Management of Enterocutaneous Fistula Dr. Onkar Singh Department of surgery MY Hospital & MGM Medical College, Indore M.P.
<ul><li>A  Fistula  is defined as an abnormal communication between two epithelized surfaces. </li></ul>
HISTORY <ul><li>The earliest record of an enterocutaneous Fistula appears in the old Testament Book of judges  Written BY ...
<ul><li>In  early  1900’s  enterostomy   was  made  in healthy  bowel  proximally in  obstructed  bowel </li></ul><ul><li>...
CLASSIFICATION <ul><li>Anatomical classification: </li></ul><ul><li>(1)  a.  Internal:   Two organ of same or different sy...
Physiological classification <ul><li>High output - output more than 500 ml/ day </li></ul><ul><li>Moderate output - output...
Etiologic Classification <ul><ul><li>Radiation </li></ul></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul><ul><u...
2. Post-operative  (75-85%) <ul><ul><li>Operations for perforations </li></ul></ul><ul><ul><li>Acute intestinal obstructio...
<ul><li>3.  Congenital </li></ul><ul><ul><li>Tracheo- esophageal </li></ul></ul><ul><ul><li>Rectovaginal </li></ul></ul><u...
 
 
 
ETIOLOGY <ul><li>Extension of bowel abnormalities to surrounding structures. </li></ul><ul><li>Extension of adjacent disea...
<ul><li>Small intestinal fistula are most common type of gastrointestinal fistulas encountered. </li></ul><ul><li>Most ser...
<ul><li>The operations commonly causing small intestinal fistulas   </li></ul><ul><ul><li>Operation for malignancy,  </li>...
<ul><li>Fistula may result from anastomosis done in unprepared bowel or in a bowel with less than adequate blood supply. <...
Pathophysiology <ul><li>Fluid and electrolyte imbalance. </li></ul><ul><li>Malnutrition </li></ul><ul><li>Sepsis  </li></u...
Natural  history Present absent Sepsis Crohn’s, cancer, foreign body, radiation Appendicitis, diverticulitis post operativ...
Unlikely to close Likely to close <200mg/dl >200mg/dl transferrin epithelization Tract >2 cm  Defect < 1cm 2 miscellaneous...
Avg. Time  to closure  <ul><li>Varies  with anatomical  location ; </li></ul><ul><li>Esophageal- 15-25 days </li></ul><ul>...
 
Clinical presentation <ul><li>Recognized 5th-10th days post operatively. </li></ul><ul><li>Fever </li></ul><ul><li>Leucocy...
<ul><li>Localized swelling of the abdominal wall. </li></ul><ul><li>Point tenderness. </li></ul><ul><li>May be  </li></ul>...
Investigations <ul><li>Objectives of investigation plan: To  define- </li></ul><ul><li>Precise anatomical location </li></...
Radiological contrast studies   <ul><li>Fistulography :  A water soluble contrast material is injected into the fistula tr...
FISTULOGRAM
 
 
Entero-colic fistula
CT-  Scan Entero colic fistula Sigmoid cutaneous fistula Gastro cutaneous fistula
Endoscopic studies <ul><li>Gastro duodenoscopy  : Demonstrates both underlying disease and presence of fistula. </li></ul>...
Colonoscopy
Management phases for gastro intestinal fistulas 5-10 days after closure 5. Healing When spontaneous closure is unlikely o...
Stabilization <ul><li>Rehydration </li></ul><ul><li>Correction of anaemia </li></ul><ul><li>Drainage of sepsis </li></ul><...
Stabilization <ul><li>Resuscitation  :   </li></ul><ul><ul><li>Restoration of normal circulating blood volume. </li></ul><...
<ul><li>Nasogastric tubes  : should be removed if  </li></ul><ul><ul><li>There is a no obstruction. </li></ul></ul><ul><ul...
Skin care management: <ul><li>Problems in skin around the fistula: </li></ul><ul><ul><li>Wetness  </li></ul></ul><ul><ul><...
Techniques of skin care: <ul><li>Wound pouch dressings </li></ul><ul><ul><li>One/two piece design </li></ul></ul><ul><ul><...
Wound pouch dressing
 
<ul><li>Skin Barriers: </li></ul><ul><ul><li>Solid wafers (pectin based) </li></ul></ul><ul><ul><li>Powders (Pectin / Kara...
