A fistula is an abnormal epithelialized tract between two or more structures or spaces.It may involve a communication tract from one body cavity or hollow organ to another hollow organ or to the skin.It is estimated that 90% of ECF arise from surgical procedures. It occurs due to unintentional enterotomy and anastomotic breakdown as a result of a foreign body close to the suture line, tension on the suture line, complicated suturing techniques, distal obstruction, hematoma, abscess formation at the anastomotic site, or tumor.Emergent/urgent surgeries involving unprepped bowel, underresuscitation, malnourishment or previously radiated tissues are other causes for fistula development.Spontaneous fistulas can develop due to crohn's disease, malignancy, infectious processes as in tuberculosis, diverticulitis, vascular insufficiency, radiation exposure and mesentric ischemia.
Fistulas can be classified according to complexity, anatomic location or physiology. Excess fluid exudating from a wound or cutaneously is the usual first indication of an external fistula.Skin excoriation rapidly occurs secondry to the high concentration of digestive enzymes in the chyme. Internal fistulas are fissuring tracts inside the body, which erode directly into adjacent viscus. These are asymptomatic unless the distal portion of the fistula enters a structure such as the bladder , rectum or vagina. Symptoms such as recurrent diarrhea with mucus, blood, cystitis, pneumaturia, flatus or stool from the vagina, perianal/perineal skin excoriation, pressure and discomfort, should all point towards an investigation for the presence of a fistula.
Closure of the fistula either spontaneously or surgically is the ultimate goal. The five main objectives towards caring for fistula are - 1.)Fluid and electrolyte replacement. 2.) Adequate nutrition.The route of nutritional support will take the form of oral, enteral or parenteral nutrition dependent upon patient tolerance, ability to ingest sufficient quantities, the fistula tract location and bowel mucosa's absorptive capacity. 3.)Perifistular skin protection and containment of fistula effluent , which in itself is a complex challenge. Advanced assessment skills, knowledge of appropriate product selection, competence in product application and teaching of the same is very important . 4.) Infection control with use of antibiotics .5.) measures to facilitate closure of the fistula.
Medical and nursing care demand a complementary, interdisciplinary approach if successful closure of an enterocutaneous fistula is to be achieved. The patient and the family are challenged by physical and psychological stressors, which is often the result of weeks of hospitalization.As health careproviders, we should remember to treat the patient as a whole person and not 'just as a hole'. The fistula should not become the only focus of care, but rather an element of the overall treatment plan.

Surgical procedures are generally recognized by Pancreatologists as the most effective treatment for chronic pancreatitis in reducing acute exacerbations and chronic symptoms.Surgery performed for chronic pancreatitis can be classified as resection procedures or drainage jejunostomy.Types of pancreatic resection surgery include Whipple and Beger's procedures.Drainage pancreaticojejunostomy procedures include Puestow and Frey's operations.When the pancreatic duct in the body or tail is dilated beyond 6 mm, the puestow procedure is usually most effective.When disease occurs predominantly in the head of the pancreas, Frey's procedure is used.When there is a focal mass in the head without significant duct dilation, the whipple's procedure is most frequently done. Beger's procedure which preserves the duodenum, is also used as an alternative.
Several expected postoperative CT and MRI findings may be confused with disease.Periportal hepatic edema, which usually resolves in 1 month, and pneumobilia which usually persists, are seen universally.The afferent loop of the bowel that drains the pancreatic and biliary ducts may be edematous in the first 3 weeks.This appearance should not be mistaken for bowel ischemia or hemorrhage. The Roux loop may be mistaken for an abscess.In puestow procedure, the Roux loop lies between the stomach and the pancreatic body in the lesser sac and should not be misinterpreted as an internal hernia or pancreatic tumor.Transient fluid collections in the pancreatic and duodenal bed are common in the first month after surgery and do not need to be drained unless clinically indicated. Reactive lymphadenopathy is seen upto 2 months postoperatively.Perivascular cuffing around the celiac, hepatic, and mesentric arteries is seen upto 6 weeks after whipple and Beger's procedures.This finding can be mistaken for tumor recurrence.Mild pancreatic duct dilation is an expected postoperative appearance.After Frey's procedure, a large cavity may be seen in the pancreatic head and may possibly be mistaken for a pseudocyst or cystic neoplasm.Some errors can be avoided if postoperative anatomy is known to the radiologist.

Gastro Esophageal Reflux Disease (GERD ) is a very common digestive disorder. Medical therapy , involving acid suppression and promotility agents are very effective for a majority of these patients but a small number of these patients do not get complete relief. Laparoscopic fundoplication is a procedure performed for patients with symptomatic GERD refractory to medical management and that which is associated with hiatal hernia .The problem lies at the junction of the esophagus and stomach where a muscular valve should prevent acid from backing upwards. If this sphincter mechanism fails, acid is free to reflux up into the food pipe and cause damage. The surgery basically augments this sphincter by wrapping a portion of the stomach known as the fundus around the lower esophageal sphincter.Before the laparoscopic approach was developed, this surgery required a large incision and the hospital stay was long. Laparoscopic fundoplication is a safe procedure, and provides less post operative morbidity in experienced hands.The fundus of the stomach which is on the left of the esophagus is wrapped around the back of the esophagus until it is once again in front of this structure.The portion of the fundus that is now on the right side of the esophagus is sutured to the portion on the left side to keep the wrap in place.The fundoplication resembles a buttoned shirt collar. The collar is the fundus wrap, and the neck represents the esophagus imbricated into the wrap.This has the effect of creating a one way valve in the esophagus to allow food to pass into the stomach, and prevent reflux of gastric acid.