SNAP
How to treat enterocutaneous fistulas
Oslo - March 13, 2015
Pär Myrelid
MD, PhD
Dept of Surgery
Unit of Colorectal Surgery
Linköping University Hospital
Linköping, Sweden
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
2
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
Fistula
Inflamed
small bowel
3
Berry et al Surg Clin North Am 1996,
Evenson & Fisher J Gastrointest Surg 2006
ECF – Definition and classification
• Simple fistula
One bowel segment – fistula – skin
• Complex fistula
One bowel segment – abscess/fistula system – skin
• Multiple fistula
Multiple bowel segment involved
• Entero-atmospheric fistula
Bowel loops in abdominal defect (without fistulous
tract)
4
Berry et al Surg Clin North Am 1996,
Evenson & Fisher J Gastrointest Surg 2006
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
5
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
6
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
The viscous circle
ECF – Dangers
• Sepsis
•
Intra-abdominal
•
Line sepsis
• Fluid and electrolyte imbalance
• Thrombosis
• Malnutrition
•
7
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
ECF – Prevention
Colon
• 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
8
Myrelid et al Dis Colon Rectum 2009, Post et al Ann Surg 1991
Yamamoto et al Dis Colon Rectum 2000, Alves et al World J Surg 2002,
Myrelid et al Colorectal Disease 2012
Ileum
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
9
•
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
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
10
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
11
ECF – Need of a dedicated team
• Gastroenterologist
• Colorectal surgeon
• Nurses and nurses aids
Refer patient to a
• Nutritionist
• Stoma therapist
specialised centre!
• Physiotherapist
• Social worker
• Home care
• Pain care (try to withdraw opioids)
• (Psychologist)
Schein W J Surg 2008
12
SNAP – The Concept
• SNAP
• Sepsis and Skin care
• Nutritional support
• Anatomy
• Patience and a Planned procedure
13
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
14
SNAP – Skin Care
• Dedicated and creative stoma therapists
Fistula opening
15
SNAP – Skin Care
• Dedicated and creative stoma therapists
16
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
17
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
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)
•
18
Sometimes combined with CT scan
Carlson Proc Nutrition 2003, Schein World J Surg 2008
Teubner et al Br J Surg 2004 , Lal et al Aliment Pharmacol Ther 2006
Colonoscopy or colonic contrast investigation
19
Colonic enema passing through a mucous fistula
Fistulogram - Contrast through the fistula to an ileocolonic anastomotic fistula
21
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
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
25
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
26
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
27
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
28
Take Home Message
• Prevent enterocutaneous fistulas
•
Pre-operative risk stratification
•
If complication - divert
• When enterocutaneous fistulas occur
29
•
Sepsis and skin care
•
Nutritional support
•
Intestinal anatomy clarified
•
Planned procedure
•
Dedicated team
•
Patience!
Thank you
Acknowledgement
For photos and truly dedicated work
Åsa Gustafsson
&
Christina Schulz
www.liu.se