Upload
bbthapa
View
918
Download
6
Tags:
Embed Size (px)
DESCRIPTION
Details about Enterocutaneous FIstula
Citation preview
bbthapa 1
MANAGEMENTOF
ENTERO-CUTANEOUS FISTULA
DR. Bikash Bk ThapaMS- General Surgery
bbthapa 2
• A Fistula is defined as an abnormal communication between two epithelized surfaces.
• Enterocutaneous fistulas (ECFs) are abnormal communications between the bowel and skin
• Morality rate of 6.5 to 21%.
bbthapa 3
HISTORY
• The earliest record of an enterocutaneous Fistula appears in the old Testament Book of judges Written BY Samuel Between 1043 BC and 1004 BC.
• Celsus described the first reported attempt of surgical repair of a colocutaneous fistula.
• In the 18th century John Hunter advocated a conservative approach to fistulas after he noted that fistulas occasionally close spontaneously.
bbthapa 4
•In early 1900’s enterostomy was made in healthy bowel proximally in obstructed bowel
•This often would close spontaneously on resolution of obstruction
•This lead to an unrealistic optimistic approach towards all enterocutaneous fistulas
bbthapa 5
CLASSIFICATION
Anatomical classification:(1)
Internal: Two organ of same or different system
• Enteroenteral, enterovesical,enterocolic,
External: Gut to body surface.
• Gastrocutaneous,duodenocutaneous, enterocutaneous.
(2)
Simple or direct.
Complicated-
1.Having multiple tracts
2. Connection with more than one viscus
3. drainage into an associated abscess cavity.
bbthapa 6
Physiological classification
• High output- output more than 500 ml/ day
• Moderate output- output 200-500 ml/day
• Low output- output less than 200ml/day
bbthapa 7
Etiologic Classification
• Radiation
• Inflammatory bowel disease
• Diverticular disease
• Appendicitis
• Ischaemic bowel disease
• Duodenal ulcer perforation
• Malignancies
• Intestinal tuberculosis
• Actinomycosis.
1. Spontaneous(15-25%)-
bbthapa 8
2. Post-operative (75-85%)
• Operations for perforations
• Acute intestinal obstruction
• Intestinal malignancies
• Adhesiolysis
• Blunt and penetrating abdominal trauma
• .
bbthapa 9
3. Congenital– Tracheo- esophageal– Rectovaginal– Umbilical fistula.
4. Traumatic – Blunt and penetrating trauma of abdomen, chest
and perineum
bbthapa 10
ETIOLOGY
• Disease bowel extending to surrounding structures
• Extraintestinal disease involving otherwise normal bowel
• Trauma to normal bowel including inadverent or missed enterotomies
• Anostomotic disruption following surgery for a vareity of conditions
bbthapa 11
• Small intestinal fistula are most common type of gastrointestinal fistulas encountered.
• Most series report 70%-90-% of small intestinal fistulas occurs after an operative procedure.
bbthapa 12
Factors Influencing
• Malnutriton• Infection• Hypotension• Anemia• Hypothermia• Poor oxygen delivery
• Mobilisation• Handling• Tension• Ischemia• hemostasis
bbthapa 13
Nutritional characteristics have been suggested to increase the risk of anastomotic breakdown:
1. Weight loss of 10–15% of total body weight over 3–4 months;
2. Serum albumin less than 3 mg/dL;
3. Serum transferrin less than 220 mg/dL;
4. Anergy to recall antigens; or
5. Inability to perform activities of daily living due to weakness or fatigue.
bbthapa 14
PATHOPHYSIOLOGY
• Fluid and electrolyte imbalance.
