Professional Documents
Culture Documents
OF
ENTERO-CUTANEOUS FISTULA
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• A Fistula is defined as an abnormal
communication between two epithelized
surfaces.
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•In early 1900’s enterostomy was made in healthy bowel
proximally in obstructed bowel
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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.
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Physiological classification
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Etiologic Classification
1. Spontaneous(15-25%)-
• Radiation
• Duodenal ulcer
perforation
• Inflammatory bowel
disease
• Malignancies
• Diverticular disease
• Intestinal tuberculosis
• Appendicitis
• Actinomycosis.
• Ischaemic bowel
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2. Post-operative (75-85%)
• Operations for
perforations •.
• Acute intestinal
obstruction
• Intestinal malignancies
• Adhesiolysis
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3. Congenital
– Tracheo- esophageal
– Rectovaginal
– Umbilical fistula.
4. Traumatic
– Blunt and penetrating trauma of abdomen, chest
and perineum
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ETIOLOGY
• Disease bowel extending to surrounding structures
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• Small intestinal fistula are most common type
of gastrointestinal fistulas encountered.
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Factors Influencing
• Malnutriton • Mobilisation
• Infection • Handling
• Hypotension • Tension
• Anemia • Ischemia
• Hypothermia • hemostasis
• Poor oxygen delivery
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Nutritional characteristics have been suggested to
increase the risk of anastomotic breakdown:
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PATHOPHYSIOLOGY
• Fluid and electrolyte imbalance.
• Malnutrition
• Sepsis
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PREDICTIVE FACTORS FOR SPONTANEOUS CLOSURE
FACTORS FAVORABLE UNFAVORABLE
STATE OF BOWEL Healthy adj tissue, intestinal Ds adj bowel, distal obst, large
continuity, absence of obstruction abscess, bowel discont, prev
irradiation
FISTULA Tract > 2 cm, defect < 1cm sq Tract < 1cm, defect > 1cm sq,
epithelilisation, FB
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MANAGEMENT
THE GOAL are
• Re-establishment of bowel continuity
• Ability to achieve oral nutrition
• Closure of the fistula
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MANAGEMENT PHASES
PHASE TIME COURSE
RECOGNITON / 24 TO 48 HRS
STABILISATION
INVESTIGATON 7- 10 DAYS
DECISION 10 DAYS TO 6 WEEKS
DEFINITIVE WHEN CLOSURE UNLIKELY OR 4-6
MANAGEMENT WKS
HEALING 5 – 10 DAYS AFTER CLOSURE
UNTILL FULL ORAL NUTRITON
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Recogniton/stabilisation
• Resuscitation
• Control of sepsis
• Electrolyte repletion
• Provision of nutrition
• Control of fistula drainage
• Local skin care n protection
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Clinical presentation
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Resuscitation :
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Control of Sepsis
• Management of local wound infections
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Skin Barriers:
– Paste
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Techniques of skin care:
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Wound pouch dressing
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Sump Drainage:
VAC
• Removes chronic edema, leading to increased localized blood flow, and
the applied forces result in the enhanced formation of granulation
tissue”
Dry dressing
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Reduction of fistula output
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SOMATOSTATIN N ANALOGUE
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Randomized clinical trials of octreotide and somatostatin use
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Reduction of fistula output
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• Nasogastric tubes : should be removed if
– There is a no obstruction.
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Nutritional management:
– May be:
• Enteral
• Parenteral
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•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.
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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
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• Patients daily protein requirement is 1.2 to
2.0 gm 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
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Recommended Nutritional Support
Low Output High Output
Form Enteral Usually Parenteral
Protein 1-1.5g/kg/day 1.5-2.5g/kg/day
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TPN indications
• Inability to obtain enteral access
• High output fistulas
• GI intolerance with enteral nutrition
• Multiple unfavorable factors (ileus, obst, )
• Rate of infusion
• Starting: 50 – 100 ml/hr
• Gradually increased by 25 – 50 ml/hr every second day
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Patient Monitoring:
• Clinically: (daily)
– Sense of well being
– Graded activity
– Vitals
– Weight / input-output
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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%)
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• Metabolic
– Acute
• Hyperglycemia/hypoglycemia
• Electrolyte abnormalities
• Fluid overload
• Hyperlipidemia
– Chronic
• Metabolic bone disease
• Alterations in bile composition
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Enteral Nutrition
nasogastic/nasoenteric/fistuloclysis
• Benefits:
– Trophic effect on bowel
– Stimulates hepatic protein synthesis
– Improve immune / hormaonal/ barrier function
– Dec infection rate/ metabolic complication
– Inexpensive
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INVESTIGATION (7-10 days)
Objectives of investigation plan: To define-
• Abscess cavity
• Fistulography :.
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CT- Scan
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DECISION: (10 days – 6 wks)
Evaluate the likelihood of spontaneous closure
Decide duration of trial of nonoperative management
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Severity of Adhesions
Extreme
Great
Moderate
Minimal
0 7 14 21 28 42 56 84 6 months
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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
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DEFINITIVE MANAGEMENT
plan 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
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• 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
• Decompression gastrostomy
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HEALING
• ensure that the patient receive full nutritional support.
• Zinc supplement
• Neuropsychiatric problems
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Prevention of Fistula:
• Prophylactic Antibiotics and Bowel Preparation:
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• Appropriate hydration to prevent Hypotension and compromised
circulation