<ul><li>Sump Drainage: </li></ul><ul><ul><li>For fistulae draining with open abdominal wound. </li></ul></ul><ul><ul><li>L...
<ul><li>Nutritional management: </li></ul><ul><ul><li>Plays Central role in  management   </li></ul></ul><ul><ul><li>Adequ...
Central line
Recommended Nutritional Support 10mg/wk 10mg/wk Vitamin K Close watch Usually not needed Minerals 2RDA Vit C –  5 –10RDA R...
<ul><li>Chapman   and colleagues demonstrated that patients receiving optimal nutritional support (3000 calories per day) ...
<ul><li>Patients should receive  3000 to 5000 non proteins calories per day </li></ul><ul><li>Amino acid 100 to 200 gm. </...
<ul><li>Patients  daily protein requirement  is 1.2 to 2.0 gm kg/day. </li></ul><ul><li>Fluid requirement  is 30ml/kg/day....
Total Parenteral Nutrition <ul><li>Conc. dextrose : 500ml of 20% Dex. (=400 kcal) </li></ul><ul><li>Fat : 500 ml 10% fat e...
Administration : <ul><li>Central Line: </li></ul><ul><ul><li>Subclavian Vein </li></ul></ul><ul><ul><li>Internal Jugular V...
Patient Monitoring: <ul><li>Clinically:  (daily) </li></ul><ul><ul><li>Sense of well being </li></ul></ul><ul><ul><li>Grad...
Complications of TPN <ul><li>Mechanical </li></ul><ul><ul><li>Catheter tip malposition (6%) </li></ul></ul><ul><ul><li>Art...
<ul><li>Metabolic   </li></ul><ul><ul><li>Acute </li></ul></ul><ul><ul><ul><li>Hyperglycemia/hypoglycemia </li></ul></ul><...
Enteral Nutrition <ul><li>Benefits: </li></ul><ul><ul><li>Trophic effect on bowel </li></ul></ul><ul><ul><li>Stimulates he...
Control of Sepsis <ul><li>Management of local wound infections </li></ul><ul><li>Drainage if Intra-abdominal collections (...
Antibiotics   <ul><li>To be withheld unless the patient is septic </li></ul>Measures to decrease secretions <ul><li>Shorte...
Emotional support <ul><li>External drainage of enteric contents can be demoralizing </li></ul><ul><li>Psychiatric evaluati...
DECISION: <ul><li>No signs of imminent closure after 4- 5 weeks  then patient should be prepared for surgery. </li></ul><u...
Treatment   <ul><li>Patient should be amply resuscitated </li></ul><ul><li>Drainage cultured </li></ul><ul><li>Intralumina...
<ul><li>Protective diverting stoma proximal to anastomosis </li></ul><ul><li>Secure closure of abdominal wall over the fis...
Operative procedure of fistula
Operated case of enterocutaneous fistula
Late Complications : <ul><li>Short bowel syndrome (after multiple fistula repair) </li></ul><ul><li>Stricture and partial ...
Prevention of Fistula: <ul><li>Prophylactic Antibiotics and Bowel Preparation: </li></ul><ul><ul><li>Polythelene glycol  a...
<ul><li>Appropriate hydration to prevent Hypotension and compromised circulation </li></ul><ul><li>Anastomosis in healthy ...
Decision making <ul><li>Adequate duodenal mobilization in case of gastroduodenal anastomosis </li></ul><ul><li>Tube duoden...
<ul><li>Stomas with mucus fistula or exteriorization to be considered in medically unfit or aged patients </li></ul><ul><l...
HEALING   <ul><li>In the postoperative period, it is necessary to ensure that the patient continues to receive full nutrit...
<ul><li>After fistula closure, whether by spontaneous or surgical means, the patient will need to resume oral intake.  </l...
THANKS
Upcoming SlideShare
Loading in …5
×

Entero Cutaneous Fistula by Dr. Onkar

14,528
-1

Published on

Published in: Education, Health & Medicine
9 Comments
12 Likes
Statistics
Notes
No Downloads
Views
Total Views
14,528
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
1,390
Comments
9
Likes
12
Embeds 0
No embeds

No notes for slide

Entero Cutaneous Fistula by Dr. Onkar

  1. 1. Management of Enterocutaneous Fistula Dr. Onkar Singh Department of surgery MY Hospital & MGM Medical College, Indore M.P.
