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BY DR KACHE S A SURGERY DEPT ABUTH, SHIKA ZARIA MODERATOR ; DR UKWENYA

DEFINITION OVERVIEW

OF INTESTINAL FISTULAE OF ENTEROCUTANEOUS FISTULA

CLASSIFICATION AETIOLOGY

PATHOPHYSIOLOGY MANAGEMENT PREVENTION CONCLUSION

PROTOCOL

Enterocutaneous fistula is an abnormal communication between a intestine & the skin. It is also called external intestinal fistula

The communication(track) is usually formed by granulation tissue but in some cases may be lined by epithelium

INTERNAL-communication between 2 or more hollow viscera, without external communication EXTERNAL(ENTEROCUTANEOUS)-when a hollow viscus discharges to body surface MIXED-when both components are present SIMPLE-single direct track COMPLICATED/-multiple tracks or an assoc abscess cavity LATERAL-arising from side of a hollow viscus END FISTULA-arising from whole circumference of the involved bowel & there is no further continuity of the gut

VOLUME
High

OF OUTPUT-

output- >500ml/24hrs Moderate Output- 200-500ml/24hrs


Low

output- <200ml/24hrs, with exception of pancreatic & hepatobilliary fistulae SITE-Proximal & distal

ANATOMIC XTIC

OF TRACK- Simple or Complicated End fistula or lateral fistula

CIRCUMFERENCE-

Proposed

by Siteges-Sera et al & modified by Schein et al as follows TYPE MORTALITY RATE

I.

Abdominal oesophagus + gastroduodenal fistulae 17%


Small bowel fistulae Large bowel fistulae 33% 20%

II. III. IV.

Fistula at any site with assoc large abd. Wall defect 60%

SURGERY-(commonest cause) .usually due to unrecognised injury to bowel as a result of careless dissection or due to breakdown of anastomosis TRAUMA- Blunt or Penetrating
SPONTANEOUS EXTENSION of intraabdominal dx thru the abd wall e.g Sloughing of a strangulated hernia

I.

II.
III.

Pointing of an empyema of the gallbladder


Duodenal ulcers eroding thru abd. wall

INFLAMATORY CONDITIONS such as TB, Anastomotic ulcer & diverticular dx, chrons dx
RADIATION ENTERITIS- presents several years after initial exposure

CONGENITAL- e.g patent vitello-intestinal duct(umbilical fistula)

Loss of GI Content Hypovolaemia, Acid-base and electrolyte abnormalities, Malnutrition. Sepsis Intra-abdominal sepsis Wound infection Skin problems.

Anaemia

Portion of gut below the fistula is by-passed resulting in malabsorption of essential nutrients
Fistula + complications + catabolic effects of sepsis = increased energy expenditure Body stores of glycogen & fat are progressively depleted & proteins mainly from muscles Vit & trace element def. also occur Resistance to infection & impaired wound healing

If fistula track is not effectively walled off from surrounding structures , there is escape of enteric content into normally sterile areas such as peritoneal or pleural cavities

Fistula is unlikely to close in presence of sepsis

Assoc. toxaemia & circulatory disturbances may result in multiple organ failure

High fluid loss:

Large fistula

High fistula

Distal obstruction

Advances

in electrolyte replacement & nutritional support measures have allowed surgeons to maintain pts in a good condition until the fistula closes spontaneously or the pt becomes fit for a definitive surgical correction at early surgical closure, in an effort to avoid the problems of fluid & electrolyte imbalance, malnutrition & sepsis, were assoc. with very high mortality rates(Monod Broca 1977)

Attempts

Sheldon et al(1971) suggested a four phase approach that could successfully put mgt priorities in order

PHASE
I. II. III. IV.

Resuscitation & stoma care Institution of nutritional treatment Investigations & continuing nutritional Rx

Definitive treatment plan

RESUSCITATION- follow ABC -correct hypovolaemia, restore fluid & electrolyte balance using plasma substitute, blood transfusion

-maintain on daily req. + est. loss via fistula

PROTECTION OF SKIN & COLLECTION OF FISTULA EFFLUENT- main aim of stoma mgt is the application of effective skin protectives & a disposable drainage bag which will collect effluent & allow accurate measurement

Irving & Beadle(1982) classified skin problems assoc. with ECF into four categories A single orifice passing thru an intact abd. Wall or otherwise healed scar around which the skin is flat & in reasonably good condition Single or multiple orifices passing thru the abd wall close to bony prominences, surg. Scars, other stomas, the umbilicus Fistula thru small dehiscence of main wound

I.

II.

III.

