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De ECHT catastrofale buik
Marja Boermeester
Amsterdam UMC, locatie AMC
De ECHT catastrofale buik (in < 12 minuten)
Marja Boermeester
Amsterdam UMC, locatie AMC
Disclosures
Grants
_______________
Speaker and/or
advisory board
Baxter
Mylan
Ipsen
Acelity / KCI
LifeCell
Bard
Johnson & Johnson / Ethicon
New Compliance
Acelity / KCI
Allergan
Johnson & Johnson / Ethicon
Bard
Gore
Smith & Nephew
De ECHT catastrofale buik in < 12 minuten
- key messages -
• Reconstructive surgery should not be undertaken for 6 to 12 months and until nutrition has been optimised.
ESCP consensus intestinal failure surgery Colorectal Disease 2016
De ECHT catastrofale buik
- key messages -
Early 3-12
weeks 6-12
months >12
months
Mortality 30-100% 7-20% 3-9% 0-3%
ECF recurrence 40-60% 17-31% 10-14% 3%
Mulier WJO, 2003,27,379
Peralta R, 2011
Pertkiewicz M,PhD dissert.1999
Vischers WJS 2008,32,445
References
Conolly PT Ann Surg 2008,247,440
Conter RL AmJS1988,54,589
Datta V Dis Col R 2010,53,192
Draus Surgery 2006, 140,570
Kelly DG:Clin.Nutr 2007, Suppl 2, 42
Levy E, BJS,1989,676
Lynch AC, Ann Surg 2004,240,825
Martinez JGS 2012,16,156.
EC/EA fistula repair: timing of surgery
West JP, SGO 1961,490
De Vries, WJS 2017
• Enterocutane fistel vs enteroatmosferische fistel
• TPV vs oraal short bowel dieet
• Wacht op je beste kans = geen ‘hostile abdomen’, anabool, goed gevoed, en in balans
• BRIDGING TO SURGERY
• Preoperatief – CT road mapping (darmen en buikwand)
• Tijdens operatie: Volledige adhesiolysis + resectie fistels
• Sluit de buik altijd ! Gebruik geen synthetische mat (ook geen vicryl mesh)
De ECHT catastrofale buik
- key messages -
De ECHT catastrofale buik
- key messages -
2018 Richtlijn Littekenbreuken, NVvH
• enterocutane fistel of enteroatmosferisch?
• EAF gaat niet dicht dus TPV + oraal short bowel dieet
• resterende dunne darmlengte ?
> 150 cm of < 150 cm functionele dunne darm
NB werkelijke lengte kan langer zijn
• jejunum verwijderd of ileum verwijderd ?
• fistel output – high vs low?
• nog sepsis / infectie J/N ?
abdominale sepsis / abcessen J/N ?
Voeding bij catastrofale buik met ECF/EAF
Parenteral feeding
• Reduction in fistula output (30-50%)
• Guaranteed delivery of nutrients
• Disadvantage: central venous catheter
Macronutrienten
- eiwitten
- koolhydraten
- vetten
geabsorbeerd < 100-150
cm jejunum
Macronutrienten
- eiwitten
- koolhydraten
- vetten
geabsorbeerd < 100-150 cm
jejunum
Academic Medical Center
Acute intestinal failure due to excessive fluid loss of enterostomy or enterocutaneous fistula
PPI 2 dd 40 mg
Loperamide Melts
Maximum 4 dd 8 mg
Codeine Maximum 3 dd 20 mg
(Somatuline analogue)LIFE study
Star
tIf
no
t ef
fect
ive,
ad
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If n
ot
effe
ctiv
e, a
dd
What is essential when making choices for reconstruction?
1. Clean or contaminated or dirty (fistula)
2. Comorbidity [obesity, COPD, diabetes, smoking]
3. Diameter of abdominal wall defect, > or < 10 cm
4. Loss of domain, > or < 25%
5. Previous hernia repair / no. recurrences [+ position of old mesh(es) in situ]
6. Infected mesh in situ
7. ‘Loss’ of skin
Wat kan een acuut darmfalenteam ?
