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GI FISTULAS

GI FISTULAS. Thusharendhu.N 2002 batch. HISTORY. Earliest record-OLD TESTAMENT book of Judges written by SAMUEL b/w 1043bc and 1004bc CELSUS-surgical repair of colocutaneous fistula. DEFINITION. DEFINITION.

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GI FISTULAS

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  1. GI FISTULAS Thusharendhu.N 2002 batch

  2. HISTORY • Earliest record-OLD TESTAMENT book of Judges written by SAMUEL b/w 1043bc and 1004bc • CELSUS-surgical repair of colocutaneous fistula

  3. DEFINITION DEFINITION • Fistula is an abnormal communication b/w two epithelialised surfaces

  4. Gastrointestinal fistula • Pathological communication -connects GI tract with skin, internal organs, peritoneal or retroperitoneal space, thorax

  5. TYPES • Oral, pharyngeal & esophageal • Gastric • Duodenal

  6. Small intestinal fistula • Pouch fistula

  7. Colonic fistula • Internal fistula

  8. CLASSIFICATION • Anatomic • Physiologic • Etiologic

  9. Anatomic… • Based on internal/external • anatomic course • Suggests etiology • Prognosticates spontaneous closure • Assists planning operative • timing & approach

  10. Physiologic • Output(ml/day) • Low<200 prognosticates mortality • Moderate assists physician in • 200-500 anticipating & treating • High>500 met.defects

  11. Etiologic Spontaneous (15-25%) Iatrogenic / post operative (75-85%) • prognosticates spontaneous closure • prognosticates mortality

  12. Spontaneous causes(15-25%) Radiation IBD Appendicitis Ischemic bowel Indwelling tubes Diverticular disease

  13. Perforated ulcers Malignancies Intestinal Actinomycosis / TB Trauma

  14. Iatrogenic causes(75-85%) Cancer Operations Operations for IBD Lysis of Adhesions Others…..

  15. Prevention • Sound surgical procedure • Anastomosis in healthy bowel with adequate blood supply • Anastomosis without tension • Mechanical bowel preparation • Antibiotics • Meticulous & precise hemostasis • Abdominal wall closure • Filling of dead space/drainage with suction • Hydration • Nutritional support

  16. Prevention contd… • Nutritional characteristics-increased risk for anastomotic breakdown • wt.loss of 10-15% of BW over 3-4 months • s.albumin conc.<3g/dl • s.trasferrin conc.<220mg/dl • anergy to injected recall antigens • inability to perform usual tasks bz of weakness/easy fatiguability

  17. PATHOPHYSIOLOGY

  18. FLUID ELECTROLYTE IMBALANCE • Defined as abnormalities in s.electrolytes of >48hrs duration & are primarily associated with high output fistulas • Most commonly these disturbances involve K,Na,Mg,PO4,Zn

  19. MALNUTRITION MALNUTRITION • 3 Main contributary factors: • Lack of adequate nutrient intake • Hypercatabolism associated with sepsis • Loss of protein rich,energy requiring secretions from fistula

  20. SEPSIS • Most common complication of enterocutaneous fistula • Most common cause of fistula related death • CT/MRI,Indium scan • Refunctionalisation

  21. MALIGNANCY • Cause of 3-7% of fistulas • Present in 5-35% of patients with fistulas • Accounts for 30-40% of fistula mortality • Rational treatment plan based on known tumor etiology should be done

  22. NATURAL HISTORY Likely to close Unlikely to close • Anatomic oropharyngeal, gastric,ileal, location duodenal,jejunal, lig.of Treitz pancreaticobiliary • Nutritional well nourished malnourished status • Sepsis absent present

  23. Natural history…. Likely to close Unlikely to close • Etiology appendicitis, crohn’s,cancer, diverticulitis, foreign body, post-op radiation • Condition healthy,small disruption,abscess of bowel leak,no abscess distal obstruction • Miscellaneous tract>2cm length epthelialisation, defect<1cm2 foreign body • Transferrin >200mg/dl <200mg/dl

  24. CLINICAL FEATURES • Pain Fever Abdominal pain / tenderness Raised WBC count • External fistulas- Discharge of intestinal contents • Eso.resp. Fistulas: Lung abscess Aspiration pneumonia Empyema

  25. Clinical features….. • Slow unusual recovery. • Abdominal pain/tenderness,fever leucocytosis. • Excessive drainage/abscess formation. • Skin changes around the wound • Presence of enteric contents in the wound within 24-48 hrs.

