SNAP How to treat enterocutaneous fistulas

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SNAP How to treat enterocutaneous fistulas 2017-04-11 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 Linköpings universitet

Outline – Enterocutaneous fistulas (ECF) 2017-04-11 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 Definition Vad orsakar enterocutana fistlar Faror med enterocutana fistlar Det viktigaste - förhindra enterocutana fistlar Prognos – hur går det SNAP – vad står akronymen för Bukväggsdefekter – ett ämne i sig Hur går det på sikt och vad har de för livskvalitet Linköpings universitet

ECF – Definition and classification 2017-04-11 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 Vad är en fistel En kommunikation mellan två epitelklädda ytor – ofta tar och hud men kan också vara till t ex vagina och urinblåsa. För två år sedan Crohnpat. Rullstolsburen. Orsaken till detta ar att så fort hon reste sig kom det flera deciliter tarminnehåll från vagina pga en fistel till vagina. Berry et al Surg Clin North Am 1996, Evenson & Fisher J Gastrointest Surg 2006 Linköpings universitet

ECF – Definition and classification 2017-04-11 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) Enkel fistel Komplex fistel Multipla fistlar Specialfall kallas inbland enteroatmosfärisk fistel Berry et al Surg Clin North Am 1996, Evenson & Fisher J Gastrointest Surg 2006 Linköpings universitet

ECF – Definition and classification 2017-04-11 ECF – Definition and classification Low-output fistula < 200ml/day Moderate-output fistula 200-500ml/day High-output fistula >500ml/day Lågflödesfistel Moderat fistel Högflödesfistel – det absolut svåraste att lösa pga flera faktorer. Bandagering. Vätskeförlust. Saltförlust. Nutritionssvårigheter. Berry et al Surg Clin North Am 1996 Linköpings universitet

ECF – Causes Surgical disasters (75 %) Spontaneous (20-30 %) Trauma 2017-04-11 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 Vad orsakar fistlar Kirurgiska katastrofer. ”Det blev fel. Mitt fel. Jag måste fixa till det igen” Man försöker laga anastomoser som läcker. Ger sig på komplikationer, en, två, tre, fler gånger – slutar nästan alltid med en ännu större katastrof. Om komplikation som kirurg. Var med men ta med erfren kollega som stöd och som förhindrar att man försöker ”fixa till allt” direkt. Spontana – Crohn (verkar minska), Cancer, Perforation, Stålning (iatgrogen) och ischemi (ökar) 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 Linköpings universitet

ECF – Dangers Sepsis Fluid and electrolyte imbalance Thrombosis 2017-04-11 The viscous circle 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 Vad är de största farorna Sepsis som inte patienten reder ut Intraabdominella infektioner och abscesser CVK och infartsinfektioner. Vr npga med skötseln. Ta inte blodprov genom infarter som skall användas för nutrition. Vätske och saltbrist Malnutrition Störst risk vid högflödesfistlar för samtliga dessa komplikationer Agwunobi et al Dis Colon Rectum 2001, Evenson & Fisher J Gastrointest Surg 2006, Kaushal & Carlson Clin Colon Rectum 2004 Linköpings universitet

ECF – Prevention Risk assessment pre-operatively Risk factors 2017-04-11 ECF – Prevention Colon Ileum 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 Hur förhindrar man enterocutana fistlar. Egentligen den viktigaste frågan. Gör en riskvärdering inför varje operation – hur ska vi göra? Riskfaktorer Pågående infektion – vid Crohn t ex fistlar eller abscesser i buken redan innan op Steroider Lågt albumin (pga infektion och/eller dåligt nutritionsstatus) Malnutrition, viktnedgång Anemi Akut operation Adherensbildning i buken pga inflammation eller efter tidigare kirurgi Ökad risk med ökat antal riskfaktorer. Om stor risk – överväg tillfällig eller t om permanent stomi i stället för anastomos 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 Linköpings universitet

ECF – Prognosis Late 1980´s mortality risk 40-65 % 2017-04-11 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 Prognos – hur går det För 25-30 år sedan nästan en dödsdom, ungefär hälften dig. Idag fortfarande en risk, upp till var femte riskerar att dö, ffa de end högflödesstomier Varför går det bättre idag? Förbättrad vård – sepsis, malnutrition, vätska, salter och kirurgisk teknik. När, var och hur….. Många kan även läka spontant Falconi et al Digestion 1999, Dudrick et al Digestion 1999, Reber et al Ann Surg 1978 Linköpings universitet

ECF – Favourable prognosis 2017-04-11 ECF – Favourable prognosis End fistulas (leakage through an intestinal stump) Jejunal fistulas Colonic fistulas Continuity-maintained fistulas Small-defect fistulas Long-tract fistulas Vilka har bäst prognos Ändfistlar, tex från en urkopplad tarm Jejunala fistlar Kolonfistlar Fistlar med bevarad kontinuitet av tarmflödet Så defekter Lång fistelgångar Låga flöden förstås Martinez et al J Gastrointest Surg 2011, Prickett et al South Med J 1991 Linköpings universitet

ECF – Unfavourable prognosis 2017-04-11 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” Dålig prognos Akronymen FRIENDS Främmande kroppar i buken Strålning Infektion, IBD, Inflammation Epitelbeklädd fistelgång Cancer Hinder av tarmflödet nedströms om fisteln Steoider Martinez et al J Gastrointest Surg 2011, Prickett et al South Med J 1991 Linköpings universitet

ECF – Need of a dedicated team 2017-04-11 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! Hur man bygger upp ett team – ett måste med ett team. Går inte att klara av annars Skicka patienterna till specialenheter med intresse och erfarenhet. I England St Marks och Manchester. 1 eller 2 fler på gång. Sverige 2-3 ställen? Norge 2? Svårt med att bara ha ett – blir för jobbigt och sårbart. Schein W J Surg 2008 Linköpings universitet

SNAP – The Concept SNAP Sepsis and Skin care Nutritional support 2017-04-11 SNAP – The Concept SNAP Sepsis and Skin care Nutritional support Anatomy Patience and a Planned procedure Sepsis och hudvård – ”brännskadad” hud ofta Nutrition Anatomin Tålamod – planerad operation när det är moget för operation Linköpings universitet

SNAP – Sepsis Drain collections Prevent line-sepsis Antibiotics 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

SNAP – Skin Care Dedicated and creative stoma therapists Fistula opening

SNAP – Skin Care Dedicated and creative stoma therapists

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

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 2008 Teubner 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 2005 03 18 Kontrast via loopileostomin till ileostomin. 10 cm emellan. Inget hinder eller läckage.

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

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

ECF – Quality of Life Low HRQoL Improved after successful treatment 2017-04-11 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 Linköpings universitet

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

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!

For photos and truly dedicated work Thank you Acknowledgement For photos and truly dedicated work Åsa Gustafsson & Christina Schulz www.liu.se