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High output gastrointestinal fistula management
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High output gastrointestinal fistula management

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    High output gastrointestinal fistula management High output gastrointestinal fistula management Presentation Transcript

    • High output gastrointestinal fistula management B86401103 Ri 烏惟新
    • Definition
      • Fistula:
        • Abnormal pathological communication between two epithelialized surfaces.
    • Categorization
      • Anatomical
      • Physiological
      • Etiological
    • Anatomy
      • External
      • Internal
      • Proximal
      • Distal
      • Simple
      • Complicated
    • Physiology
      • High-output fistula
        • Pancreatic fistulae
          • >200 ml/24 hours
        • Intestinal fistulae
          • >500 ml/24 hours
      • Low-output fistula
        • Pancreatic fistulae
          • <200 ml/24 hours
        • Intestinal fistulae
          • <500 ml/24 hours
    • Etiology
      • Abdominal surgical procedure
        • Leading cause, 67-85%
      • Inflammatory bowel disease
      • Diverticular disease
      • Malignancy
      • Radiation enteritis
      • Trauma
      • Congenital
      • Other causes
    • Abdominal surgical procedures
      • Predisposing factor
        • Cancer
        • Inflammatory bowel disease
        • Lysis of adhesions
        • Peptic ulcer
        • Pancreatitis
        • Emergency
        • Technical failure
    • Complications
      • Loss of GI contents
        • Hypovolemia
        • Acid-base and electrolyte abnormalities
      • Malnutrition
        • Lack of food intake, loss of protein in fistula discharge, hypercatabolism associated with sepsis
      • Sepsis
      • Skin excoraiation
      • Hemorrhage
      • Psychological effect
    • High output fistula
      • Fistula output
        • A predictor of morbidity and mortality
        • Not an independent indicator of spontaneous closure
      • Fistula mortality rates have decreased over the past few decades from as high as 40–65% to 5.3–21.3%
      • High output fistulae continue to have a mortality rate of approximately 35% .
    • Clinical/physical signs
      • Slow or unusual course of post-operative recovery
      • Abdominal pain or tenderness
      • Fever, and leukocytosis
      • Skin:
        • Cellulitic appearance
        • Excessive drainage
        • Abscess formation
    • Evaluation
      • History
      • Physical examination
      • Radiographic studies
      • Laboratory studies
    • Image study
      • Contrast radiography
        • fistulography, oral contrast , contrast enema, pyelography, cystography
      • Endoscopy
      • Abdominopelvic CT scan, MRI, ultrasound
      • X-ray
    • Management
      • Conservative
        • Fluid resuscitation
        • Correct acid-base and electrolyte abnormalities
        • Complete bowel rest
        • Nutritional support
        • Infection control
        • Fistula drainage
        • Skin protection
      • Surgery
    • Fluid resuscitation
      • Correct hypovolemia
      • Accurate measurement of ongoing fluid losses
      • Intravenous fluid administration
        • Iso-osmotic and high in potassium
        • Replaced with a balanced salt solution that contains added potassium
        • Sample of fistula fluid
    • Correct acid-base and electrolyte abnormalities
      • Site of the fistula
      • Quantity of fluid loss
        • High-output gastric fistulas
          • Hydrochloric acid
        • Biliary and pancreatic fistula
          • Hypertonic
          • Large bicarbonate and sodium losses
    • Complete bowel rest
      • Reduce fistula drainage
        • Solid food stimulates secretion of digestive juices and therefore increases fistula output, exacerbating poor nutritional status and limiting healing
      • Simplify the evaluation
    • Nutritional support
      • Early, aggressive parenteral nutritional therapy has dramatically decreased mortality from fistulas from 58% to 16% (am J surg 108:157, 1964).
