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Научни трудове на Съюза на учените в България-Пловдив. Серия Г. Медицина, фармация и дентална медицина т. XXII. ISSN 1311-9427 (Print), ISSN 2534-9392 (On-line). 2017. Scientific works of the Union of Scientists in Bulgaria-Plovdiv, series G. Medicine, Pharmacy and Dental medicine, VoLXXII. ISSN 13119427 (Print), ISSN 2534-9392 (On-line). 2018.
ENTERO-ATMOSPHERIC FISTULAS AS COMPLICATION OF
LAPAROSTOMY
Sakakushev Boris, Chakarov Djevdet, A.tanasov Bojko, Hadzhiev Dimitar, Hadzhieva Elena Medical University Plov^v/Urnversky Hospital Sit George
ABSTRACT
Entero- atmospheric fistula is a lethal complication following abdominal surgery, with non-standardized management, relying either on self-experience or several published case series. Although principles of management are almost defined, technical performance methods and consumptives for stoma and wound protection are so numerous, that may cause primary confusion of a novice. Treatment is long and with obscure outcome and prognosis.
KEY WORDS: EAF/Entero-atmo spheric fistula/, OA/Open abdomen/, VAC/Vacuum assisted closure/, ACS/Abdominal compartment syndrome/.
INTRODUCTION
Entero-atmospheric fistula is a grave complication following abdominal surgery. The numerous methods to treat EAF and the many reviews published on the topic indicate a great deal of inconsistency in management of this complication. EAF fistula remains a considerable source of morbidity and mortality despite advances in nutritional support, infection control and surgical techniques. The discussion of EAF is still in its early stage (in the non- trauma setting). Personal experience, expert opinion, case studies and retrospective studies form the core basis for our current knowledge. No based guidelines exist (in regard to EAF management). Publications related to EAF in emergency surgery in the period 2011 - 2016 are 12, reviews of which have been 8. RESULTS
After a detailed search of the available literature on PubMed and Embase, we found out that currently the most discussed questions concerning EAF are their definition, classification, developmental risk factors, patients' nutritional demands & supplements, means of effluent isolation and wound management and time for definitive repair (abdominal wall). EAF is defined as an enteric opening(s) onto a dehisced wound therefore exposing and communicating the bowel and its effluent to the atmosphere. The OA management strategy increases this complication incidence if preventive measures are untaken. According to Lynch A & alt. Fistula is an abnormal passage between two or more (epithelized) structures or spaces/1/. An Enteric fistula- a fistula that communicates specifically between the lumen of the gastrointestinal tract and the skin (most common), while Non-enteric fistula- an abnormal passage from a body cavity to an organ other than the intestines. Unexposed fistula- extends in an unknown direction and has an unknown endpoint, while exposed fistula- endpoint of the fistula evident.
EAF is not a true fistula as no fistula tract exists. Some of the management practices of ECF are valid in controlling EAF, such as the attempt at spillage control and the attempt to seal the fistula. DISCUSSION
In average 75-85% of the cases EAF are iatrogenic post-operative and in 15-25% "spontaneous" in origin. Common factors related to this postoperative misfortune are radiation, inflammatory bowel disease, diverticular disease, malignancy and tuberculosis /2/. The EAF incidence is 5-15%
of trauma, 20% of operations for abdominal sepsis and 50% of operations for pancreatic necrosis with a Mortality of 30-40%/3/. EAF cause increased ICU and hospital loss, and raised expenditures/4/. The reported rate of spontaneous healing of EAF is 70% /2,5/.Current classification schemes echo the problematic and challenging issues related to the management of EAF which should be personalized according to standard classifications and grading systems. The anatomical, physiological, clinical classification of OA with EAF has been updated in 2016, where a rationalized approach to this surgical nightmare and proposal of clinical algorithm has been presented/6/. Future- dynamic classification will be based on scoring anatomical+ physiological+ clinical variables.
Diverse clinical circumstances may contribute to the development of EAF and few risk factors may predict its development, therefore awareness of this complication and avoidance of contributing conditions for its development are mandatory. Predictors of EAF are large bowel resections, large-volume fluid resuscitation (> 5-10lit/24h) and increased number of abdominal re-explorations/7/.
The etiology of EAF is related to anastomotic disruption, bowel injury due to dissection or inproper handling, use of temporary abdominal closure (synthetic mesh), deep wound infection, burst abdomen, prolonged exposed bowel, intra-abdominal sepsis and ACS/8/. Common sites of EAF are colon - 69%, small bowel- 53%, duodenum- 36%, stomach- 19%, where multiple openings are to be found in 56%/2/. Preemptive measures require sound judgment and implementation of some practical maneuvers like skin or biological dressing/9/, early abdominal wall closure, highly experienced surgeon/team deal with OA, no direct VAC on bowel, which lead to a 7% fistula rate/10-13 /.
The metabolic disturbances in EAF are hyperactabolic state with high nutritional demands (protein losing laprostomy), fluid and electrolytes losses and acid- base homeostasis disturbances. These higher nutritional demands require nutritional supplements for proper healing like positive nitrogen balance, adequate trace elements and vitamins supplements /14/. EAF require proper antibiotics and drainage of collection/15/. Separating the wound into different compartments in order to facilitate the collection and perifistular skin protection is of paramount importance, as well as reducing fistula output/ 16,17/. Many fistula management techniques are described/ baby bottle nipple + VAC, floating stoma, tube, fistula, chimney VAC, primary suturing, fibrin glue, pedicle flap (to cover), fistula plug, patch, suspension/, as well as many methods for wound care exist /19,20/. In the presence of EAF in OA, NPWT makes effluent isolation feasible and wound healing conceivable/21-26/. Definitive management of EAF should be delayed to after the patient has recovered and the wound healed/27/. Local therapy relies on two approaches - surgical/suture, resection/ and non-surgical/ drainage via catheter, fistula-VAC, wound dressing, pacifier, laparostomy bag. CONCLUSION
EAF management scheme should include preventing risk factors, nutritional support, sepsis control, isolation and fluid control, manage fistula and reconstruct abdominal wall all performed in a stepwise approach.
References
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