Sie sind auf Seite 1von 34

ENTERO-CUTANEOUS FISTULA

 A Fistula is defined as an abnormal


communication between two epithelized
surfaces.

 Enterocutaneous fistulas (ECFs) are abnormal


communications between the bowel and skin

 Morality rate of 6.5 to 21%.

2
Anatomical classification:
(1)
Internal: Two organ of same or different system
▪ Enteroenteral, enterovesical,enterocolic,
External: Gut to body surface.
▪ Gastrocutaneous,duodenocutaneous,
enterocutaneous.

3
(2)
Simple or direct.
Complicated-
1.Having multiple tracts
2.Connection with more
than one viscus
3.drainage into an
associated abscess
cavity.
 High output- output more than 500 ml/ day

 Moderate output- output 200-500 ml/day

 Low output- output less than 200ml/day

5
1. Spontaneous(15-25%)-
• Radiation
• Duodenal ulcer
perforation
• Inflammatory bowel
disease
• Malignancies
• Diverticular disease
• Intestinal tuberculosis
• Appendicitis
• Actinomycosis.
• Ischaemic bowel disease
6
• Operations for
perforations .

• Acute intestinal
obstruction

• Intestinal
malignancies

• Adhesiolysis

• Blunt and penetrating


abdominal trauma 7
3. Congenital
 Tracheo- esophageal
 Rectovaginal
 Umbilical fistula.

4. Traumatic
 Blunt and penetrating trauma of abdomen, chest
and perineum
8
 Disease bowel extending to surrounding structures

 Extraintestinal disease involving otherwise normal


bowel

 Trauma to normal bowel including inadverent or


missed enterotomies

 Anostomotic disruption following surgery for a


vareity of conditions

bbthapa 9
 Small intestinal fistula are most common
type of gastrointestinal fistulas encountered.

 Most series report 70%-90-% of small


intestinal fistulas occurs after an operative
procedure.

bbthapa 10
 Malnutriton  Mobilisation
 Infection  Handling
 Hypotension  Tension
 Anemia  Ischemia
 Hypothermia  hemostasis
 Poor oxygen delivery

bbthapa 11
 Fluid and electrolyte imbalance.

 Malnutrition

 Sepsis

 Skin irritation and excoriation

bbthapa 12
 Recognized 5th-10th days  Abdominal tenderness
post operatively.
 Drainage of enteric
 Fever material through the
abdominal wound or
 Leucocytosis through or existing
drains.
 Prolonged ileus
 Varies with anatomical location

1. Esophageal- 15-25 days

2. Duodenal- 30-40 days

3. Colonic - 30- 40 days

4. Small Bowel- 40-60 days

14
THE GOAL are
 Re-establishment of bowel continuity
 Ability to achieve oral nutrition
 Closure of the fistula

15
PHASE TIME COURSE
RECOGNITON / 24 TO 48 HRS
STABILISATION
INVESTIGATON 7- 10 DAYS
DECISION 10 DAYS TO 6 WEEKS
DEFINITIVE WHEN CLOSURE UNLIKELY OR
MANAGEMENT 4-6 WKS
HEALING 5 – 10 DAYS AFTER CLOSURE
UNTILL FULL ORAL NUTRITON
16
 Resuscitation
 Control of sepsis
 Electrolyte repletion
 Control of fistula drainage
 Local skin care n protection
 Provision of nutrition

bbthapa 17
 Restoration of normal circulating blood volume

 Correction of electrolyte & acid base imbalance.

 Plasma oncotic pressure should be restored by


exogenous albumin administration. - 3 mg/dl
 Management of local wound infections

 Drainage if Intra-abdominal collections (percutaneous)

 Laparotomy may be required for:


 Extensive cellulitis/necrotising fascitis
 Incomplete percutaneous drainage of collections
 Disruption of anastomosis

 Antibiotics as per indicated

 CVP only after 24 hrs of drainage


19
 Restrict hypo-osmolar fluids
 Encourage electrolyte mix
 Antisecretory agents
 Proton pump inhibitors
 Somatostatin or octreotide
 Antimotility agents
 Loperamide
 Codeine

20
T
 Problems in skin around the fistula:
 Wetness
 Burning pain
 Discomfort from skin edema

 Goals of skin care:


 Containing the effluent
 Patient independence and mobility

22
 Solid wafers (pectin based)

 Powders (Pectin / Karaya based)

 Paste

 Spray and wipes

 Ointments and creams (zinc/petroleum based)


 Wound pouch dressings

 One/two piece design


Wound pouch dressing
bbthapa 24
25
Nutritional management

 Plays Central role in management

 Adequate circulation and tissue oxygenation must


for optimal utilization.

 May be:
▪ Enteral
▪ Parenteral

bbthapa
26
Objectives of investigation plan: To define-

 Precise anatomical location

 Is the bowel in continuity or is disrupted

 Abscess cavity

 Condition of adjacent bowel

 Is there a distal obstruction

 Etiological disease process


27
 Fistulogram

 MRI

 Barium transit studies

28
 By using water soluble gastrograffin is the
investigation of choice
 length and diameter of the tract
 site of bowel wall defect
 health of the adjacent bowel,
 and the presence of strictures
 abscess cavities
 distal obstruction
 anastomotic dehiscence.
Gastro cutaneous fistula

Entero colic fistula bbthapa Sigmoid cutaneous fistula 30


 Gastro duodenoscopy : Demonstrates both
underlying disease and presence of fistula.

 Colonoscopy : Fistula is usually not visible but


presence of disease and its nature by biopsy can be
demonstrated.

bbthapa 31
 No signs of imminent closure after 4- 6 weeks then
patient should be prepared for surgery

 Uncontrolled sepsis urgent drainage of sepsis.

 General condition very poor then only abscess


drainage

 In case of malignancies early operation should be


done.

32
 Optimal nutrition parameters
 Free of sepsis
 Well healed abdominal wall without inflammation
 Prophylactic antibiotics
 Tapering of tube feeding
 Prevent contamination of abdominal wall tissues
 Treat the cause

33
 a. Foreign Body
 b. Radiation
 c. Inflammation/ infection
 d. Epithelialisation [F-R-I-E-N-D-S]
 e. Neoplasm
 f. Distal intestinal obstruction
 g. Steroids.

Das könnte Ihnen auch gefallen