  26. MANAGEMENT PHASES • Stabilisation • Investigation • Decision • Definitive therapy • Healing

  27. STABILISATION(within 24-48hrs)

  28. STABILISATION • Resuscitation • Drainage of abscess & local control • Nutritional management • Control of sepsis • Nasogastric tubes • Decrease the volume of secretion • Emotional support

  29. RESUSCITATION • Rehydration-usually crystalloid 3-4 Lit. • Correction of anemia to a hematocrit of 35 by transfusion of packed red cells • Oncotic pressure restoration until s.albumin reaches 3mg/dl

  30. Drainage of abscessand local control • Abscess should be drained 24hrs prior to line insertion • Control of fistula drainage by latex catheter/high pressure suction • Karaya seal,ileostomy cement,glycerine,ion exchange resins-keep skin acidic&prevent activation of pancretic enzymes • Stomadhesive

  31. NUTRITIONAL MANAGEMENT • TPN-gastric,duodenal,pancreatic,jejunal • ENTERAL -esophagus, distal ilium, colon • GI tract should be used if possible provide at least portion of nutritional needs of patient

  32. Control of sepsis • Org. are of bowel origin-coliforms,bacteroides,enterococcus • Staph. Involved in intra abdominal sepsis • Percutaneous drainage under CT guidance • Operative therapy

  33. Measures to decrease vol. of secretion H2 antagonists/proton pump inhibitors Decrease gastric secretion Somatostatin / octreotide • Decrease gastric, pancreatic, small intestinal secretions • Increase absorption of water and • Electrolytes from small intestine • Accelerates gastric emptying but decrease motility of rest of GIT

  34. Emotional support • Continued involvement&reassurance • Attention to ambulation&physical therapy

  35. INVESTIGATION(after 7-10 days)

  36. Fistulogram -define anatomy&pathophysiology • CT/MRI-locate collections&stage cancer

  37. EGD/Colonoscopy • Barium enema

  38. Gatsrocolic fistula Enterocolic fistula

  39. DECISION(7-10 days to 4-6 wks)

  40. Goal of therapy- re-establishment of intestinal integrity • Asses the likelihood of spontaneous closure-depends on • underyling cause • presence/absence of sepsis • anatomic location • condition of the bowel • nutritional status

  41. Decision… • No spontaneous closure/ • No signs of imminent closure after 4-5 wks of nutritional support in a sepsis free patient -decide the surgical timing -patient should be prepared for surgery

  42. DEFINITIVE THERAPY • WHEN SPONTANEOUS CLOSURE IS UNLIKELY / AFTER 4-6 WKS • Plan operative approach

  43. Factors unfavourable for spontaneous closure 1.Total anastomotic disruption 2.Strictured bowel/distal obstruction

  44. 3.Fistulas with associated abscesses

  45. 4.Gastric ,lateral duodenal or lig .treitz fistulas 5.Ileal fistulas

  46. 7.Tract<2cm 6.Defect >1cm2

  47. Indications for Surgery 1.Persistent fistula fails to close After 4-6 weeks conservative treatment in a sepsis free patient 2.Uncontrolled sepsis 3.Fistula poorly prognostic for conservative treatment

  48. Pre-op preparation • Meticulous skin care • Control of fistula drainage • Culture of fistula drainage • Intraluminal & iv antibiotics • Discontinuation of enteral nutrition

  49. Continued…. • If receiving parenteral nutrition • -reduce rate to 40 ml/hr just prior to operation • Operation carried out thru a healhty abdominal wall • Abdomen & operative site-anti bacterial solution • Bowel preparation

  50. SURGERY • Extensive resection with meticulous technique & hemostasis • Approach thru a new incision • Dissection from lig. of Treitz to rectum • All adhesions freed

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