  2. 2. <ul><li>A Fistula is defined as an abnormal communication between two epithelized surfaces. </li></ul>
  3. 3. HISTORY <ul><li>The earliest record of an enterocutaneous Fistula appears in the old Testament Book of judges Written BY Samuel Between 1043 BC and 1004 BC. </li></ul><ul><li>Celsus described the first reported attempt of surgical repair of a colocutaneous fistula. </li></ul><ul><li>In the 18 th century John Hunter advocated a conservative approach to fistulas after he noted that fistulas occasionally close spontaneously. </li></ul>
  4. 4. <ul><li>In early 1900’s enterostomy was made in healthy bowel proximally in obstructed bowel </li></ul><ul><li>This often would close spontaneously on resolution of obstruction </li></ul><ul><li>This lead to an unrealistic optimistic approach towards all enterocutaneous fistulas </li></ul>
  5. 5. CLASSIFICATION <ul><li>Anatomical classification: </li></ul><ul><li>(1) a. Internal: Two organ of same or different system </li></ul><ul><ul><ul><li>Enteroenteral, enterovesical,enterocolic, colovesical </li></ul></ul></ul><ul><li>b. External : Gut to body surface. </li></ul><ul><ul><ul><li>Gastrocutaneous,duodenocutaneous, enterocutaneous. </li></ul></ul></ul><ul><li>(2) a. Simple or direct. </li></ul><ul><li>b. Complicated - </li></ul><ul><ul><ul><li>1.Having multiple tracts </li></ul></ul></ul><ul><ul><ul><li>2. Connection with more than one viscus </li></ul></ul></ul><ul><ul><ul><li>3. drainage into an associated abscess cavity. </li></ul></ul></ul>
  6. 6. Physiological classification <ul><li>High output - output more than 500 ml/ day </li></ul><ul><li>Moderate output - output 200-500 ml/day </li></ul><ul><li>Low output - output less than 200ml/day </li></ul>
  7. 7. Etiologic Classification <ul><ul><li>Radiation </li></ul></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul><ul><ul><li>Diverticular disease </li></ul></ul><ul><ul><li>Appendicitis </li></ul></ul><ul><ul><li>Ischaemic bowel disease </li></ul></ul><ul><ul><li>Duodenal ulcer perforation </li></ul></ul><ul><ul><li>Malignancies </li></ul></ul><ul><ul><li>Intestinal tuberculosis </li></ul></ul><ul><ul><li>Actinomycosis. </li></ul></ul><ul><li>Spontaneous (15-25%)- </li></ul>
  8. 8. 2. Post-operative (75-85%) <ul><ul><li>Operations for perforations </li></ul></ul><ul><ul><li>Acute intestinal obstruction </li></ul></ul><ul><ul><li>Intestinal malignancies </li></ul></ul><ul><ul><li>Adhesiolysis </li></ul></ul><ul><ul><li>Blunt and penetrating abdominal trauma. </li></ul></ul>
  9. 9. <ul><li>3. Congenital </li></ul><ul><ul><li>Tracheo- esophageal </li></ul></ul><ul><ul><li>Rectovaginal </li></ul></ul><ul><ul><li>Umbilical fistula. </li></ul></ul><ul><li>4. Traumatic </li></ul><ul><ul><li>Blunt and penetrating trauma of abdomen, chest and perineum </li></ul></ul>
  10. 13. ETIOLOGY <ul><li>Extension of bowel abnormalities to surrounding structures. </li></ul><ul><li>Extension of adjacent disease to normal bowel </li></ul><ul><li>Inadvertent or unrecognized trauma to the bowel. </li></ul><ul><li>Anastomotic disruption . </li></ul>
  11. 14. <ul><li>Small intestinal fistula are most common type of gastrointestinal fistulas encountered. </li></ul><ul><li>Most series report 70%-90-% of small intestinal fistulas occurs after an operative procedure. </li></ul>
  12. 15. <ul><li>The operations commonly causing small intestinal fistulas </li></ul><ul><ul><li>Operation for malignancy, </li></ul></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul><ul><ul><li>Adhesiolysis. </li></ul></ul><ul><li>The different complications leading to fistula formation include </li></ul><ul><ul><li>Disruption of an anastomosis, </li></ul></ul><ul><ul><li>Unrecognized injury to the bowel at the time of lysis of adhesions </li></ul></ul><ul><ul><li>Inadvertent suture of the bowel at the time of abdominal closures. </li></ul></ul>