      • Therapeutic role
        • Decrease in fistula output
        • Modify the composition of gastrointestinal pancreatic secretions
    • Role of TPN
      • Conservative treatment with TPN
        • Reduce the maximal secretory capacity of the gastrointestinal tract by 30–50%
        • Not suppress basal or cephalic secretions
        • Long term administration the presence of lipids and amino acids can stimulate GI secretions
      • TPN complications
        • Bacterial translocation, superinfection of central venous access, and metabolic disorders as a result of fistula losses
    • Nutritional support
      • Enteral feeding
        • Primary method of choice
        • Esophagus, distal ileum, and colon
        • Given below proximal fistula if accessible
      • Parenteral nutrition
        • Intolerance to enteral nutrition
        • Gastroduodenal, pancreatic, or jejuno-ileal fistulae
        • Proximal fistulas if distal enteral access is not possible
      • Reinfusion into the distal bowel
    • Infection control
      • Intraabdominal abscess
      • Intravenous antibiotics
      • Infected wounds
    • Fistula drainage
      • Wound management
        • Dressings
        • Intubation
        • Suction or sump drainage system
      • Pharmacotherapy
        • Octreotide
        • H2-receptor antagonists
    • Skin protection
      • Barrier device
      • Powder
      • Examined and cleansed frequently
    • Surgical treatment
      • Fistulas fail to heal with nonoperative measures
      • Sepsis cannot be controlled
    • Spontaneous closure unlikely..
      • FRIEND
        • Foreign body
        • Radiation injury
        • Inflammatory bowel disease
        • Epithelialization of fistular tract
        • Neoplasia
        • Distal obstruction
    • Fistula site: • Oropharyngeal • Esophageal • Duodenal stump • Pancreatobiliary • Jejunal Fistula site: • Gastric • Lateral duodenal • Ligament of Treitz • Ileal   Enteral defect <1 cm Enteral defect >1 cm Fistula tract >2 cm — non-epithelialised Fistula tract <2 cm — epithelialisation Free distal flow Distal obstruction Adjacent bowel healthy Adjacent bowel diseased No associated abscess Large adjacent abscess End fistula Lateral fistula Favourable Unfavourable
    • High output fistula
      • High morbidity and mortality
      • Strategy to reduce both output volume and the content of corrosive enzymes in the exudate would be likely to decrease the healing time, greatly improving prognosis
    • Somatostatin-14 in combination with TPN
      • Accelerated spontaneous closure of postoperative gastrointestinal fistulae, significantly reducing the required period of TPN treatment (time to healing 13.9±1.84 days somatostatin-14+tpn v 20.4±2.98 days TPN alone; N=20, respectively; Ph0.05) with a consequent reduction in morbidity (35% somatostatin-14+tpn v 68.85% TPN alone; Ph0.05).
      • Inhibit both basal and stimulated digestive secretion, as well as reducing fluid loss, electrolyte imbalance, and malnutrition, leading to potential reductions in fistula output and time to closure.
    • Mechanisms of octreotide
      • Inhibits the release of gastrin, cholecystokinin, secretin, motilin, and other GI hormones.
        • Decreases secretion of bicarbonate, water, and pancreatic enzymes into the intestine, subsequently decreasing intestinal volume.
      • Relaxes intestinal smooth muscle, thereby allowing for a greater intestinal capacity.
      • Increases intestinal water and electrolyte absorption
    • Reasons for pharmacotherapy
      • Rapidly reduce fistula output
        • Improvement in nutritional and electrolyte status
        • Reduction of the concentration of caustic enzymes in the discharge will convey beneficial effects on both wound healing and nutritional losses
      • Significantly shorten healing time
        • Shortening hospitalisation
        • Improvements in quality of life
        • Reductions in overall treatment costs
      • However, lacking data from large scale, double blind, randomised, controlled studies
    • Guideline : Somatostatin use
    • Guideline : GI fistula management
    • Summary: high output GI fistula management
      • Early detection
      • Stabilize the patient
        • Aggressive fluid resuscitation
        • Electrolyte and acid-base balance
        • Nutrition support and bowel rest
        • Control infection
        • Drainage and skin protection
      • Evaluation the status and prognosis factor
      • Try pharmacotherapy
      • Surgical treatment if needed
    • Reference
      • The Washington Manual of Surgery, 2nd ed.
      • Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed
      • Optimising the treatment of upper gastrointestinal fistulae, I González-Pinto and E Moreno González Gut 2001; 49 (Suppl 4): iv21-iv28
      • The relevance of gastrointestinal fistulae in clinical practice: a review M Falconi and P Pederzoli Gut 2001; 49 (Suppl 4): iv2-iv10
    • End Thank you for attention!!