ECF Maj(Dr) Ajay Kumar

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Enterocutaneous Fistula ppt

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ECF Maj(Dr) Ajay Kumar

  1. 1. Maj Ajay Kumar Rresident Surgery Army Hospital(R&R)
  2. 2. 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)
  3. 3. 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.
  4. 4. 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 enterocutaneous fistulas. Surg Clin North Am. Oct 1996;76(5):1009-18
  5. 5. ETIOLOGY  Post-operative  Traumatic  Spontaneous
  6. 6.  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
  7. 7.  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
  8. 8. 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
  9. 9.  Maingot’s Abdominal operation 11th edition Favourable Not favourable Organ of origin Oropharyngeal, Esophageal, Duodenal stump, Jejunal Colonic Gastric, Lateral duodenal, Ileal Etiology Post-op, Appendicitis, Diverticulitis Malignancy IBD Output Low(<200-500ml/day) High(>500ml/day) Nutritional state Well nourished Transferrin >200mg/dl Malnourished Transferrin <200mg/dl State of bowel Healthy adjacent tissue Intestinal continuity Diseased adjacent bowel Distal obstruction Fistula characteristics Tract >2cm Bowel wall defect <1cm 2 Tract <2cm Bowel defect >1cm2
  10. 10.  Skin excoriation
  11. 11. 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
  12. 12. 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)
  13. 13. 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
  14. 14. MANAGEMENT Main Principal of management:- SNAPP  S- Sepsis  N- Nutrition  A-Anatomy of fistula  P- Protection of skin  P- Planned procedure
  15. 15. 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.
  16. 16. Nutrition  Poor enteral intake  Hypercatabolic septic state  Loss of protein rich enteral contents Correction of-  Dehydration  Hyponatremia  Hypokalemia  Metabolic acidosis
  17. 17. 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 enteral route  Fistuloclysis
  18. 18. 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
  19. 19. 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
  20. 20. 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  Psychology Pt ready and prepared psychologically
  21. 21. 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
  22. 22.  Resection of fistula and EEA  Reconstruction of abdominal wall defect:-  Primary closure  Component separation technique  Prosthetic mesh- single stage or vicryl and prolene based two stage closures  Biological mesh- decellularised collagen matrices (allograft / xenograft) or non cross linked porcine derived mesh  Emotional and psychological support
  23. 23. Hyperventilation THANK YOU

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