What is the best course of action for a woman who develops a small bowel fistula after a cesarean section (CS), presenting with abdominal pain, tenderness, and distension?

Management of Small Bowel Fistula After Cesarean Section

Resection with primary anastomosis (option B) is the definitive treatment of choice for a woman presenting with small bowel fistula after cesarean section with abdominal pain, tenderness, and distension. 1

Rationale for Surgical Management

The World Journal of Emergency Surgery guidelines strongly recommend resection with primary anastomosis for small bowel fistula after cesarean section for several reasons:

• It definitively addresses the source of infection
• It has fewer recurrences compared to simple repair
• It is appropriate for stable patients with localized pathology
• It prevents further peritoneal contamination and systemic inflammatory response 1

The timing of presentation (5 days post-CS) suggests an iatrogenic injury rather than a spontaneous fistula, requiring prompt surgical intervention.

Why Other Options Are Not Recommended

• Colostomy (option A): Not appropriate for small bowel fistula as it does not address the primary pathology and is unnecessarily invasive for this condition 1
• Soft diet only (option C): Conservative management is contraindicated in this scenario as the patient already has signs of peritonitis (abdominal pain, tenderness, distension) and imaging confirms a small bowel fistula 1
• Hemicolectomy (option D): This is an excessive procedure for a small bowel fistula and would remove uninvolved colon tissue 1

Surgical Approach

The surgical procedure should include:

1. Exploratory laparoscopy/laparotomy starting from the ileocecal junction and working proximally
2. Complete assessment of the small bowel
3. Resection of the affected segment with primary anastomosis
4. Thorough peritoneal lavage
5. Consideration of biopsies of any suspicious tissue 1

Important Considerations

• Timing is critical: Delay in surgical intervention beyond 48 hours is associated with significantly increased mortality 1
• Approach selection: Open approach is recommended for hemodynamically unstable patients or those with peritonitis, while laparoscopic approach may be considered in hemodynamically stable patients if expertise is available 1
• Antibiotic therapy: Administer appropriate antibiotics for 4-7 days based on clinical condition (e.g., Piperacillin/tazobactam 4g/0.5g q6h) 1

Post-Operative Management

• Monitor for complications such as anastomotic leak, recurrent fistula, short bowel syndrome, and wound infection
• Consider delayed primary closure in contaminated cases
• Monitor for recurrence symptoms, particularly in the first year after surgical management 1

Clinical Pearls

• Early intervention prevents further peritoneal contamination and systemic inflammatory response
• Mandatory resection of any necrotic segment is required in cases of non-viable bowel
• Primary anastomosis is preferred in hemodynamically stable patients
• Consider temporary stoma only in cases of severe peritoneal contamination or hemodynamic instability 1