the six months on this patient And you're preparing to take the patient to the OR.

How do you manage the patient's expectations and consent them? Well, I always tell them that they may have a temporary stoma. I think it's very important not to make them think that they're going to get rid of everything because if there

are a lot of adhesions, if it's a very bloody case, I think it's in the patient's interest to have What's done to be safe.

And you always want to do tell them ahead of time that they may have a temporary stoma. And it's not, it's stupid to try to think you're gonna close everything all at once if it's not safe. And you have to tell them that ahead of time. And they realize that you want to do what's. And that's what's safe for them.

I always in these patients tell them that if there are a lot of adhesions, they're going to get a gastrostomy tube because everybody hates and G tubes and the gastrostomy tube is just easier. You want to take as much pressure off the anastomosis or anastomosis, depending on how many there are as you can.

And again, a temporary stoma is. One of the ways you can do that if they're if it's very hostile, and

in terms of assessing the abdomen, sometimes you'll have a safe periphery of the abdomen, but just the region around the fistula will be harder on examining, and that's acceptable too. But you realize that there'll just be a lot of adhesions just in the vicinity of the fistula itself.

So I'm hearing that we should consent widely on all possibilities and I know personally I've been taught to review all prior op notes and imaging. Make it your first and only case of the day. Eat breakfast. Have a friend on standby if you have to take a break for Diet Coke. And cause you need to get it right the first time cause you don't want to be in there doing it a second or third time.

So, with all fistula surgery, we'll kind of dive into a little bit further. The goal is to one, restore as much continuity of the entire bowel as possible, resect the fistula with goal of end to end anastomosis of the

bowel and to appropriately address abdominal wall closure. In regards to actually being in the operating room, Dr.

Glandyak, what are some of your go to tips and tricks of dissecting the bowel? You know, where do you go to with closing? And then we can kind of open it up to the other folks in the room of what their preferences are. But I, you know, because I've operated with you in the past, I know you have specific go to moves.

Cowardice is key. You always want to start in the So this is not the time to make tiny incisions. So you always want to start in the area where you think there has been least operating and start from the safest area first and work toward your worst area. You always want to ellipse out the area of the fistula.

And again, start in an area where you think there's been less incision. trauma

or a physical exam the area where it's softest. So always and I totally agree with Dr. Wolszynski using sharp dissection for entering the abdomen using a blunt scissors, either a Mayo scissors or Harrington scissors.

You, you want to, Do something that will cause least trauma to the bowel. And I agree with Dr. Cavalucos, you don't want to lyse all adhesions because you don't want to leave any kind of distal obstruction. I always will put patients, unless I know they have No rectum in Lloyd Davies position. So modified lithotomy because you never know when you need access down below or whether you might need to scope from below.

And if you have a patient who has. You don't have obvious bowel loops in a fistula, and you only have pinpoint areas, then I will, before surgery starts, inject methylene blue into those tracts

to ensure that I can, once I'm in the abdomen, access all, see all those areas where the fistula has been draining to.

And for the trickiest, and this is where I've learned from you most, is to use that hydro dissection. And at the end of your case, you want to measure and document how much small bowel you have left with your measuring tape or umbilical tape, whatever, however you do math best. And, you know, check for those leaks.

Run the bowel as many times as you need to assure that you have it missed, a serosal or, you know, an tear or an enterotomy. And if that means using before you close an enterotomy or bulb syringe to test any other leakages or with a Foley balloon, that that's what you have to do. Any other tips and tricks that you guys like to use?

I try to, I will spend a vast majority of. The week

before really thinking long and hard about why I think they got that intercutaneous fistula. I mean, they certainly happen, but I think that. You really need to, you know, if this is a 24 year old that you were operating on for a weird, small valve structure, and I would certainly double check and make sure I didn't think that Crohn's disease or something because.

This is not an operation that I would like to do two and three times over. And so sometimes it just happens. And then other times it's, you know, something that you really need to try very hard to exhaust all the possibilities as to why it happened so that you're not that person that's going back doing the same thing twice and getting the same results.

Yeah, so you do your whole dissection, no distal obstruction, and now you have to close the abdomen. Dr. Balszynski. Thanks. I have to fly the flag for surgeons with autistic traits of whom there are a lot.