  13. 16. <ul><li>Fistula may result from anastomosis done in unprepared bowel or in a bowel with less than adequate blood supply. </li></ul><ul><li>Anastomosis may also be jeopardized by hypotension owing to inadequate resuscitation or by excess tension placed on the suture lines </li></ul><ul><li>Poor nutritional status contributes to anastomotic breakdown. </li></ul>
  14. 17. Pathophysiology <ul><li>Fluid and electrolyte imbalance. </li></ul><ul><li>Malnutrition </li></ul><ul><li>Sepsis </li></ul><ul><li>Skin irritation and excoriation </li></ul>
  15. 18. Natural history Present absent Sepsis Crohn’s, cancer, foreign body, radiation Appendicitis, diverticulitis post operative Etiology malnourished Well nourished Nutritional status Gastric,ileal Esophageal, Duodenal stump, jejunal Anatomic location Unlikely to close Likely to close
  16. 19. Unlikely to close Likely to close <200mg/dl >200mg/dl transferrin epithelization Tract >2 cm Defect < 1cm 2 miscellaneous Total disruption,abscess,total obstruction, active disease. Healthy adjacent tissue, small leak,quiescence disease, no abscess. Condition of bowel
  17. 20. Avg. Time to closure <ul><li>Varies with anatomical location ; </li></ul><ul><li>Esophageal- 15-25 days </li></ul><ul><li>Duodenal- 30-40 days </li></ul><ul><li>Colonic - 30- 40 days </li></ul><ul><li>Small Bowel- 40-60 days </li></ul>
  18. 22. Clinical presentation <ul><li>Recognized 5th-10th days post operatively. </li></ul><ul><li>Fever </li></ul><ul><li>Leucocytosis </li></ul><ul><li>Prolonged ileus </li></ul><ul><li>Abdominal tenderness </li></ul><ul><li>Drainage of enteric material through the abdominal wound or through or existing drains. </li></ul>
  19. 23. <ul><li>Localized swelling of the abdominal wall. </li></ul><ul><li>Point tenderness. </li></ul><ul><li>May be </li></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>dehydration </li></ul></ul><ul><li>Decreased peripheral vascular resistance </li></ul>
  20. 24. Investigations <ul><li>Objectives of investigation plan: To define- </li></ul><ul><li>Precise anatomical location </li></ul><ul><li>Is the bowel in continuity or is disrupted </li></ul><ul><li>Abscess cavity </li></ul><ul><li>Condition of adjacent bowel </li></ul><ul><li>Is there a distal obstruction </li></ul><ul><li>Etiological disease process </li></ul>
  21. 25. Radiological contrast studies <ul><li>Fistulography : A water soluble contrast material is injected into the fistula tract through a 5 or 8 size pediatric tube and it is observed fluoroscopically or through static radiological films. </li></ul><ul><li>Barium transit studies : Barium meal follow through & barium enemas. </li></ul>
  22. 26. FISTULOGRAM
  23. 29. Entero-colic fistula
  24. 30. CT- Scan Entero colic fistula Sigmoid cutaneous fistula Gastro cutaneous fistula
  25. 31. Endoscopic studies <ul><li>Gastro duodenoscopy : Demonstrates both underlying disease and presence of fistula. </li></ul><ul><li>Colonoscopy : Fistula is usually not visible but presence of disease and its nature by biopsy can be demonstrated. </li></ul><ul><li>CT scan : To evaluate the abdomen for presence of abscess in an aseptic patient. </li></ul>
  26. 32. Colonoscopy
  27. 33. Management phases for gastro intestinal fistulas 5-10 days after closure 5. Healing When spontaneous closure is unlikely or after 4-6 wks. 4. Definitive therapy 7-10 days to 4-6 wks. 3. Decision After 7-10 days 2. Investigation Within 24-48 hrs. 1. Stabilization
  28. 34. Stabilization <ul><li>Rehydration </li></ul><ul><li>Correction of anaemia </li></ul><ul><li>Drainage of sepsis </li></ul><ul><li>Electrolyte repletion </li></ul><ul><li>Osmotic pressure restoration </li></ul><ul><li>Nutrition support </li></ul><ul><li>Control of fistula drainage </li></ul><ul><li>Institution of local skin care </li></ul>
