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Oslo - March 13, 2015 SNAP How to treat enterocutaneous fistulas Pär Myrelid MD, PhD Dept of Surgery Unit of Colorectal Surgery Linköping University Hospital.

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Presentation on theme: "Oslo - March 13, 2015 SNAP How to treat enterocutaneous fistulas Pär Myrelid MD, PhD Dept of Surgery Unit of Colorectal Surgery Linköping University Hospital."— Presentation transcript:

1 Oslo - March 13, 2015 SNAP How to treat enterocutaneous fistulas Pär Myrelid MD, PhD Dept of Surgery Unit of Colorectal Surgery Linköping University Hospital Linköping, Sweden

2 Outline – Enterocutaneous fistulas (ECF) Definition and classification Causes of ECF Dangers with ECF Prevention Prognosis SNAP – the concept Abdominal wall defects Outcome and Quality of life 2

3 ECF – Definition and classification An abnormal communication between two epithelialized surfaces – most often between the small or large bowel and the skin Other common entries of the fistulas are e.g. bladder or vagina 3 Berry et al Surg Clin North Am 1996, Evenson & Fisher J Gastrointest Surg 2006 Fistula Inflamed small bowel

4 ECF – Definition and classification 4 Berry et al Surg Clin North Am 1996, Evenson & Fisher J Gastrointest Surg 2006 Simple fistula One bowel segment – fistula – skin Complex fistula One bowel segment – abscess/fistula system – skin Multiple fistula Multiple bowel segment involved Entero-atmospheric fistula Bowel loops in abdominal defect (without fistulous tract)

5 ECF – Definition and classification Low-output fistula < 200ml/day Moderate-output fistula 200-500ml/day High-output fistula >500ml/day 5 Berry et al Surg Clin North Am 1996

6 ECF – Causes Surgical disasters (75 %) Enterotomy after e.g. adhesiolysis Anastomotic leak Repeat laparotomies Spontaneous (20-30 %) Crohn´s disease Cancer Intra-abdominal sepsis (perforation) Radiation enteritis Ischemia Trauma 6 Agwunobi et al Dis Colon Rectum 2001, Berry et al Surg Clin North Am 1996, Fischer et al J Trauma 2009, Falconi et al, Digestion 1999

7 ECF – Dangers Sepsis Intra-abdominal Line sepsis Fluid and electrolyte imbalance Thrombosis Malnutrition A high-output fistula (>500 ml/day) increases the risk of fluid and electrolyte imbalance as well as malnutrition 7 Agwunobi et al Dis Colon Rectum 2001, Evenson & Fisher J Gastrointest Surg 2006, Kaushal & Carlson Clin Colon Rectum 2004 The viscous circle

8 ECF – Prevention Risk assessment pre-operatively Risk factors Intra-abdominal sepsis (abscess/fistulas) Steroid treatment Low albumin Malnutrition/weight loss (>10 % within 6 months or 5 % within 1 month) Anemia Emergency surgery Severe adhesions Increasing risk with increasing number of risk factors High risk – consider diverting with temporary stoma 8 Myrelid et al Dis Colon Rectum 2009, Post et al Ann Surg 1991 Yamamoto et al Dis Colon Rectum 2000, Alves et al World J Surg 2002, Myrelid et al Colorectal Disease 2012 Colon Ileum

9 ECF – Prognosis Late 1980´s mortality risk 40-65 % Today 5-20 % mortality risk, in high output ECF still 30-35 % Improved intensive care, management of sepsis, malnutrition, fluid/electrolyte imbalance and surgical technique Up to 70 % close on conservative therapy Of those 91 % heal within 1 month of successful sepsis treatment The remaining heal within 3 months 9 Falconi et al Digestion 1999, Dudrick et al Digestion 1999, Reber et al Ann Surg 1978

10 ECF – Favourable prognosis End fistulas (leakage through an intestinal stump) Jejunal fistulas Colonic fistulas Continuity-maintained fistulas Small-defect fistulas Long-tract fistulas 10 Martinez et al J Gastrointest Surg 2011, Prickett et al South Med J 1991