• Malnutrition
• Sepsis
• Skin irritation and excoriation
bbthapa 15
bbthapa 16
PREDICTIVE FACTORS FOR SPONTANEOUS CLOSUREFACTORS FAVORABLE UNFAVORABLE
ORIGIN Orophyrayngeal, esophageal, duodenal , PB, Jejunal, colonic
Gastric, lateral duodenal, ligment of teritz, ileal
EITOLOGY Postop, appendicitis, diverticulitis Maligancy, IBD
OUTPUT low high
NUTRITION Well nourishedtransferrin > 200 mg/dl
Malnourished< 200 mg/dl
SEPSIS Absebt Present
STATE OF BOWEL Healthy adj tissue, intestinal continuity, absence of obstruction
Ds adj bowel, distal obst, large abscess, bowel discont, prev irradiation
FISTULA Tract > 2 cm, defect < 1cm sq Tract < 1cm, defect > 1cm sq, epithelilisation, FB
MISC Same institution Refered
bbthapa 17
bbthapa 18
Avg. Time to closure
• Varies with anatomical location
1. Esophageal- 15-25 days
2. Duodenal- 30-40 days
3. Colonic - 30- 40 days
4. Small Bowel- 40-60 days
bbthapa 19
MANAGEMENT
THE GOAL are• Re-establishment of bowel continuity• Ability to achieve oral nutrition• Closure of the fistula
bbthapa 20
MANAGEMENT PHASES
PHASE TIME COURSE
RECOGNITON / STABILISATION
24 TO 48 HRS
INVESTIGATON 7- 10 DAYS
DECISION 10 DAYS TO 6 WEEKS
DEFINITIVE MANAGEMENT
WHEN CLOSURE UNLIKELY OR 4-6 WKS
HEALING 5 – 10 DAYS AFTER CLOSURE UNTILL FULL ORAL NUTRITON
bbthapa 21
Recogniton/stabilisation
• Resuscitation• Control of sepsis• Electrolyte repletion• Provision of nutrition• Control of fistula drainage• Local skin care n protection
bbthapa 22
Clinical presentation
• Recognized 5th-10th days post operatively.
• Fever/ shock
• Prolonged ileus
• Erythema of wound
• Abdominal tenderness
• Drainage of enteric material through the abdominal wound or through or existing drains.
• leucocystosis
• confirmation can be obtained by oral administration of a nonabsorbable marker, such as charcoal or Congo red
bbthapa 23
Resuscitation :
– Restoration of normal circulating blood volume • Hct- 30%
– Correction of electrolyte & acid base imbalance.
– Plasma oncotic pressure should be restored by exogenous albumin administration. - 3 mg/dl
bbthapa 24
Control of Sepsis
• Management of local wound infections
• Drainage if Intra-abdominal collections (percutaneous)
• Laparotomy may be required for:– Extensive cellulitis/necrotising fascitis– Incomplete percutaneous drainage of collections– Disruption of anastomosis
• Antibiotics as per indicated
• CVP only after 24 hrs of drainage
bbthapa 25
Skin care management:
• Problems in skin around the fistula:– Wetness – Burning pain – Discomfort from skin edema
• Goals of skin care:– Containing the effluent– Patient independence and mobility
T
bbthapa 26
Skin Barriers:
– Solid wafers (pectin based)
– Powders (Pectin / Karaya based)
– Paste
– Spray and wipes
– Ointments and creams (zinc/petroleum based)
bbthapa 27
Techniques of skin care:
• Wound pouch dressings
– One/two piece design
– Clip closure or Urostomy type
– May be attached to a bed side bag or suction catheter
bbthapa 28Wound pouch dressing
bbthapa 29
bbthapa 30
Sump Drainage:
– For fistulae draining with open abdominal wound.
– Large bore drains or sumps
– High pressure suction
VAC • Removes chronic edema, leading to increased localized blood flow, and the
applied forces result in the enhanced formation of granulation tissue”
Fistuloscopy with fibrin glue injection Closure within 2-30 days. (Eleftheriadis, 2002)
Dry dressing
bbthapa 31
bbthapa 32
Reduction of fistula output
• Restrict hypo-osmolar fluids• Encourage electrolyte mix• Antisecretory agents– Proton pump inhibitors– Somatostatin or octreotide
• Antimotility agents– Loperamide– Codeine British Journal of Surgery 2006; 93: 1045–1055
bbthapa 33
SOMATOSTATIN N ANALOGUE
• Naturally occuring peptide hormone• Inhibitory to gastrointestinal secrection• Plasma half life 1-2 min• Mode– Inhibit gastrin n cholecystokinin– Reduces splanchic blood flow– Reduces rate gastric emptying – Inhibit gall bladder contraction
bbthapa 34
Randomized clinical trials of octreotide and somatostatin use
bbthapa 35
Reduction of fistula output
•Infliximab (monoclonal antibody) (in Crohn’s disese)
•Oral tacrolimus (in Crohn’s disese)
bbthapa 36
• Nasogastric tubes : should be removed if
– There is a no obstruction.
– Fistula is a low in intestinal tract.
bbthapa 37
Nutritional management:
– Plays Central role in management
– Adequate circulation and tissue oxygenation must for optimal utilization.
