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

Colonoscopy or colonic contrast investigation

Colonic enema passing through a mucous fistula

Fistulogram - Contrast through the fistula to an ileocolonic anastomotic fistula

Fistulogram - Contrast through a prolapsing fistula which is 10 cm proximal of an end ileostomy

CT and fistulogram - Fistula in a hernia with a catheter placed in the fistula

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!

www.liu.se

Thank you

Acknowledgement

For photos and truly dedicated workÅsa Gustafsson

&Christina Schulz