enterocutaneous fistulas and their management.pptx

management of enterocutaneous fistula

1. Enterocutaneus Fistula Current management Algorithms Dr. Shabi Ahmad Professor Surgery M. L. N. Medical College, Prayagraj KGMU2024

2. Enterocutaneus Fistula Current management Algorithms Classification Source -- segment of bowel involved Output – Low -<200ml Moderate - 200-500 mL/d High - >500mL/d Etiology – Iatrogenic Spontaneous KGMU2024

3. Enterocutaneus Fistula Current management Algorithms KGMU2024 Enterocutaneous Fistula Enteroatmospheric Fistula Proximal Diversion

4. Enterocutaneus Fistula Current management Algorithms Cause Frequency (percent) Postoperative 85 Spontaneous 15 Crohn disease 39 Ulcerative colitis 13 Malignancy 9 Radiation 6 Diverticular disease 5 Other* 27 KGMU2024

5. Enterocutaneus Fistula Current management Algorithms Spontaneous fistula (15-25%) IBD Malignancy Appendicitis Diverticulitis Radiation Infection: TB/ actinomucosis Ischemia KGMU2024

6. Enterocutaneus Fistula Current management Algorithms Iatrogenic Fistulas 75-85% iatrogenic Trauma Operation for malignancy Adhesiolysis Small bowel fistulas 50% missed enterotomy 50% anastomic leak KGMU2024

7. Enterocutaneus Fistula Current management Algorithms Foreign body Radiation Infection/Inflammation-IBD Epithelialization Neoplasm Distal obstruction Stricture/Stenosis KGMU2024 F R I E N D S

8. Enterocutaneus Fistula Current management Algorithms Most Common co diagnosis with EF diagnosis Infection 57.1% Fliud /Electrolyte Imbalance 36.9% Anemia 34.6% Sepsis 25% Malnutrition 22.5% Crohns Disease 19.3% Coagulopathy 18.0% Bowel obstruction 13.1% KGMU2024

9. Enterocutaneus Fistula Current management Algorithms Source Sodium ( mEq /L) Potassium (mEq/L) Bicarbonate (mEq/L) Chloride (mEq/L) Volume (mL/d) Replacement Gastric 60 10 90 2000 to 2500 0.45 NS + 10 K Pancreatic 140 5 90 to 110 30 to 45 1000 NS + 10 K + HCO3 Bile 140 5 35 100 1500   Small bowel 100 to 130 15 25 to 35 100 to 140 3500 NS + 10 K Colon (diarrhea) 50 30 50 50 1000 to 4000 0.45 NS + 20 K KGMU2024

10. Enterocutaneus Fistula Acute Management – To Operate or not to operate Enteric Content is in seen on the abdominal incision…. Is the patient septic Is the patient stable How much output What was the initial surgery When was the initial surgery KGMU2024

11. Enterocutaneus Fistula Acute Management Role of CT scan – with oral contrast Identification of associated abscess Considertion of drainage Proximal diversion ? KGMU2024

12. Enterocutaneus Fistula Current management Algorithms Surgical Interventions Surgical Tips • What to do in the OT ? • Primary repair • Primary resection • Diversion • Drainage KGMU2024

13. Enterocutaneus Fistula Current management Algorithms For patients considering operative approach What is likelihood of success ? Co-morbidities Presumptive etiology of fistula What is the operative plan? Primary repair Resection Drainage Diversion KGMU2024

14. Enterocutaneus Fistula Current management Algorithms Acute Management Timing of intervention matters POD. #. 0-10 13% mortality POD # 11-42. 21% “ POD. #. >43. 11% “ KGMU2024

15. Enterocutaneus Fistula Current management Algorithms Acute Management Focus on Sepsis – antibiotics,PCD,operative drainage or source control Diversion in presence of sepsis rather than redo anastomosis or primary repair Restoration of hemodynamic stability – fluids, electrolyte and vitals

16. Enterocutaneus Fistula Current management Algorithms Chronic Management Fluid therapy Nutrition Goals Wound Care Bag drainage NPWT Fistula output reduction

17. Enterocutaneus Fistula Current management Algorithms Non operative Fistula Closure Endoscopic therapies – in stable,nonspetic patients only ( esophagus,gastric,colon ) Covered enteric stents Endoscopic clipping – for acute fistulas, postop perforatins Fistula plugs Fibrin sealant – multiple application (small series)

18. Enterocutaneus Fistula Current management Algorithms Antibiotics Acutely 5-7 days empirrcally 5-7 days after control of sepsis Long term No good data Increasing multidrug resistant bacteria KGMU2024

19. Enterocutaneus Fistula Current management Algorithms NPO while controlling sepsis Start refeeding – does it change the output Fistula output goal <1.5 L >75 cm of proximal bowel KGMU2024

20. Enterocutaneus Fistula Current management Algorithms

21. Enterocutaneus Fistula Current management Algorithms Chronic Management Fluids & Electrolytes PPI/H2 receptor blockers Reduce effluent by 60% Antimotility Imodium: 40 mg / day Codiene : 240 mg/ day KGMU2024

22. Enterocutaneus Fistula Current management Algorithms

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24. Enterocutaneus Fistula Current management Algorithms Chronic Management Nutrition Mortality is 0% when albumin >3.5 (Fazio WJS 1983) Nutrition Inadequate nutrition 93% mortlity 7% healing rate Adequate nutrition 27% mortality rate 81 % healing rate. ( Chapman AJS. 1964) KGMU2024

25. Enterocutaneus Fistula Current management Algorithms KGMU2024

26. Enterocutaneus Fistula Current management Algorithms KGMU2024

27. Enterocutaneus Fistula Current management Algorithms Non Operative management KGMU2024 Negative pressure wound therapy

28. Enterocutaneus Fistula Current management Algorithms KGMU2024

29. Enterocutaneus Fistula Current management Algorithms When to Operate Is the patient ready for Surgery? Nutrition Skin Mobility Mentally KGMU2024

30. Enterocutaneus Fistula Current management Algorithms Surgical Interventions – Tips Post operative NG tube Await bowel function Small bowel follow through - gastrofraffin THEN enteric intake KGMU2024

31. Enterocutaneus Fistula Current management Algorithms Abdominal wall closure Avoid mesh Risk of infection/recurrence Consider component separation KGMU2024

32. Enterocutaneus Fistula Mortality Mortality Historically 40-65% Reduced in specialized centers Intestinal failure units – 10.8% to 21 % Etiology Sepsis. - 77% of mortality from fistula Malnutrition Electrolyte disturbances KGMU2024

33. Enterocutaneous Fistula

34. Enterocutaneus Fistula Current management Algorithms KGMU2024

35. Enterocutaneus Fistula Current management Algorithms Summary KGMU2024

36. Enterocutaneus Fistula Current management Algorithms Thanks