  29. 35. Stabilization <ul><li>Resuscitation : </li></ul><ul><ul><li>Restoration of normal circulating blood volume. </li></ul></ul><ul><ul><li>Correction of electrolyte & acid base imbalance. </li></ul></ul><ul><ul><li>Plasma oncotic pressure should be restored by exogenous albumin administration. </li></ul></ul>
  30. 36. <ul><li>Nasogastric tubes : should be removed if </li></ul><ul><ul><li>There is a no obstruction. </li></ul></ul><ul><ul><li>Fistula is a low in intestinal tract. </li></ul></ul>
  31. 37. Skin care management: <ul><li>Problems in skin around the fistula: </li></ul><ul><ul><li>Wetness </li></ul></ul><ul><ul><li>Burning pain </li></ul></ul><ul><ul><li>Discomfort from skin edema </li></ul></ul><ul><li>Goals of skin care: </li></ul><ul><ul><li>Containing the effluent </li></ul></ul><ul><ul><li>Patient independence and mobility </li></ul></ul>T
  32. 38. Techniques of skin care: <ul><li>Wound pouch dressings </li></ul><ul><ul><li>One/two piece design </li></ul></ul><ul><ul><li>Clip closure or Urostomy type </li></ul></ul><ul><ul><li>May be attached to a bed side bag or suction catheter </li></ul></ul>
  33. 39. Wound pouch dressing
  34. 41. <ul><li>Skin Barriers: </li></ul><ul><ul><li>Solid wafers (pectin based) </li></ul></ul><ul><ul><li>Powders (Pectin / Karaya based) </li></ul></ul><ul><ul><li>Paste </li></ul></ul><ul><ul><li>Spray and wipes </li></ul></ul><ul><ul><li>Ointments and creams (zinc/petroleum based) </li></ul></ul>
  35. 42. <ul><li>Sump Drainage: </li></ul><ul><ul><li>For fistulae draining with open abdominal wound. </li></ul></ul><ul><ul><li>Large bore drains or sumps </li></ul></ul><ul><ul><li>High pressure suction (better results). </li></ul></ul>
  36. 43. <ul><li>Nutritional management: </li></ul><ul><ul><li>Plays Central role in management </li></ul></ul><ul><ul><li>Adequate circulation and tissue oxygenation must for optimal utilization. </li></ul></ul><ul><ul><li>May be: </li></ul></ul><ul><ul><ul><li>Enteral </li></ul></ul></ul><ul><ul><ul><li>Parenteral </li></ul></ul></ul>
  37. 44. Central line
  38. 45. Recommended Nutritional Support 10mg/wk 10mg/wk Vitamin K Close watch Usually not needed Minerals 2RDA Vit C – 5 –10RDA RDA Vit C – 2RDA Vitamins Parenteral (20-30%) Enteral (20-30%) Lipids BEE x 1.5 BEE Calories 1.5-2.5g/kg/day 1-1.5g/kg/day Protein Usually Parenteral Enteral Form High Output Low Output
  39. 46. <ul><li>Chapman and colleagues demonstrated that patients receiving optimal nutritional support (3000 calories per day) had a mortality rate of 12% as compared to 55% mortality among patients receiving a sub optimal nutritional regimen. </li></ul><ul><li>Robauk and Nichdoff reported closure of 73% enteric fistulae in patients with adequate caloric supplementation but only 19% healed when nutritional support was inadequate. </li></ul>
  40. 47. <ul><li>Patients should receive 3000 to 5000 non proteins calories per day </li></ul><ul><li>Amino acid 100 to 200 gm. </li></ul><ul><li>TPN should initiate early in the course of treatment while adynamic ileus persist and before the fistula tract is well established. </li></ul>
  41. 48. <ul><li>Patients daily protein requirement is 1.2 to 2.0 gm kg/day. </li></ul><ul><li>Fluid requirement is 30ml/kg/day. </li></ul><ul><li>Electrolyte requirement/day </li></ul><ul><li>Na-70-100 meq/day </li></ul><ul><li>K- 70-100 meq/day </li></ul><ul><li>Mg- 15-20 meq/day </li></ul><ul><li>Ca- 10-20 meq/day </li></ul>
  42. 49. Total Parenteral Nutrition <ul><li>Conc. dextrose : 500ml of 20% Dex. (=400 kcal) </li></ul><ul><li>Fat : 500 ml 10% fat emulsion (=450 kcal) </li></ul><ul><li>Crystalline Amino Acids : 500 ml 10% Amino acids (=8.4 g Nitrogen) </li></ul><ul><li>Daily Vitamin Supplementation ( Vit. K 10 mg weekly) </li></ul>
