“enteroatmospheric” fistula: the feared complication of ... · fistula closed almost...
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“Enteroatmospheric” Fistula:
The Feared Complication of the
“Open Abdomen”
William Schecter, MD, FACS
Professor of Clinical Surgery
University of California, San Francisco
Chief of Surgery
San Francisco General Hospital
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Definitions
• Fistula: Abnormal communication between two epithelialzed surfaces
• Enterocutaneous fistula: Abnormal communication between the gastrointestinal tract and the skin
• “Enteroatmospheric” fistula: A hole in the gastrointestinal tract in an open abdomen without overlying soft tissue
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Causes of Chronic Fistula
• Foreign body
• Radiation
• Inflammatory bowel disease/Infection
• Epithialized tract
• Neoplasm
• Distal Obstruction
• Sepsis
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Enterocutaneous Fistulas
• 75-85% iatrogenic post-operative
– “Entero-atmospheric” Fistula always a post-operative
problem
• 15-25% “spontaneous” in origin
– Radiation
– Inflammatory bowel disease
– Diverticular disease
– Malignancy
– Tuberculosis
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Principles of Fistula Management
• Resuscitation
– Fluids and Electrolytes
– Nutritional Support
• Enteral
• Parenteral
• Drain Local Abscess/Infection
• Define Anatomy of Fistula
• Rule out/Treat Distal Obstruction
• Resect chronic fistula if it fails to heal
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Problem of
“Entero-atmospheric” Fistula
• Absence of overlying soft tissue with good
blood supply precludes spontaneous healing
• Exposed abdominal viscera predisposes to
development of additional holes in the GI
tract
• Complex Wound difficult to manage
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Principles of Management
Specific for
“Entero-atmospheric” Fistula • PREVENTION
– Protect exposed abdominal viscera during open abdomen management
– Limit access to the wound to one or two SENIOR people
• Attempt to seal leak when first recognized
• Protect adjacent viscera with biologic dressings to avoid additional holes
• Control fistula effluent
• Rotate flaps with good blood supply to cover fistula in selected cases
• Resect well established “entero-atmospheric” fistula only when patient fit and infection free
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Principles of Management Specific for
“Entero-atmospheric” Fistula
• The patient should be “adopted” by a senior
surgeon who sees the patient and the family
daily and dictates long term management
goals
– The patients are “psychological disasters”
– Body image, odor and cleanliness are major
issues
– Intra-familial tensions are the norm
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Principle 1:
Prevention
Viscera Protection with Cadavre Skin
as a Biologic Dressing
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Wound healed by Serial Abdominal
Closure without Fistula
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Complex ventral hernia following
open abdomen therapy
5 years s/p gsw to stomach and left adrenal gland. Following
Initial operation developed bowel ischemia due to cocaine,
Treated with open abdomen and skin graft closure of viscera
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Completion of Herniorrhaphy
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“Enteroatmospheric Fistula”
POD #3 – Tachycardia – to OR –ischemic
Right Colon – Right hemicolectomy
Open abdomen managed with wound VAC.
Did well for 5 days until n-g output suddenly
Increased over a 12 hour period
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Principle 2: Attempt to Seal Leak
Principle 3: Protect Adjacent
Viscera
Small bowel “springs a leak” through small hole.
Hole covered with fibrin glue and Alloderm.
Fistula closed almost immediately-”a miracle”
Abdomen closed eventually with autograft
Girard S, Sideman M, Spain D. A Novel Approach to the problem of intestinal fistulization in
Patients managed with open peritoneal cavities. Am J Surg 2002;184:166-7.
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Ruptured Abdominal Aortic
Aneurysm
Courtesy of Dr. Andre Campbell
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Alloderm Closure of Facial Defect
Courtesy of Dr. Andre Campbell
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Principle 4
Control Fistula Effluent
• Free Peritoneal Cavity
– Major problem is lack of source control causing
peritonitis and SIRS
– Exteriorize fistula if possible or divert
proximally: OFTEN IMPOSSIBLE IN AN
OPEN ABDOMEN
– Consider “floating stoma” if exteriorization
impossible
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PICTURE OF
FLOATING STOMA
Subramanian MH, Liscum KR, Hirshberg A. The Floating Stoma: A New Technique
For Controlling Exposed Fistulae in Abdominal Trauma. J Trauma2002;53:386-8.