– May be:• Enteral • Parenteral
bbthapa 38
•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.
•Robauk and Nichdoff reported closure of 73% enteric fistulae in patients with adequate caloric supplementation but only 19% healed when nutritional support was inadequate.
bbthapa 39
General guidelines• 25–32 kcal/kg/day with a calorie:nitrogen
ratio of 150:1 to 100:1 and at least 1.5 grams per kilogram per day of
• Patients should receive 3000 to 5000 non proteins calories per day
bbthapa 40
• Patients daily protein requirement is 1.2 to 2.0 gm kg/day.
• Fluid requirement is 30ml/kg/day.
• Electrolyte requirement/day• Na-70-100 meq/day• K- 70-100 meq/day• Mg- 15-20 meq/day • Ca- 10-20 meq/day
bbthapa 41
Low Output High Output
Form Enteral Usually Parenteral
Protein 1-1.5g/kg/day 1.5-2.5g/kg/day
Calories BEE BEE x 1.5
Lipids Enteral (20-30%) Parenteral (20-30%)
Vitamins RDAVit C – 2RDA
2RDAVit C – 5 –10RDA
Minerals Usually not needed
Close watch
Vitamin K 10mg/wk 10mg/wk
Recommended Nutritional Support
bbthapa 42
TPN strategy
If BW loss> 20%, TPN initiated gradually to avoid refeeding syndrome
J Clin Gastroenterol 2000; 31(3)
bbthapa 43
Harris Benedict Equation
• BEE in kcal per day for men = 66.4 + (13.7 × weight in kg) + (5.0 × height in cm)
– (6.7 × age in years)
• BEE in kcal per day for women = 655 + (9.6 × weight in kg) + (1.8 × height in cm) –
(4.7 × age in years)
bbthapa 44
TPN indications
• Inability to obtain enteral access• High output fistulas• GI intolerance with enteral nutrition• Multiple unfavorable factors (ileus, obst, )
• Not proven well in mortality reduction in ECF, but improve spontaneous closure
J Clin Gastroenterol 2000; 31(3)
bbthapa 45
TPN• Conc. dextrose: 500ml of 20% Dex. (=400 kcal)
• Fat: 500 ml 10% fat emulsion (=450 kcal)
• Crystalline Amino Acids: 500 ml 10% Amino acids (=8.4 g Nitrogen)
• Daily Vitamin Supplementation ( Vit. K 10 mg/wk)
• Rate of infusion• Starting: 50 – 100 ml/hr• Gradually increased by 25 – 50 ml/hr every second day
bbthapa 46
Patient Monitoring:
• Clinically: (daily)– Sense of well being– Graded activity– Vitals– Weight / input-output
• Laboratory profile: (daily until patient stable then twice weekly)– Serum albumin– Serum Electrolytes– RFT– LFT/ coagulation profile– Lipid profile
bbthapa 47
Complications of TPN
• Mechanical– Catheter tip malposition (6%)– Arterial laceration (1.4%)– Hydro-pneumo-haemo thorax (1.1%)– Subclavian/Superior vena cava thrombosis (0.3%)– Thrombophlebitis (0.1%)– Catheter embolism (0.1%)
• Septic – Catheter related sepsis (7.4%)
bbthapa 48
• Metabolic – Acute• Hyperglycemia/hypoglycemia• Electrolyte abnormalities• Fluid overload• Hyperlipidemia
– Chronic • Metabolic bone disease• Alterations in bile composition
bbthapa 49
Enteral Nutritionnasogastic/nasoenteric/fistuloclysis
• Benefits:– Trophic effect on bowel– Stimulates hepatic protein synthesis– Improve immune / hormaonal/ barrier function– Dec infection rate/ metabolic complication– Inexpensive
• 4 ft of functional bowel/ distal patency required
• Lipid based formula absorbed more efficiently
bbthapa 50
INVESTIGATION (7-10 days)Objectives of investigation plan: To define-
• Precise anatomical location
• Is the bowel in continuity or is disrupted
• Abscess cavity
• Condition of adjacent bowel
• Is there a distal obstruction
• Etiological disease process
bbthapa 51
Radiological contrast studies
• Fistulography :.
• Barium transit studies :
bbthapa 52
bbthapa 53
CT- Scan
Entero colic fistula Sigmoid cutaneous fistula
Gastro cutaneous fistula
bbthapa 54
Endoscopic studies• Gastro duodenoscopy : Demonstrates both
underlying disease and presence of fistula.