  43. 50. Administration : <ul><li>Central Line: </li></ul><ul><ul><li>Subclavian Vein </li></ul></ul><ul><ul><li>Internal Jugular Vein </li></ul></ul><ul><li>Peripheral line </li></ul>Rate of Infusion: <ul><li>Starting: 50 – 100 ml/hr </li></ul><ul><li>Gradually increased by 25 – 50 ml/hr every second day </li></ul>
  44. 51. Patient Monitoring: <ul><li>Clinically: (daily) </li></ul><ul><ul><li>Sense of well being </li></ul></ul><ul><ul><li>Graded activity </li></ul></ul><ul><ul><li>Vitals </li></ul></ul><ul><ul><li>Weight / input-output </li></ul></ul><ul><li>Laboratory profile: (daily until patient stable then twice weekly) </li></ul><ul><ul><li>Serum Electrolytes </li></ul></ul><ul><ul><li>RFT </li></ul></ul><ul><ul><li>LFT/ coagulation profile </li></ul></ul><ul><ul><li>Lipid profile </li></ul></ul>
  45. 52. Complications of TPN <ul><li>Mechanical </li></ul><ul><ul><li>Catheter tip malposition (6%) </li></ul></ul><ul><ul><li>Arterial laceration (1.4%) </li></ul></ul><ul><ul><li>Hydro-pneumo-haemo thorax (1.1%) </li></ul></ul><ul><ul><li>Subclavian/Superior vena cava thrombosis (0.3%) </li></ul></ul><ul><ul><li>Thrombophlebitis (0.1%) </li></ul></ul><ul><ul><li>Catheter embolism (0.1%) </li></ul></ul><ul><li>Septic </li></ul><ul><ul><li>Catheter related sepsis (7.4%) </li></ul></ul>
  46. 53. <ul><li>Metabolic </li></ul><ul><ul><li>Acute </li></ul></ul><ul><ul><ul><li>Hyperglycemia/hypoglycemia </li></ul></ul></ul><ul><ul><ul><li>Electrolyte abnormalities </li></ul></ul></ul><ul><ul><ul><li>Fluid overload </li></ul></ul></ul><ul><ul><ul><li>Hyperlipidemia </li></ul></ul></ul><ul><ul><li>Chronic </li></ul></ul><ul><ul><ul><li>Metabolic bone disease </li></ul></ul></ul><ul><ul><ul><li>Alterations in bile composition </li></ul></ul></ul>
  47. 54. Enteral Nutrition <ul><li>Benefits: </li></ul><ul><ul><li>Trophic effect on bowel </li></ul></ul><ul><ul><li>Stimulates hepatic protein synthesis </li></ul></ul><ul><li>4 ft of functional bowel required (proximal or distal) </li></ul><ul><li>Lipid based formula absorbed more efficiently </li></ul>
  48. 55. Control of Sepsis <ul><li>Management of local wound infections </li></ul><ul><li>Drainage if Intra-abdominal collections (percutaneous) </li></ul><ul><li>Laparotomy may be required for: </li></ul><ul><ul><li>Extensive cellulitis/necrotising fascitis </li></ul></ul><ul><ul><li>Incomplete percutaneous drainage of collections </li></ul></ul><ul><ul><li>Disruption of anastomosis </li></ul></ul>
  49. 56. Antibiotics <ul><li>To be withheld unless the patient is septic </li></ul>Measures to decrease secretions <ul><li>Shortens time to closure ( no role in </li></ul><ul><li>spontaneous closure) </li></ul><ul><li>H2 antagonists/ Proton pump inhibitors </li></ul><ul><li>Somatostatin / octreotide </li></ul><ul><li>Infliximab (monoclonal antibody) (in Crohn’s disese) </li></ul><ul><li>Oral tacrolimus (in Crohn’s disese) </li></ul>
  50. 57. Emotional support <ul><li>External drainage of enteric contents can be demoralizing </li></ul><ul><li>Psychiatric evaluation and use of antidepressant drugs </li></ul><ul><li>Reassurance </li></ul>
  51. 58. DECISION: <ul><li>No signs of imminent closure after 4- 5 weeks then patient should be prepared for surgery. </li></ul><ul><li>Unfavorable characteristics since beginning </li></ul><ul><li>Uncontrolled sepsis urgent drainage of sepsis. </li></ul><ul><li>If patient general condition very poor then only abscess drainage should be done . </li></ul><ul><li>In case of malignancies early operation should be done. </li></ul>