And I think in and these types of operations really bring those to the fore because in a case where there's so much unpredictability, it's so important to reduce the variability as much as you can with the things you can control.

And so I have a particular scissor that I use, and Dr. Glandiak touched upon it with rounded tips. I want the same sutures, which are the same color. I, I'd like the same retractor so that When I'm focusing, I'm really just focusing on the challenges of this specific case. The other thing is, I think these cases are so long, and they kind of lend to teaching.

And of course, teaching is very important, and certainly these cases are usually done in academic centers. And what I've realized, or maybe a point for, particularly consultants or attendings when they start, is the realizations that what they can see is not necessarily what the trainee can see

from a pattern recognition perspective.

And so, I kind of observed the trainee and see how much hesitation they have with when they dissect with scissors. And when they start really kind of moving the scissors in a point of semi guessing, it's time to to take them back. And so I think I think that's something which is, I picked up from Jeremy Lipman, who's who's in the Cleveland Clinic, and he's an excellent educator and so it's an interesting way to observe trainees but I think it's useful.

But sorry, I digressed. Back to the abdominal wall these are very long cases and I'm sure there's many opinions but my aim is to simplify and make things as foolproof as possible. And certainly that would mean just closing the abdomen without any pressure. contributing to abdominal wall compromise.

Now, the fistulas in their nature have a fistula relate, sorry, fistula, a hernia related

to them. And so there is loss of abdominal domain. And so I would have to mobilize the fascia quite wide to get that to close. And I am sometimes or frequently forced to do that with interrupted I use PDS, interrupted sutures to make sure that the abdominal the fascia is closed.

Obviously, if I can't, then I'd use a bridging mesh and I would use Vicro, which is dissolvable. On top of that, I always close the skin with non dissolvable interrupted sutures. with a proline or nylon. And my view on that is that it's an extra layer of protection against a burst abdomen. So, I think it's almost inevitable that these patients will represent with a complex hernia.

And in fact, I can send them highlighting that that is going to be the But the aim of my procedure is to control and repair the fistula

and restore intestinal continuity. And I think it's important not to digress from that primary aim. And outside of using that non absorbable interrupted suture for your skin I think the majority of surgeons probably just reach for staples in a contaminated field.

Dr. Skavloukis and Glandiak, do you want to briefly discuss how you close the abdomen as there's, you know, many ways to skin a cat?

I think that I agree with Dr. Wolszynski. I do, I, it kind of, a lot of it just depends on, How much loss of domain the person had how wide the midline is, you know, I, I, my when I don't have intercutaneous fistula as I close with number 1 looped PDFs. And if I didn't have in a running fashion, and if I don't have any, you know, there's a small off midline intercutaneous fistula and I enter through the midline.

I don't think that necessarily changes it for me. If it's. a very wide defect

and certainly bridging mesh or interrupted or sometimes even internal retention sutures, depending on the patient's body habitus is something that I would consider. Or, you know, for some of these, I've had a few that are just absolutely enormous and the patient's entire belly is an intercutaneous fistula.

And at that point, I might have classics get involved to see if they need to do some Some, you know, some sort of either, not necessarily flap closures, but more advanced things that they're more equipped to deal with as far as tissue transfer techniques. The, the worst disservice you can do in these patients is put in some kind of mesh because I think and I've se seen I mean many of my general surgery colleagues swear about how OEC is incredible pardon me for mentioning a brand name.

But you know, a, but anytime you put in a mesh, you're just ask asking for trouble. And I think doing a primary closure. is really, really important for these patients. Having any kind of foreign

body there, unless you're just really, really strapped, is horrible. So I think it is very important to mobilize the fascia to do rectus fascia releases if you need to, even if you harm their abdominal wall.

I tell all my patients after surgery, they will likely get a hernia, but after the fistula is closed, we can then worry about. repairing it later, and I can send them to someone excellent who will put in mesh at that time once their fistula has closed. I think it's incredibly important to agree with Dr.

Volshinsky about closing the skin over this. Every layer you get over it, if you leave the skin open, you will have nurses packing things incredibly hard in that area. The more you pack it, the more likely you're going to be able to get a fascial dehiscence. And packing is evil.

