Maj Ajay Kumar

Rresident Surgery

Army Hospital(R&R)

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)

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.

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 enterocutaneousfistulas. Surg Clin North Am. Oct 1996;76(5):1009-18

ETIOLOGY

Post-operative

Traumatic

Spontaneous

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

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

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

Maingot’s Abdominal operation 11th edition

Favourable Not favourable

Organ of origin Oropharyngeal, Esophageal, Duodenal stump, JejunalColonic

Gastric, Lateral duodenal, Ileal

Etiology Post-op, Appendicitis, Diverticulitis

MalignancyIBD

Output Low(<200-500ml/day) High(>500ml/day)

Nutritional state Well nourished Transferrin >200mg/dl

MalnourishedTransferrin <200mg/dl

State of bowel Healthy adjacent tissueIntestinal continuity

Diseased adjacent bowelDistal obstruction

Fistula characteristics Tract >2cmBowel wall defect <1cm 2

Tract <2cmBowel defect >1cm2

Skin excoriation

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

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)

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

MANAGEMENTMain Principal of management:- SNAPP

S- Sepsis

N- Nutrition

A-Anatomy of fistula

P- Protection of skin

P- Planned procedure

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.

Nutrition

Poor enteral intake

Hypercatabolic septic state

Loss of protein rich enteral contents

Correction of-

Dehydration

Hyponatremia

Hypokalemia

Metabolic acidosis

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 enteralroute

Fistuloclysis

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

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

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

PsychologyPt ready and prepared psychologically

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

Resection of fistula and EEA

Reconstruction of abdominal wall defect:-

Primary closure

Component separation technique

Prosthetic mesh- single stage or vicryl and prolenebased two stage closures

Biological mesh- decellularised collagen matrices (allograft / xenograft) or non cross linked porcine derived mesh

Emotional and psychological support

Hyperventilation

THANK YOU