• Service:
vroeg ontslag naar home care setting onder supervisie van het darmfalen team in samenwerking met de verwijzer
bridging to surgery & pre-operatieve work-up
reconstructie chirurgie in centrum of verwijzend ziekenhuis
physician assistant } verpleegkundig consulent } case manager dietist } TPV verpleegkundige wond / stoma verpleegkundige internist – endocrinoloog / TPV expert chirurg plastisch chirurg
andere betrokken disciplines: vaatchirurg, radiologie, interventie radiologen, intensive care, microbiologie, urologie
Acuut Darmfalenteam - spelers
Organisatie complexe buik/darmfalen AMC
Gespecialiseerde spreekuren:
• Abd inf /buikwand poli (Boermeester/Gooszen/vdVelde)
+ parallel PCH spreekuur
+ parallel darmfalen PA
+ parallel wond/stoma VPK – Re-re-recidief littekenbreuk
– Grote littekenbreuk met weefselproblematiek
– Aanwezigheid van geinfecteerde mat
• Darmfalen poli (team) + parallel PCH spreekuur
+ parallel wond/stoma VPK – Aanwezigheid van enterocutane fistel of enteroatmosferische
fistel of high output stoma of short bowel
Case. CT angio
• CT angio: dunne darm ileus – obstructie, kalibersprong. St na resecties ivm ischemie
Case. CT angio
• CT angio: truncus, AMS, AMI dicht, collateralen via
a. hepatica en a. gastroduodenalis
Situatie schets
Reconstructie
Catastrophic abdomen – steps before reconstruction -
• All information available (history, OR reports, lab, cultures, imaging)
• Intestinal failure management (medication, TPN)
• Comorbidity (CPET, consultations)
• Preoperative work-up (CT in all, other imaging when needed)
• Operative plan (surgical concept, timing, botox y/n, prehab y/n)
• Prehabilitation & nutrition
• Definite operative plan (result prehab, result botox)
• Prevention of complications
Symptom-limited
ECG
• HR
Measure expired gas
• Oxygen consumption
• CO2 production
• Minute ventilation
SpO2 or PO2
Perceptual responses
• Breathlessness
• Leg discomfort
Allows calculation of peak oxygen consumption, anaerobic threshold
What is CPET ? CardioPulmonary Exercise Test
Skin defect? yes/no PCH?
Operative plan work-up: complexity assessment
Example Loss of Domain
Loss of domain – volumetrics (3-dimensional)
61 x 231 162 181 x 252 354
HSV = 61x231x162 x 0.52 ACV = 181x252x354 x 0.52
HSV / ACV x 100 = 14% HSV / TPV x 100 = 12%
Total Peritoneal Volume (TPV) = HSV + ACV
Loss of domain: HSV/ACV ratio [Tanaka method]
Loss of domain: HSV/TPV ratio [Sabbagh method]
Poor man’s estimate: repeat this in several planes (3-4), good estimate although not 3-dimensional
Previous meshes
Abdominal wall muscles
Case 1. Recurrence after synthetic mesh AWR
Case 1 Summary - based on history & reports, phys exam, CT -
• VHWG grade 1
• HPW stage 2 (H2P0W0)
• Width 15.3 cm
• LOD > 25% (being 30%)
• No fistula
• First recurrence
• Synthetic mesh present (operative report for type mesh) + multiple tackers
• Done as an onlay repair
• Mesh not infected
• No previous CST / myofascial release
• Good quality muscles
• Retracted bulged lateral muscles
• No skin defect
Case 2
• 3 Jan 2018 appendicitis, diagnostic lapsc, infiltrate + abscess drain
• 27 Feb 2018 large ab wall abscess; surgical drainage
• Nov 2018 incisional hernia with colo-cutaneous fistula
Case 2
Case 2 summary - based on history & reports, phys exam, CT -
• VHWG grade 3
• HPW stage 3 (H2P0W1)
• Width 12 cm
• LOD < 25% (20%)
• Colonic fistula
• No recurrence
• No mesh present
• No previous CST / myofascial release
• Good quality muscles
• Retracted bulged lateral muscles
• Small skin defect
botuline toxin bilateral 3x
Botuline toxin - 4-6 weeks preoperative – Chemical CST
Botox effect evaluation – preoperative CT -
Botuline toxine
• in plaats van CST = chemische CST
• met CST
• minder postoperatieve pijn
• betere compliantie buikwand – respiratoir voordeel ?
Component Separatie Technieken (CST)
• Anterieure open CST
• TAR = Transversus Abdominis Release = extended Reeve-Stoppa
• Endoscopische CST
• Biomesh tractie techniek
Endo-CST (ECST)
- approach from the rib cage, BEFORE laparotomy -
Semilunar line
Musc part of ext obliq
Internal obliq muscle
Aponeurosis of ext obliq
Endo CST
Photographs taken by MA Boermeester, with permission of the patient
Transverse Abdominis Release (TAR)
Transverse Abdominis Release (TAR)
TAR
TAR ????: no posterior plane or layer
Photographs taken by MA Boermeester, with permission of the patient
Drawings by Pieter Zwanenburg, PhD fellow Amsterdam UMC, AMC
Biomesh to avoid bridging even in the extreme
Additionele technieken up and running
• echo duplex identificatie van perforatoren voor huidtransposities
• SPY indocyanine green
• full thickness skin flaps of ALT (anterolateral thigh flap)
• profylactische negatieve druk therapie
• VAC Veraflow = installatie VAC = spoel VAC
VAC VeraflowTM installation NPWT
• Dwell time 10-20 min
• Installation volume varies (usually 50-150 mL)
• Negative pressure time 2-3 hours, usually 2.5 hrs
• 100 - 125 mmHg
• Change every 2-3 days
