oslo - march 13, 2015 snap how to treat enterocutaneous fistulas pär myrelid md, phd dept of...
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Oslo - March 13, 2015
SNAP How to treat enterocutaneous fistulas
Pär MyrelidMD, PhD
Dept of SurgeryUnit of Colorectal Surgery
Linköping University HospitalLinköping, Sweden
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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
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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
Berry et al Surg Clin North Am 1996, Evenson & Fisher J Gastrointest Surg 2006
Fistula
Inflamed small bowel
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ECF – Definition and classification
Berry et al Surg Clin North Am 1996, Evenson & Fisher J Gastrointest Surg 2006
• Simple fistulaOne bowel segment – fistula – skin
• Complex fistulaOne bowel segment – abscess/fistula system – skin
• Multiple fistulaMultiple bowel segment involved
• Entero-atmospheric fistulaBowel loops in abdominal defect (without fistulous
tract)
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ECF – Definition and classification
• Low-output fistula
< 200ml/day
• Moderate-output fistula
200-500ml/day
• High-output fistula
>500ml/day
Berry et al Surg Clin North Am 1996
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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
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
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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
Agwunobi et al Dis Colon Rectum 2001, Evenson & Fisher J Gastrointest Surg 2006, Kaushal & Carlson Clin Colon Rectum 2004
The viscous circle
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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
Myrelid et al Dis Colon Rectum 2009, Post et al Ann Surg 1991Yamamoto et al Dis Colon Rectum 2000, Alves et al World J Surg 2002,Myrelid et al Colorectal Disease 2012
Colon
Ileum
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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
Falconi et al Digestion 1999, Dudrick et al Digestion 1999, Reber et al Ann Surg 1978
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ECF – Favourable prognosis
• End fistulas (leakage through an intestinal stump)
• Jejunal fistulas
• Colonic fistulas
• Continuity-maintained fistulas
• Small-defect fistulas
• Long-tract fistulas
Martinez et al J Gastrointest Surg 2011, Prickett et al South Med J 1991
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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”
Martinez et al J Gastrointest Surg 2011, Prickett et al South Med J 1991
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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)
Refer patient to a
specialised centre!
Schein W J Surg 2008
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SNAP – The Concept
• SNAP
• Sepsis and Skin care
• Nutritional support
• Anatomy
• Patience and a Planned procedure
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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
Carlson Proc Nutrition 2003, Evenson & Fisher J Gastrointest Surg 2006
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SNAP – Skin Care
• Dedicated and creative stoma therapists
Fistula opening
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SNAP – Skin Care
• Dedicated and creative stoma therapists
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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
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
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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
Carlson Proc Nutrition 2003, Schein World J Surg 2008Teubner et al Br J Surg 2004 , Lal et al Aliment Pharmacol Ther 2006
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Colonoscopy or colonic contrast investigation
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Colonic enema passing through a mucous fistula
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Fistulogram - Contrast through the fistula to an ileocolonic anastomotic fistula
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Fistulogram - Contrast through a prolapsing fistula which is 10 cm proximal of an end ileostomy
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CT and fistulogram - Fistula in a hernia with a catheter placed in the fistula
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No strictures between fistula and down stream loop ileostomy
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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
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ECF – Abdominal wall defects
• Often big defects
• Component separation
• Polyglactin mesh
• Most certainly hernia later on
• Biological mesh
• Pig dermis
Connolly et al Ann Surg 2008
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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
Härle Master Thesis Linköping, 2013, Visschers et al Br J Surg 2008
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ECF – Outcome
• Closure achieved in approx 85 % of operated ECF patients
• Severe morbidity
• Postop infections
Approx mortality
• Totally 15 %
• Low output fistulas 6 %
• High output fistulas 30 %
• Complex fistulas 40 %
Martinez et al World J Surg 2008
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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!
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www.liu.se
Thank you
Acknowledgement
For photos and truly dedicated workÅsa Gustafsson
&Christina Schulz