11 ECF – Unfavourable prognosis “FRIENDS” Foreign body (e.g. mesh) Radiation Infection/Inflammation/IBD Epithelialization of the fistula tract Neoplasm Distal obstruction Steroids “With friends like these you don´t need enemies” 11 Martinez et al J Gastrointest Surg 2011, Prickett et al South Med J 1991

12 ECF – Need of a dedicated team Gastroenterologist Colorectal surgeon Nurses and nurses aids Nutritionist Stoma therapist Physiotherapist Social worker Home care Pain care (try to withdraw opioids) (Psychologist) 12 Refer patient to a specialised centre! Schein W J Surg 2008

13 SNAP – The Concept SNAP Sepsis and Skin care Nutritional support Anatomy Patience and a Planned procedure 13

14 SNAP – Sepsis Drain collections CT/US-guided (Open) Prevent line-sepsis Antibiotics Anti fungus Protect skin – wound care Acidic/Alkaline Enzymes Decrease fistula output PPI/Octeotride Loperamide/Codeine 14 Carlson Proc Nutrition 2003, Evenson & Fisher J Gastrointest Surg 2006

15 SNAP – Skin Care Dedicated and creative stoma therapists 15 Fistula opening

16 SNAP – Skin Care Dedicated and creative stoma therapists 16

17 SNAP – Nutritional support Compensate losses of fluid and electrolytes Check for imbalance in urine as well If the gut works – use it! Patients loose appetite with parenteral nutrition Parenteral nutrition/support Remember risk of liver failure – if signs of cholestasis need of days without lipids Home nutrition Fistuloclysis 17 Levy et al Br J Surg 1988, Carlson Proc Nutrition 2003, Teubner et al Br J Surg 2004, Lal et al Aliment Pharmacol Ther 2006

18 SNAP – Intestinal Anatomy Rule out further collections CT scan/Ultrasonography If collections – Drain! Define involved bowel segments Make sure no down stream obstructions/stenosis Endoscopy Colonic contrast enemas Stoma contrast enemas Fistulogram (water soluble contrast) Sometimes combined with CT scan 18 Carlson Proc Nutrition 2003, Schein World J Surg 2008 Teubner et al Br J Surg 2004, Lal et al Aliment Pharmacol Ther 2006

19 19 Colonoscopy or colonic contrast investigation

20 Colonic enema passing through a mucous fistula

21 21 Fistulogram - Contrast through the fistula to an ileocolonic anastomotic fistula

22 Fistulogram - Contrast through a prolapsing fistula which is 10 cm proximal of an end ileostomy

23 CT and fistulogram - Fistula in a hernia with a catheter placed in the fistula

24 No strictures between fistula and down stream loop ileostomy

25 SNAP – Planned Procedure Patience, patience, patience…… Prolapse of bowel loops – “mature abdomen” Softened adhesions Plan for a whole day procedure Experienced team of surgeons Gentle and sharp surgery Resect fistula segment Put all bowel into continuity Beware of anastomoses in septic area No closed bowel loops 25

26 ECF – Abdominal wall defects Often big defects Component separation Polyglactin mesh Most certainly hernia later on Biological mesh Pig dermis 26 Connolly et al Ann Surg 2008

27 ECF – Quality of Life Low HRQoL Improved after successful treatment Dependant – burden for others Leaks and wound care major impact Patients develop coping strategies Nurses important in the care and support 27 Härle Master Thesis Linköping, 2013, Visschers et al Br J Surg 2008

28 ECF – Outcome Closure achieved in approx 85 % of operated ECF patients Severe morbidity Postop infections Approx mortality Totally15 % Low output fistulas 6 % High output fistulas30 % Complex fistulas40 % 28 Martinez et al World J Surg 2008

29 Take Home Message Prevent enterocutaneous fistulas Pre-operative risk stratification If complication - divert When enterocutaneous fistulas occur Sepsis and skin care Nutritional support Intestinal anatomy clarified Planned procedure Dedicated team Patience! 29

30 www.liu.se Thank you Acknowledgement For photos and truly dedicated work Åsa Gustafsson & Christina Schulz


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