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Maj Ajay Kumar
Rresident Surgery
Army Hospital(R&R)
OVERVIEW
Abnormal communication between small or large bowel and skin
(Duodenum, Jejunum, Ileum, colon, or rectum)
Esophagus
Stomach Different presentation and
Fistula in Ano and management
Mortality : 5- 15%(Sepsis, Nutritional abnormalities, and Electrolyte imbalances)
HISTORY
Celsus (53 BC) : “The large intestine can be sutured, not with any certain assurance, but because this doubtful hope is preferable to certain despair; for occasionally it heals up.”
John Hunter(mid 19th century) : “In such cases nothing is to be done but dressing the wound superficially, and when the contents of the wounded viscus become less, we may hope for a cure.”
Edmunds et al : 157 patients( 67 developed ECF following surgery) Mortality-62% with gastric and duodenal fistulas, 54% in patients with small-bowel, and 16% with colonic fistula.
CLASSIFICATION Low-output fistula (< 200mL/day)
Moderate-output fistula (200-500mL/day)
High-output fistula (>500mL/day)
Determine the prognosis
High output- Electrolyte imbalance, Malnutrition
Berry SM, Fischer JE. Classification and pathophysiology of enterocutaneousfistulas. Surg Clin North Am. Oct 1996;76(5):1009-18
ETIOLOGY
Post-operative
Traumatic
Spontaneous
Post-operative
Disruption of anastomosis-blood flow
-tension on anastomotic line
-inadequate mobilization
-min leak-perianastomotic abscess
Inadvertent enterotomy - adhesions,
- serosal/full thickness tears
Inadvertent small bowel injury - Occurs during abdominal closure, especially after ventral hernia repair
Traumatic
Iatrogenic surgical trauma
Road traffic accidents
Spontaneous -20-30% of cases
Malignancy
Radiation enteritis with perforation
Intra-abdominal sepsis
Inflammatory bowel disease – eg. Crohn disease
PROGNOSIS 90% ECF closed within first month.
10% with in next TWO months. Remaining unlikely to get closed spontaneously
Factors preventing the spontaneous closure
F oreign body
R adiation
I nflammation/infection/inflammatory bowel disease
E pithelialization of the fistula tract
N eoplasm
D istal obstruction
Maingot’s Abdominal operation 11th edition
Favourable Not favourable
Organ of origin Oropharyngeal, Esophageal, Duodenal stump, JejunalColonic
Gastric, Lateral duodenal, Ileal
Etiology Post-op, Appendicitis, Diverticulitis
MalignancyIBD
Output Low(<200-500ml/day) High(>500ml/day)
Nutritional state Well nourished Transferrin >200mg/dl
MalnourishedTransferrin <200mg/dl
State of bowel Healthy adjacent tissueIntestinal continuity
Diseased adjacent bowelDistal obstruction
Fistula characteristics Tract >2cmBowel wall defect <1cm 2
Tract <2cmBowel defect >1cm2
Skin excoriation
INVESTIGATIONS
Lab studies
TLC: sepsis
Serum Na+/K+: Electrolyte abnormalities
CBC, total proteins, serum albumin, and globulin : malnutrition-associated anemia/hypoalbuminemia
Serum transferrin - Low levels (< 200mg/dL) are a predictor of poor healing
Serum C-reactive protein - levels may be elevated
Fistulogram
Water soluble contrast
I – Simple, short blind ending, < 2cm
II - Continuous linear, long single, >2cm
III - Continuous complex, multiple linear
Tract positions are as follows:
Anterior - Ventral, 10- to 2-o’clock position
Posterior - Dorsal, 4- to 8-o’clock position
Lateral - Right (2- to 4-o’clock position) or left (8- to 10-o’clock position)
CT Scan
Fistula tracts are not usually visible
on axial CT imaging, although
sagittal or reconstructed images
may provide useful information
Identify abscesses and guide percutaneous interventions
MANAGEMENTMain Principal of management:- SNAPP
S- Sepsis
N- Nutrition
A-Anatomy of fistula
P- Protection of skin
P- Planned procedure
Sepsis- most important factor.
65 % of death in ECF pt
Culture based Antibiotics (consider infection with fungal organism)
Intrabdominal collection should be drained radiological assisted.
Nutrition
Poor enteral intake
Hypercatabolic septic state
Loss of protein rich enteral contents
Correction of-
Dehydration
Hyponatremia
Hypokalemia
Metabolic acidosis
Calories :25–32 kcal/kg/day(upto 40-45kcal/kg/day)
(Calorie:nitrogen ratio of 150:1 to 100:1 )
Protein: 1.5-2 gm/kg/day
Parenteral nutrition followed by early shift to enteralroute
Fistuloclysis
Step-by-Step regimen to control the output:-
Step 1
- ISOTONIC solution and fluid restriction- pt should be restricted to total of oral fluid of 1500ml/24hrs out of which 1 liter should be oral electrolyte solution. Remaining 500 ml can be pt choice
- Drinking water should be avoided with in 30 min of meals
Step2
- PPI- omeprazole 40-80 mg /24 hrs
Step3
- Loperamide - 4 mg QID to start than go up to 16 mg QID.
and codeine – 60 mg QID
Step4
- Octreotide- limited evidence of benefit
Start with 200micrgram SC TDS for 48 hrs
Protection of Skin:-
Wound Care- intestinal content are corrosive d/t proteolyitc enzymes
Wound manager, vacuum dressing
Failure to protect skin around the ECF is one of the indications of early surgery
Plan and time surgery:-
Factors determining the readiness for surgical repair of ECF:- Physiological-
Sepsis adequately treated.
Nutritionally replete/ positive nitrogen balance
Abdominal Hostility-
Abdomen soft, clinically no induration
Granulating wound/ prolapsing bowel loop
Time since fistula development
Minimum 6 wks
Usual time around 6 months
PsychologyPt ready and prepared psychologically
Strategy for surgery:- Indications for Re-laparotomy in the early post-opeartive
period:-• Generalized peritonitis• Deterioration despite radiological assisted drainage.• Multiple or septate collections• Ischemic bowel• Abd compartment syndrome• Inability to protect the skin from intestinal content
Principles to follow in complicated cases:-• Construction of stoma proximal to an anastomotic leak or
fistula.• Peritoneal lavage(toileting)• Debridement of dead tissue
Resection of fistula and EEA
Reconstruction of abdominal wall defect:-
Primary closure
Component separation technique
Prosthetic mesh- single stage or vicryl and prolenebased two stage closures
Biological mesh- decellularised collagen matrices (allograft / xenograft) or non cross linked porcine derived mesh
Emotional and psychological support
Hyperventilation
THANK YOU