LBJ Ventral Hernia Protocol – Enterocutaneous Fistula Takedown

• Preop – Weeks to Months Before Surgery
  • MRSA decontamination
    • Mupirocin ointment BID x 5 days
  • Botox – if indicated (may facilitate primary closure at the time of takedown)
    • Inject 4 weeks before planned surgery (range 3-5)
    • 300u divided, injected in all 3 muscle layers bilaterally
  • Chlorhexidine showers
    • Night before and morning of surgery
    • Need to make sure this happens if patient is inpatient preop
  • Nutrition labs
    • CBC, BMP, LFTs, ESR, CRP, prealbumin, zinc, copper, vitamin C, vitamin A, and vitamin E
  • Consider preoperative admission for the following patients:
    • Patients who require a mechanical bowel prep
    • Patients with high output fistulae (would benefit from preop hydration)
• Preop – Day of Surgery
  • DVT prophylaxis – If not getting epidural, 5000u (or 7500u based on weight) subQ heparin preoperatively
  • Regional pain – Epidural or ESP catheters as indicated/able, checking for patient-specific contraindications
  • Entereg – To be given in preop area (it is an oral medication) if patient is not taking narcotics at baseline
  • Preop labs – Obtains labs on day of surgery for small bowel fistulae and patients who underwent a bowel prep.
• Intra-op
  • Foley
  • Arterial line
    • Often placed, but at discretion of anesthesia attending
  • Surgical prophylactic antibiotics following standard guidelines
    • Typically Ancef, add anaerobic coverage if anticipating colon resection
  • TXA
    • 1 gram at the start of surgery and 1 gram at skin closure
    • Additional doses may be given at the discretion of anesthesia
  • Betadine irrigation (diluted to 1%)

IMPORTANT NOTES

• Small bowel EC fistula takedowns do not follow an ERAS pathway. These cases differ from other elective bowel surgery, as these patients almost always develop a postoperative ileus, which can sometimes be quite prolonged. The cases are long and nearly always require extensive lysis. As a result, it is difficult to protocolize things like NG removal, as they will vary patient to patient. Please discuss plans with the faculty before initiating them (particularly changes like NG tube removal or advancing diet).
• Communication expectations:
  • The resident team updates the faculty daily after morning rounds.
  • For more urgent patient-related concerns, residents should call Ferguson. If unable to reach Dr. Ferguson for an urgent question/concern, residents should speak to the on-call surgery attending or call one of the other hernia attendings (Dr. Stulberg or Dr. Holihan).
• Urinary retention: Bladder scans are unreliable if the bladder was mobilized off the abdominal wall during surgery. Additionally, a hematoma could easily be mistaken for a full bladder. Always maintain a low threshold to replace the Foley if AKI, oliguria, or urinary retention develop.

POSTOPERATIVE PATHWAY

• Postop Day 0
  • Communication
    • The operating resident is expected to communicate the following information to the resident group and ICU team: patient info, relevant history (including important home meds that have been restarted or held), operative details (procedure, case duration, EBL, intra-op concerns, relevant details such as extent of lysis and number of anastomoses), drains, postop plan (and any planned deviation from protocol), any special concerns
      • Residents are expected to pass on this information to the night team during sign out
  • Typically admit to SICU
  • DVT prophylaxis – Lovenox starts on night of surgery, followed by BID
    • Use heparin in setting of AKI or CKD
  • Recommended pain regimen
    • Acetaminophen, Ketorolac, Methocarbamol, & Gabapentin scheduled
    • Oxycodone PRN
    • Note: regional pain team follows for catheter management
  • IV fluids – All patients receive maintenance isotonic fluids (i.e., LR or Isolyte)
    • Monitor hourly UOP à titrate fluid rate & administer boluses as indicated
      • Urine output should be maintained at >0.5mL/kg/hr
        • This requires actively checking urine output, not waiting for notification
      • The longer the case duration, the more likely the patient will require additional fluids due to high insensible losses
  • Diet
    • Typically keep NPO except for meds
    • Continue TPN if it was started preoperatively
  • Mobilization
    • Abdominal binder
    • Up in chair on the evening of surgery
    • Consult PT & OT
  • Medications
    • Pain regimen & DVT ppx as above
    • Scheduled PPI if ordering NSAID
    • Continue Entereg until patient has bowel function (flatus or BM)
    • Milk of magnesia BID
    • Continue rate control meds (beta blockers, CCBs) if hemodynamically appropriate
    • Hold other anticoagulation/antiplatelet therapy
    • Hold ACEi & ARBs, initiate on/after POD 1 as appropriate based on renal function & hemodynamic status
    • Diabetics:
      • Sliding scale insulin (low/med/high based on home dose), target glucose 120-160 mg/dL
      • Hold oral hypoglycemics until tolerating regular diet
      • Blood glucose >300 on 2 checks should prompt initiation of insulin drip
    • Typically resume all home psych medications
      • If patients take scheduled benzodiazepines at home, continue inpatient. Otherwise, try to avoid benzodiazepines (even PRN) to prevent delirium.
    • Resume other medications as appropriate
  • Labs
    • Order stat post-op CBC, BMP, Mg, PO4, and lactate
    • Order early AM CBC, BMP, Mg, & PO4 for POD 1
  • Lines/Tubes/Drains
    • Keep Foley in place
    • Typically keep NG postop
    • Consider keeping arterial line
    • If present, measure drain output Q12H
• Day 1
  • Diet – Discuss with faculty
  • Mobilization – PT/OT, out of bed to chair TID with all meals
  • Pain regimen – As above
  • Labs – CBC, BMP, Mg, PO4
  • Lines/Tubes/Drains
    • Assess NG output and quality on morning and evening rounds
    • Consider removing Foley catheter if UOP >0.5mL/kg and no evidence of dehydration
    • If present, measure drain output Q12H
    • Consider removal of arterial line &/or CVC if present
• Day 2
  • Diet – Discuss with faculty
  • Mobilization – Up out of bed unless sleeping, in chair or walking
  • Medications
    • If anticoagulated at baseline, can consider re-initiation of anticoagulation. Decisions to anti-coagulate should be made on a case-by-case basis & discussed with the attending.
  • Labs – CBC, BMP, Mg, PO4
  • Lines/Tubes/Drains
    • Assess NG output and quality
      • Consider clamp trial when output <1 L over 24 hours and quality is gastric
      • Always discuss with faculty before performing clamp trial
    • If present, measure drain output daily
    • Consider removal of CVC, foley, etc. if present
  • Remove dressing for wound check; incisional vac stays in place until POD 7
• Day 3
  • Diet – Discuss with faculty
  • Mobilization – Out of bed unless sleeping
  • Medications – Resume home medications as able, start to wean pain medications as able.
  • Labs – CBC, BMP
  • Lines/Tubes/Drains
    • Assess NG output and quality, consider clamp trial if indicated
    • If present, measure drain output daily and consider removal
    • Consider removal of CVC, foley, etc. if present
• Day 4+
  • Diet – Discuss with faculty
  • Mobilization – As above
  • Medications – Continue to wean pain medications and resume home medications as able
  • Labs – As clinically indicated
  • Lines/Tubes/Drains
    • Assess NG output and quality, consider clamp trial if indicated
    • If present, measure drain output daily and consider removal
    • Consider removal of CVC, foley, etc. if present
    • Remove incisional vac on POD 7 or prior to discharge