Some of my colleagues have started injecting Botox before surgery as a chemical component release. I personally don't have

much experience with this, but, but in principle, it seems like a fairly safe thing to do. I don't know how much benefit, but that may be something to, you know, pursue. It's an interesting, do they do it in clinic under ultrasound guidance or how do they do it?

I, I think they, the ones that I've heard about are under CT guidance in radiology, but I gather ultrasound would be fine. It is quite a, You know, Palarva because it's not a common thing. So, you know, it then attracts a lot of time and resources where ultimately it probably is far easier to do. It shouldn't be that dissimilar to a tap block, really.

You just want to do a few weeks ahead of time, at least. Okay, we'll say, you know, we're back to our case. Six months have passed and the patient develops another enteric cutaneous fistula. Aside going back to your tenants that we've already discussed

previously, what now? I would send that patient to Dr.

Galandiuk. Me too.

I send them back to you. I will drop it in your office with a smile and praying hands and say, I'm so sorry. Yes. No, but I certainly think that, you know, discussing it in a, in a, you know, with your partners and more experienced colleagues and you know, sort of, you know, just having A fresh set of eyes, both for you and the patient.

I mean, sometimes it's okay to talk to a patient, say, Hey, I'm getting my partners involved. I want to get their opinion. So the patient knows that you're also doing everything you can to try to help them out the problem instead of just spinning your wheels. And they're wondering in the back of their mind.

If you're doing the right thing. I don't think that 2nd opinions ever hurt, but I, that's why I'm very lucky to have Dr. Glyndyck at my institution. Yeah, what now, Vlad?

I guess I think going back to playing chess, I think this is where dividing all the adhesions and restoring the anatomy completely in the first operation kind of pays dividends for these rare recurrences.

So, you know, trying to understand is this a. Is this a new fistula from the last surgery or is this the missed fistula originally? And I mean, every patient is unique. There's no one answer for this, but certainly if I would have to do it again, there is absolutely no way that they're getting out of this without a proximal diverting stoma.

And so, I think I would really want Proximal control knowing that that may be a high output stoma. But I would want to do that. And then obviously this would be a staged thing. Yeah, but apart from that, I don't think that there's unfortunately. Very humbling situation for, for every surgeon involved, but it happens.

But you also have to think about weird things as well. Does the patient have

some obstructive defecation or other things that other people may have overlooked? So you always want to go back to ground one and figure why, what unusual things could have made this patient have a recurrent fistula. Yeah, vascular issues, underlying strange autoimmune disorders, pelvic floor disorders.

I agree. This is tricky. So kind of to start wrapping things up here EC fistulas remain, you know, an extreme surgical challenge, despite a lot of recent improvement in the support we can give patients advanced endoscopy techniques and having all the imaging at our, at our disposable at the end of the day.

Patient optimization and operative decision making and technique is what makes the difference in a patient's life. So once you once an endocrinogenic fistula occurs your key tenets of care are basically, you know, stabilizing patient

source control with sepsis. Thoroughly investigate your fistula anatomy and then, you know, non operative medical management and support is basically, you know, I, especially if you're outside of your optimal window and then once you get to surgery, you know, careful planning you know, rolling out the causes, trying to find the treatment or the the, the, the etiologies of this meticulous dissection and all of the tricks that we heard about earlier.

And re anastomosis and reconstruction of the abdominal wall are critical and multidisciplinary team approach with gastroenterologists, interventional radiologists, certainly your wound care nurses will maximize successful fistula closure. Okay, so as we wrap up, clinical challenges in colon and rectal surgery, management of intercutaneous fistulas.

Let's review our five quick hits. Well, first, I think it's very important to optimize nutrition, correct modifiable risk factors,

set clear perioperative expectations for the patient make the case your first and only case of the day, and exclude causes of distal obstruction. Two, wait until physical exam findings tell you it is safe to proceed to surgery.

Three, start dissection where no man has gone before and this is not the time to be minimally invasive. Four, when you're in the operating room, think many steps ahead, just as if you were playing chess. And five, don't be a hero. Ask for help from experienced colleagues, avoid mesh, and don't rush to reoperate.

Thank you all for tuning in, and until next time, dominate the day.