This topic is about managing small-bowel fistulas after abdominoperineal resection (APR) surgery and understanding what to expect from a fistulogram. A person who recently underwent APR surgery and now has a draining small-bowel fistula is seeking advice and insights on how to cope with this situation, especially with the fear of further surgery.

Here are some helpful points and advice:

1. **Understanding a Fistulogram**:
- A fistulogram is performed by an interventional radiologist.
- It involves injecting a contrast dye directly into the fistula and using CT fluoroscopy to track the dye’s path.
- The procedure is usually painless, lasts about 10 minutes, and typically does not require sedation, although light sedation may be used if necessary.

2. **Managing the Fistula**:
- Consider the placement of a pelvic or abdominal drain to divert output, reduce skin damage, and lower infection risk.
- Total parenteral nutrition (TPN) and a very low-residue or nil-per-os diet can help rest the bowel and encourage spontaneous closure.
- Regular blood tests are important to monitor for sepsis during this period of "watchful waiting."
- Protect the skin around draining sites, as leaking intestinal fluid can quickly erode tissue.

3. **Timing of Surgery**:
- Repairing a fistula often requires patience, with surgeons sometimes waiting 6–12 months after the original operation to allow inflammation and infection to settle.
- However, if the fistula enlarges rapidly, skin damage worsens, or there are signs of sepsis, more urgent intervention may be needed.
- It’s important to gather full information, ask questions, and weigh the risks of early versus delayed surgery.

4. **Living with Drains, TPN, and Lifestyle Adjustments**:
- Night-time TPN infusion allows for some daytime mobility.
- Drains can be bulky and affect body image, so choosing appropriate clothing and securing the collection bag can help with going out.
- The emotional toll can be significant, so peer support and setting realistic goals can help maintain morale.

5. **Treatment Sequencing Perspective**:
- Opting for surgery before chemo/radiation can be beneficial, as radiation may damage colon tissue and chemo can weaken healing capacity, complicating later surgery.

6. **General Coping Advice**:
- Monitor the wound closely for increasing output, odor, redness, or fever.
- Consider a wound VAC if suggested, as it can speed up healing and protect surrounding skin.
- Keep in touch with your surgical, wound-care, and nutrition teams, and promptly address any concerns about pain, fever, or increased drainage.
- Utilize family or community support to help ease daily management tasks.

For practical tips on managing fistulas, you might find the blog run by Clare Mee helpful.