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Makafui Seth C-J. K. Đayie ( MBChB ) CCTH

Management of Acute Intestinal Failure from Entero -Cutaneous Fistula in a Resource Deprived Environment. Makafui Seth C-J. K. Đayie ( MBChB ) CCTH. OUTLINE. Introduction Definition Classification The study Conclusion. Introduction.

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Makafui Seth C-J. K. Đayie ( MBChB ) CCTH

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  1. Management of Acute Intestinal Failure from Entero-Cutaneous Fistula in a Resource Deprived Environment Makafui Seth C-J. K. Đayie (MBChB) CCTH

  2. OUTLINE • Introduction • Definition • Classification • The study • Conclusion

  3. Introduction • Intestinal failure is defined as the reduction in intestinal absorption so that micronutrients and/or water and electrolyte supplements are needed to maintain health and growth. • It is a clinical syndrome. • Route of supplementation1: oral, enteral, parenteral 1Nightingale JMD. Definition and classification of intestinal failure. In Intestinal failure 2001; pp. ix-x. London: Greenwich Medical Media Limited.

  4. Intestinal failure • Acute • Very common; 90% in perioperative period1 • Surgery is pivotal in its management; some resolve spontaneously • Type 1 and type 2 • Chronic 1Nightingale JMD. Definition and classification of intestinal failure. In Intestinal failure 2001; pp. ix-x. London: Greenwich Medical Media Limited.

  5. The study • Adopting simple yet effective and proven strategies to reduce severity of intestinal failure. • A prospective longitudinal descriptive study • Patients recruited from the Central Regional Hospital, Cape Coast • 18 month period from April 2010

  6. Data extent • Epidemiological profile • Underlying disease • Nature of the primary operation • Number of operations • Number and nature of fistulae • Wound care technique • Mode of nutrition employed • Nature and dosage of drug therapy to slow bowel transit • Serial weight and serum albumin measurements

  7. Results

  8. Each patient had at least one laparotomy at the referring centre before laparostomy(median=2; range=1-3). • One case was nursed a the ICU; had the most surgeries done (7). • Dressings were done on the ward under sedation.

  9. Patient care • Decision to proceed to the initial laparotomy after the diagnosis of entero-cutaneous fistula was made largely on clinical grounds. • Contrast enhanced CT scan not available • Procedures • Diverting loop ileostomy • Proximal end stoma with distal mucus fistula + peritoneal lavage. • Abdominal wound care • Mass closure of the wound with loop PDS; skin unstitched • Bogota bag (1/4) • Entero-atmospheric sandwich dressing (2/3)

  10. Post operative fluid requirements • IV dextrose saline + ORS then free fluids; water deliberately avoided • High protein, high calorie low fibre diet

  11. Discussion • Multidisciplinary approach to management • Surgeon, nutritionist, dedicated ward nurses and counselors. • Control of sepsis • Soeters et al2 • laparotomy and lavage +/-ileostomy +/- mucus fistula • ?CT scan + drainage • Obviating need for repeated surgeries. 2Soeters PB, Ebeid AM, Fischer JE. Review of 404 patients with gastrointestinal fistulas. Impact of parenteral nutrition. Ann Surg 1979; 190: 189-202.

  12. Nutritional care • Fistulae +/- surgery affected distal ileum • Positive water and sodium balance was achieved; no need for parenteral nutrition (particularly total parenteral nutrition) • Had Plumpy’Nut (nutritional value as F-100; 2100kJ) • Daily egg consumption • Monitoring: • Weekly weight • 2x monthly Hb

  13. Wound care (mass closure)

  14. Wound care with Bogota bag

  15. Enteroatmospheric sandwich dressing

  16. Decreasing effluent from high output fistulae • Avoiding oral administration of water3, 4, 5 • Loperamide use • Use of codeine phosphate *octreotide 3Newton CR, Gonvers JJ, McIntyre PB, Preston DM, Lennard-Jones JE. Effect of different drinks on fluid and electrolyte losses from a jejunostomy. Journal of the Royal Society of Medicine 1985; 78, 27-34. 4Rodrigues CA, Lennard-Jones JE, Thompson DG, Farthing MJG. What is the ideal sodium concentration of oral rehydration solutions for short bowel patients? Clinical Science 1989; 74, Suppl. 18, 69. 5Nightingale JMD, Lennard-Jones JE, Walker ER, Farthing MG. Oral salts supplements to compensate for jejunostomy losses: comparison of sodium chloride capsules, glucose electrolyte solution and glucose polymer electrolyte solution (Maxijul). Gut 1993b; 33, 759-761

  17. Delineating fistula anatomy • Definitive management • Restoration of bowel continuity

  18. Conclusion • A structured multidisciplinary approach and cheaper innovations are readily available in resource deprived regions to ensure improved morbidity and mortality outcomes.

  19. Thank you!

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