  52. 59. Treatment <ul><li>Patient should be amply resuscitated </li></ul><ul><li>Drainage cultured </li></ul><ul><li>Intraluminal and intravenous antibiotic </li></ul><ul><li>Discontinuation enteral nutrition 1-2 day prior while continuing parenteral nutrition </li></ul><ul><li>Operative approach preferably through a new incision </li></ul><ul><li>Best results are with definitive resection and end-to-end anastomosis </li></ul>
  53. 60. <ul><li>Protective diverting stoma proximal to anastomosis </li></ul><ul><li>Secure closure of abdominal wall over the fistula </li></ul><ul><li>Post-op nasogastric decompression </li></ul><ul><li>Feeding jejunostomy ( for proximal fistulae) </li></ul><ul><li>Post op continuation of nutrition with gradual shift from parenteral to enteral form </li></ul>
  54. 61. Operative procedure of fistula
  55. 62. Operated case of enterocutaneous fistula
  56. 63. Late Complications : <ul><li>Short bowel syndrome (after multiple fistula repair) </li></ul><ul><li>Stricture and partial obstruction at fistula site </li></ul><ul><li>Esophageal stricture after prolonged nasogastric sump decompression </li></ul>
  57. 64. Prevention of Fistula: <ul><li>Prophylactic Antibiotics and Bowel Preparation: </li></ul><ul><ul><li>Polythelene glycol administrtion decreases bacterial load from 10 12-15 to 10 4-5 </li></ul></ul><ul><ul><li>Enteral non-absorbable antibiotics reduce it to 10 2-3 </li></ul></ul><ul><ul><li>Prophylactic I/v antibiotic at time of induction of anaesthesia with repetition of dose in case of prolonged surgery </li></ul></ul><ul><ul><li>Post op continuation of antibiotic </li></ul></ul>
  58. 65. <ul><li>Appropriate hydration to prevent Hypotension and compromised circulation </li></ul><ul><li>Anastomosis in healthy bowel with adequate blood supply; without tension </li></ul><ul><li>Meticulous and precise hemostasis </li></ul><ul><li>Selection of proper needle size,suture </li></ul><ul><li>Omental covering if possible </li></ul><ul><li>Dead space obliterated with live tissue and properly drained </li></ul><ul><li>Drains kept away from anastomosis site </li></ul>
  59. 66. Decision making <ul><li>Adequate duodenal mobilization in case of gastroduodenal anastomosis </li></ul><ul><li>Tube duodenostomy to prevent duodenal stump blow out </li></ul><ul><li>In multiple typhoid perforations resection of diseased segment and end to end anastomosis is better than primary repair </li></ul><ul><li>Small bowel defects greater than half the circumference should be treated by resection and anastomosis </li></ul><ul><li>Proximal diverting stoma should be contemplated in case of gross contamination. </li></ul>
  60. 67. <ul><li>Stomas with mucus fistula or exteriorization to be considered in medically unfit or aged patients </li></ul><ul><li>Proper proximal decompression while doing anastomosis . </li></ul>
  61. 68. HEALING <ul><li>In the postoperative period, it is necessary to ensure that the patient continues to receive full nutritional support. </li></ul><ul><li>Adequate protein and calories must be provided to maximize healing and minimize complications. </li></ul><ul><li>Although enteral nutrition may be attempted early in the post-operative course, it is nearly impossible to meet the patient's entire nutritional demand by this route. </li></ul><ul><li>Postoperative care will most likely include parenteral and enteral supplementation in an overlapping manner. </li></ul>
  62. 69. <ul><li>After fistula closure, whether by spontaneous or surgical means, the patient will need to resume oral intake. </li></ul><ul><li>This may be especially difficult in an individual who has had little or no oral intake for 4 to 6 weeks or more, and enlisting the assistance of a dietician and the patient's family is often helpful. </li></ul>
  63. 70. THANKS
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×