4. Fistula thru a large dehiscence or at bottom of gaping wounds


Stoma mgt cat. 1-silicon barrier preparation -apply adhesive drainable bags Extra skin protection(adhesive wafers)-in high output fistula Stoma mgt cat 2-severely excoriated skin, impossible for any appliance to adhere -Nurse pt face down on a split bed or Stryker frame for up to 48hrs

Stoma mgt cat 2 cont- use large sheets of adhesive wafer(20x20) -cut to fit various holes in the abd
-protective paste can be used to seal edges -Apply large bag(sometimes 2 or 3 small bags) -if abd scarred by previous surg, resulting grooves & gullies shd be filled Stoma mgt cat 3- use adhesive wafers -large sized bags

Stoma mgt cat 4


-Initially low pressure sump suction drainage to remove effluent

-This is continued until the wound shrinks to a size that can be managed by the techniques described above

Aim is to provide adequate & sustained nutritional Rx in order to maintain the pt, until the fistula closes spontaneously or until the pt is fit for surgery. High output or proximal fistula- commence parenteral nutrition within 48hrs.once phase I procedures have been completed If subsequent invx reveal >100cm of functioning small bowel, proximal or distal to the fistula, it may be possible to phase in enteral regimens

In pts with low output or distal fistula, enteral feeding can be commenced from the beginning Parenteral nutrition-via central feeding lines Enteral nutrition-orally

-NG tube
-Gastrostomy, Jejunostomy

Nitrogen requirement= Daily urinary nitrogen excretion + 3-4g Septic pts=25-30g(10-15g) Energy Req = 4000-5000kcal/day(rarely exceeds 2000-3000kcal/day)
ENTERAL PREPS- Elemental diet of AA, Oligopeptides, Triglycerides, Simple sugars preferably in liquid form Said to be totally absorbed from 150-250cm of small bowel E.g conplan, casilla, astymin

Once nutritional Rx has been established the pt is investigated fully to answer the following questions What is the origin of the fistula & the anatomy of its track What is the condition of the bowel at the site of the fistula? discontinuity or active disease Is there obstruction distal to the fistula?

1.

2.

3. 4. 5.

How much normal bowel is available?


Is there an assoc. abscess cavity?

CLINICAL EVALUATION Hx of surgery Hx of discharging wound from surgical scar or any other part of the body Hx of underlying dx Hx of fever, abd. Pain Hx of bowel habit; is pt passing stool or not

O/E Fever, tarchycardia, abd. Tenderness, guarding, rigidity Signs of Dehydration & Malnutrition Discharging wound

FISTULOGRAPHY- valuable for narrow well defined fistula opening, doubtful value for high output fistula in depths of gaping wounds -outline track & abscess cavity

BARIUM CONTRAST STUDIES-outline track, abscess cavity, demonstrate length of remaining bowel ULRASOUND SCANNING- abscess cavity

CT SCAN- abscess cavity, Percut. Drainage ENDOSCOPY- useful in revealing underlying dx ROUTINE INVX- Fbc, U&E

If pt is improving & flow charts indicate a falling fistula effluent & a rising plasma albumin & body wt- it is worth persisting with non-surgical Rx without time limit(Alexander Williams & Irving 1982) However, if peritonitis or abscess cavity is presenturgent operative Rx shd be instituted In the absence of spontaneous closure within 46wks of nutritional support- surgical closure shd be undertaken

FACTORS RESULTING IN FAILURE OF SPONTANEOUS CLOSURE Complicated fistula with abscess cavity

Distal obstruction Total discontinuity of bowel ends Mucocut. Continuity(short track <2cm) or epithelialized track Radiation enteritis

Presence of active dx at site of fistula

TREATMENT OF COMPLICATIONS

Infection- antibiotics indicated in resp, uti, septicaemia, spreading cellulitis, I & D for abscess Haemorrhage-bleeding may arise from
Erosion of a bld vessel by an abscess cavity Stress ulceration due to assoc severe sepsis

I.

II.

From underlying dx e.g pud, neoplasm RX-H2 antagonist


III.

-pack abscess cavity following drainage

-selective embolization

Venous thromboembolism

-Anticoagulants

PHARMACOLOGIC TREATMENT H2 Antagonist gastroduodonal fistulae

Somatostatin Analogues (Octreotide) small bowel fistulae

Those designed to improve pts condition I&D for abscesses Insertion of central lines Creation of feeding enterostomies
Those designed to close the fistula Usually a staged procedure Incision shd be extensive, commencing from virgin area of abdomen In septic pts- initial resection, anastomosis at a later date

In non septic pts- resection + prim end to end anastomosis done

Identification of high risk individuals.


Meticulous surgical technique. Proper use of peri-operative antibiotics.

Thorough preoperative bowel preparation.

Most uncomplicated ECF will close spontaneously when properly managed Surgery is usually not an immediate priority except to deal with complications
When surgery is required, fistula resection & anastomosis or by-pass procedures are the preferred surgical procedures

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