Enterocutaneous Fistula sesuai guideline dan journal

Penanganan fistula ani secara konvehensiv

1. Enterocutaneous Fistula dr. Tommy Ruchimat , Sp.B , Subsp.BD(K) 1 st Beyond the Scalpel ( B.t.S .) Controversies in Trauma & Minimally Invasive Surgery

2. 1 st Beyond the Scalpel ( B.t.S .) Controversies in Trauma & Minimally Invasive Surgery

3. An abnormal communication between two epithelialized surfaces Anatomic classification names according to organs involved High pressure to low Aortoenteric , gastrocutaneous , colovesicle Physiologic classification based on output High-output > 500 cc/day Moderate-output 200-500 cc/day Low-output < 200 cc/day Enterocutaneous Fistula 1 st Beyond the Scalpel ( B.t.S .) Controversies in Trauma & Minimally Invasive Surgery

4. Causes Post-operative 75-85% a. Anastomotic disruption b. Operative trauma (unrecognized) c. Synthetic mesh Others: 15-25% a. Inflammatory b. Neoplastic c. Post-irradiation d. Post-trauma Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

5. FRIEND F oreign body R adiation I nflammation, I nfection E pithelialization N eoplasm D istal obstruction Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

6. SNAP Control of S epsis and appropriate S kin care N utrition Define underlying A natomy P lan to deal with the fistula Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

7. Post-Operative Enteric Fistula Most frequent cause of death Most frequent surgical indication Inadequate drainage of infected area Sepsis

8. Post-Operative Enteric Fistula Stabilization Investigation Decision Definitive therapy Healing 5 Phases of Treatment Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780 Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

9. Step 1: Stabilization (2-5 Days) Identification Resuscitation (crystalloid, colloid, blood) Control of sepsis Nutritional support Control of fistula drainage Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

10. Conservative Treatment Peritonitis Abscess Bacteremia Bleeding Intestinal necrosis Contraindications Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

11. Step 2: Investigation (7-10 days) Fistulography with water soluble contrast Identify source, length, course of the fistula Determine the nature of adjacent bowel (inflammation, stricture) Evaluate absence or presence of bowel continuity, distal obstruction, abscess cavity Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

12. Factors Increasing Chance of Spontaneous Closure Surgical etiology Free distal flow Healthy surrounding bowel No abscess cavity Fistula tract> 2 cm Fistula tract not epithelialized Defect < 1 cm (no discontinuity) Low output (<500 ml/day) No co-morbidity Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

13. Conservative Treatment Local wound care Avoid electrolyte imbalance Nutritional support Maintain patient morale Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

14. Nutrition Normal energy expenditure 25 kcal/kg/day Hypoalbuminemia is a significant risk factor for mortality Mortality rate of 42% with alb <2.5 vs 0% if >3.5 Nutritional support is mandatory if illness is anticipated to be longer than 10 days Good markers are albumin, prealbumin, transferrin, and retinol binding protein “If the gut works, use it” > 75 cm of distal small bowel is required for absorption Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

15. Psychological support Great importance !! Patient underwent major surgery with complication Prolonged hospital stay Open wound and fistula effluent has a detrimental effect on body image Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

16. Methods of reducing fistulas output Restrict hypo- osmolar fluids Encourage electrolyte mix Antisecretory agents ( PPI,Octreotide ) Antimotility agents ( Loperamide,codeine ) Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

17. Octreotide Trial of Octreotide is worthwhile once patients have been stabilized If significant reduction in fistula output within 3 days, octreotide should be continued Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

18. Post-Operative Enteric Fistula Important role of stomal therapist Keep skin dry and clean Protection against digestion Measurement of output Wound Care Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

19. JH090505

20. Layton et al. The American Journal of Surgery (2010) 199, e48–e50 Pacifying the open abdomen with concomitant intestinal fistula

21. Anchor System for Abdominal Reappoximation

22. Layton et al. The American Journal of Surgery (2010) 199, e48–e50 Pacifying the open abdomen with concomitant intestinal fistula

23. Wound VAC Trial of Wound Vac is in order if wound is clean and starts to granulate Best if open wound with some depth and no exposed mucosa Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

24. Types of NPWT Continous vs Intermittent

25. Types of NPWT NPWT without interface material vs with interface material Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

26. Predictive factors for spontaneous closure and/or mortality Factor Favorable Unfavorable Organ of origin Esophageal, Duodenal stump, Pancreatic, Biliary, Jejunal, Colonic Gastric, Lateral duodenal, Ligament of Treitz, Ileal Etiology Postop ( anast leak), Appendicitis, Diverticulitis Malignancy, IBD Output Low (<200-500cc/day) High (>500cc/day) Nutritional status Well nourished, Transferrin >200 Malnourished, Transferrin <200 Sepsis Absent Present State of bowel Intestinal continuity, absence of obstruction Diseased adjacent bowel, Distal obstruction, Abscess, Discontinuity, Irradiation Fistula characteristics Tract >2 cm, Defect <1cm Tract <1cm, Defect >1cm Miscellaneous Original operation at same institution Referred from outside institution

27. Failure of Conservative Treatment Complete separation of anastomosis Distal obstruction Adjacent abscess Diseased bowel Epithelialized short tract (<2 cm) Large intestinal opening (>1 cm) Foreign body Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

28. Post-Operative Enteric Fistula Emergency: Peritonitis Early (<3 weeks) Bleeding Bowel obstruction Intra-abdominal abscess Late (>6 weeks) Surgical Treatment Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

29. Obliterative peritonitis No man’s land Between 10 to 42 days 95% of spontaneous closure occur within 4-5 weeks “Smart” to wait at least 4 months from previous operation Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

30. Post-Operative Enteric Fistula Surgeon calm and meticulous Decompression of proximal bowel 2 layers anastomosis Continuation of TPN Antibiotics Closure of abdominal wound Operative “Tactics” Ghimire, Pradeep. “Management of Enterocutaneous Fistula: A Review.”  JNMA; journal of the Nepal Medical Association  vol. 60,245 93-100. 15 Jan. 2022, doi:10.31729/jnma.5780

31. JH090505 World J Surg 1983 vol.7

32. CONCLUSIONS Best outcome result from well-defined management protocol Early diagnosis,resuscitation,control of sepsis,nutritional support may limit morbidity abd mortality Avoid risk of major reoperative procedure by an attempt of non-operative management to allow spontaneous closure

33. CONCLUSIONS If reoperation needed (> 4 months) , plan and execute meticulous resection and anastomosis Simultaneous reconstruction of the abdominal wall by a Plastic surgeon Maintain adequate nutrition during the transition back to oral feedings

34. TERIMA KASIH 1 st Beyond the Scalpel ( B.t.S .) Controversies in Trauma & Minimally Invasive Surgery