• Colonoscopy : Fistula is usually not visible but presence of disease and its nature by biopsy can be demonstrated.
bbthapa 55
DECISION: (10 days – 6 wks)
Evaluate the likelihood of spontaneous closure Decide duration of trial of nonoperative management
• No signs of imminent closure after 4- 6 weeks then patient should be prepared for surgery.
• Unfavorable characteristics since beginning
• Uncontrolled sepsis urgent drainage of sepsis.
• General condition very poor then only abscess drainage
• In case of malignancies early operation should be done.
bbthapa 56
• 90 – 95 % of fistulas that will spontaneously close typically do so within 5 weeks of operation
• Operation during the first 10 days to 6 weeks from diagnosis of postoperative fistulas is made more difficult by the obliterative peritonitis
bbthapa 57
Extreme
Great
Moderate
Minimal
Time after Operation
Severity of Adhesions
0 7 14 21 28 42 56 84 6 months
bbthapa 58
Window Period
• 7 to 12 days from the most recent laparatomy
• Within this “window period” severity of adhesions are usually milder and repeat laparotomy with the intent of diverting and or repairing the fistula is justified since caring for a well matured stoma is much easier than ECF.
bbthapa 59
Why not to operate outside the window period?
• risk of further enterotomy, and fistula formation and devascularization of the small
• If operation occurred outside the window and is difficult ,put tube gastrostomy and “GET OUT”
• Defer any attempt of repeat laparotomy up to 4 preferably to 6 months
bbthapa 60
DEFINITIVE MANAGEMENTplan operative approach
• Optimal nutrition parameters• Free of sepsis• Well healed abdominal wall without inflammation• Prophylactic antibiotics • Tapering of tube feeding• Operative approach preferably through a new incision– Transeverse– Midline
• Prevent contamination of abdominal wall tissues
bbthapa 61
• Bowel refunctionalisation– Free all adhesion– Drain any abscess– Releive any obstruction
• Disection/ Adhesiolysis – – Start with least dense adhesion– Sharp Dissection– Wet laparotomy pads– Saline injection (hydro dissection)– Extrafascial dissection
• Repair enterotomies – Heineke- Mikulicz
• Repair serosal tears- Lembert sutures ( 5-0 prolene)
bbthapa 62
• Best results are with definitive resection and EEA
• > 1/2 circumference be treated by resection and anastomosis
• Direct attack on duodenal fistula is unwise
• Tube duodenostomy to prevent duodenal stump blow out
• Proximal diverting stoma / Tube enterostomy
• Omental flap – to prevent fistulization
• Stomas with mucus fistula or exteriorization
bbthapa 63
• Protective diverting stoma proximal to anastomosis
• Secure closure of abdominal wall over the fistula
• Decompression gastrostomy
• Post-op nasogastric decompression
• Feeding jejunostomy ( for proximal fistulae)
• Post op continuation of nutrition with gradual shift from parenteral to enteral form
bbthapa 64
bbthapa 65
bbthapa 66
bbthapa 67
bbthapa 68
bbthapa 69
bbthapa 70
bbthapa 71
HEALING • ensure that the patient receive full nutritional support.
• Adequate protein and calories
• Parenteral and enteral supplementation in an overlapping
• Contibue NG feeding untill 1500 kcal/ day orally
• Oral feeding – 1 week with soft diet
• Zinc supplement
• Cycling tube feedings
• Psychological n emotional support
bbthapa 72
Late Complications:
• Short bowel syndrome (after multiple fistula repair)
• Stricture and partial obstruction at fistula site
• Esophageal stricture after prolonged nasogastric sump decompression
• Neuropsychiatric problems
bbthapa 73
Prevention of Fistula:
• Prophylactic Antibiotics and Bowel Preparation:
– Polythelene glycol administrtion decreases bacterial load from 10 12-15 to 10 4-5
– Enteral non-absorbable antibiotics reduce it to 10 2-3
– Prophylactic I/v antibiotic at time of induction of anaesthesia with repetition of dose in case of prolonged surgery
– Post op continuation of antibiotic
bbthapa 74
• Appropriate hydration to prevent Hypotension and compromised circulation
• Anastomosis in healthy bowel with adequate blood supply; without tension
• Meticulous and precise hemostasis
• Selection of proper needle size,suture
• Omental covering if possible
• Dead space obliterated with live tissue and properly drained
• Drains kept away from anastomosis site
bbthapa 75THANK YOU