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Principle 4
Control Fistula Effluent
• Fixed Visceral Block
– Vacuum Assisted Wound Management System
– Wound Drainage Bags
• Requires expert enthusiastic nursing assistance
• Creativity
1.Hyon SH, Martinez-Garbino JA, Benati ML, et al. Management of a high-output postoperative
Enterocutaneous fistual with a vacuum sealing method and continuous enteral nutrition. ASAIO J.
2000;46:511-4.
2.Erdmann D, Drye C, Heller L et al. Abdominal wall defect and enterocutaneous fistula treatment
With Vacuum –Assisted closure (V.A.C.) system. Plast Reconstr Surg 2001;108:2066-8
3.Alvarez AA, Maxwell GL, Rodriguez GC. Vacuum-assisted closure for cutaneous gastrointestinal
Fistula management. Gynecol Oncol 2001;80:413-6.
4. Cro C, George KJ, Donnelly J, et al. Vacuum assisted closure in the management of enterocutaneous
Fistulae. Postgrad Med J. 2002;78:364-5.
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Principle 4
Control Fistula Effluent
• DO NOT INTUBATE A FISTULA in the
middle of a fixed visceral block open
abdomen
– You won’t control the drainage
– You will make the hole bigger
– Risk of additional holes
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Options for Soft Tissue Coverage
• Fascia
– Progressive closure with Vacuum Assisted Wound
Management
– Temporary fascial tension devices to reduce lateral
retraction combined with underlying visceral protection
and Vacuum Assisted Wound Management
– Use plastic sheet between visceral block and lateral
abdominal walls to maintain abdominal wall mobility
– “Separation of Parts” Technique
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Gunshot wound to stomach and
pancreas - damage control laparotomy
• 24 hours later-necrotizing pancreatitis-distal pancreatectomy, gastrojejunostomy, open abdomen
• Fistula x 2
• Serial closure of abdomen
• Final closure with separation of parts technique plus intubation of fistulae
Courtesy of Dr. Robert Mackersie
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Other Options for
Soft Tissue Coverage
• Skin Flaps
• Dermal Matrix
• Rotation Muscle Flap
• Free Muscle Flap
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22 year old man admitted in
shock with GSW to abdomen • GSW to IVC – repaired
• GSW to SMV –oversewn
• Complex injury to duodenum (2nd-3rd portion)- resected
• Right hemicolectomy
• Damage control laparotomy
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Second Look Laparotomy
Findings Reconstruction
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Multiple small bowel fistulas
following GSW to abdomen
• Now 1 ½ years after
injury
Multiple fistulas to remaining
bowel
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Fistulas closed, abdomen closed
with separation of parts technique
Post operative Course
• Leak from small bowel
• Low output fistula
• Fascial necrosis requiring debridement
• Exposed viscera managed with fibrin glue
and CSTSG (Principle 3)
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Chang P, Chun JT, Bell JL. Complex Enterocutaneous Fistula: Closure with Rectus Abdominis
Muscle Flap. Southern Med J 2000;93:599-602.
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Intestinal Leak-Fascial
Dehiscence
• Rectus abdominus
transposition flap
covers exposed bowel
and fistula – Principle
5
• Fibrin glue used to
limit fistula output –
Principle 2
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Fistula closed
Kearney R, Payne W, Rosemurgy A. Extra-abdominal closure of enterocutaneous fistula.
Am Surg 1997;63:406-9.
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Healed Wound –
Oral Nutrition
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Principle 6
Resect Fistula when patient fit
and infection free
PLEASE: Do not cover open abdomens
with Marlex mesh!!!!!
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Viscera covered with previously “delayed”
Rotation skin flap
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Principle 7:
Daily Attention
by a Senior Surgeon
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Principles of Management
Specific for
“Entero-atmospheric” Fistula • PREVENTION
– Protect exposed abdominal viscera during open abdomen management
– Limit access to the wound to one or two SENIOR people
• Attempt to seal leak when first recognized
• Protect adjacent viscera with biologic dressings to avoid additional holes
• Control fistula effluent
• Rotate flaps with good blood supply to cover fistula in selected cases
• Resect well established “entero-atmospheric” fistula only when patient fit and infection free
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Principles of Management
Specific for
“Entero-atmospheric” Fistula
• The patient should be “adopted” by a senior
surgeon who sees the patient and the family
daily and dictates long term management
goals
– The patients are “psychological disasters”
– Body image, odor and cleanliness are major
issues
– Intra-familial tensions are the norm