ECF Maj(Dr) Ajay Kumar
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Maj Ajay Kumar
Rresident Surgery
Army Hospital(R&R)
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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)
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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.
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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
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ETIOLOGY
Post-operative
Traumatic
Spontaneous
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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
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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
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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
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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
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Skin excoriation
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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
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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)
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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
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MANAGEMENTMain Principal of management:- SNAPP
S- Sepsis
N- Nutrition
A-Anatomy of fistula
P- Protection of skin
P- Planned procedure
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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.
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Nutrition
Poor enteral intake
Hypercatabolic septic state
Loss of protein rich enteral contents
Correction of-
Dehydration
Hyponatremia
Hypokalemia
Metabolic acidosis
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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
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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
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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
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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
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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
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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
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Hyperventilation
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