Simple Suture With Omental Patch

Approach Considerations, Medical Therapy, Surgical Therapy. Initial treatment of intestinal fistulas is medical, including resuscitation, control of sepsis, local control of fistula output, nutritional support, pharmacologic management, and radiologic investigations. The final therapeutic step, if necessary, is definitive surgery to restore gastrointestinal GI tract continuity. See the image below. Elements of nonsurgical treatment. Resuscitation. Most patients with GI fistulas experience significant fluid and electrolyte imbalances. Download Mozilla Firefox 31 For Windows 7 32 Bit more. Carefully monitored replacement of the losses is essential and is often paired with central venous monitoring to accurately estimate fluid deficits. Intraoperative+Details.jpg' alt='Simple Suture With Omental Patch' title='Simple Suture With Omental Patch' />The evolution of the surgical incision has been closely correlated to the major developments in the field of surgery, medicine, and technology. In the. Resuscitation aims to restore intravascular fluid volume and to ensure a urine output of 3. Lhr or hgiher. The circulation volume deficits result from extracellular fluid losses, and replacement is best achieved with isotonic crystalloid solutions, such as normal saline or lactated Ringer solution. Simultaneous electrolyte repletion is necessary. Isolated measures of serum levels may not reflect the degree of intracellular electrolyte depletion thus, continued monitoring for ongoing losses is necessary. Patients with high output and proximal fistulas develop significant metabolic acidosis, which may require intravenous sodium bicarbonate administration. Control of sepsis. S2049080115000473-gr3.jpg' alt='Simple Suture With Omental Patch' title='Simple Suture With Omental Patch' />Uncontrolled sepsis is a major cause of mortality in patients with small intestinal fistulas. Tachycardia, persistent fever, and leukocytosis indicate the presence of infection associated with the fistula. Patients are treated with broad spectrum antibiotics and local drainage of abscesses if present. Most deep or intraperitoneal collections are amenable to drainage guided by computed tomography CT or ultrasonography. Of postoperative intra abdominal abscesses, 1. Percutaneous drainage allows temporary control of the fistula and may achieve long term fistula healing in as many as 7. Surgical drainage may be required if the abscess is not safely accessible. At the time of surgery, definitive repair of the fistula should not be attempted, because the presence of adjacent infection precludes healing. The abscess should be drained, and if necessary, the fistula should be completely exteriorized to the skin level to prevent further intraperitoneal fluid collection. Local control of fistula. An attempt should be made to decrease fistula output by placing enteric drainage tubes proximal to the fistula an important treatment step. Nasogastric or nasojejunal tubes are usually placed, and the patient is given nothing by mouth while total parenteral nutrition TPN is initiated. The goal of controlling enterocutaneous fistula output is to prevent the intraperitoneal accumulation of intestinal contents and to protect the skin from the effects of the intestinal contents. Journals/SURG/9421/spc9007t2.png' alt='Simple Suture With Omental Patch' title='Simple Suture With Omental Patch' />Control of enterocutaneous fistula drainage is individualized according to the patient and the fistula output. Drainage with a simple catheter placed into the fistula tract invariably fails as a result of occlusion and inability to capture all of the output. In some instances, low constant suction applied via a soft sump catheter into the fistula tract can contain fistula drainage. Adjacent or escaping fluid requires placement of a collecting bag, which can also be attached to low continuous suction. Various modifications of the use of drainage tubes within the fistula tract have been described. Fistulas are abnormal communications between two epithelialized surfaces. An intestinal fistula is an abnormal anatomic connection between a part or. Simple Suture With Omental Patch' title='Simple Suture With Omental Patch' />See the image below. The skin surrounding the fistula opening is exposed to intestinal contents, and this leads to excoriation and breakdown. Skin protection is an important part of fistula output control and is achieved through the placement of a Hollister appliance, which consists of a karaya ring with adhesive backing to encircle the fistula opening. The ring is attached to an ileostomy bag that should be emptied frequently or continuously via an attachment to continuous suction. Stomahesive is a skin barrier material that can be applied to eroded skin to protect and allow it to heal. It contains a mixture of pectin, gelatin, and carboxymethylcellulose in wafer form. The wafer is applied to the skin, and the ostomy appliance is applied over the wafer. Skin protectants eg, zinc oxide cream, aluminum paste, karaya gum powder, tincture of benzoin are used to liberally coat skin that is exposed to intestinal contents. After the fistula output is locally controlled, the applied suction is gradually reduced and finally replaced with gravity drainage. Similarly, the caliber of catheter within the fistula opening is progressively decreased. This allows the fistula tract to slowly close and heal. This process requires the careful monitoring of fistula output as changes are made, as well as frequent evaluation of the skin surrounding the fistula. Sponge vacuum dressings can be applied to low output fistulas to keep the surrounding skin dry. Case studies have reported some success using vacuum dressings to heal fistulas. Larger studies are required to validate these findings and to identify the appropriate use of vacuum dressings in fistula treatment. Nutritional support. Adequate nutritional support has a significant impact on the outcome of patients with GI fistulas. Total caloric requirements for a patient with an enteric fistula are calculated on the basis of the patients overall clinical condition and must take into account the degree of physiologic stress. Patients with localized infections and malnutrition require 3. The total caloric needs are met by glucose and fats glucose provides approximately two thirds to three fourths of the total caloric requirements, and lipids provide the remainder. Proteins are not taken into account in calculating the total caloric requirements. This allows for efficient protein sparing and for the occurrence of an anabolic state. Proteins are administered as amino acids in parenteral formulas and protein hydrosylates in enteral formulas. To ensure that enteric protein losses are adequately replaced, 1. Fluid and electrolyte balances are maintained by frequent monitoring of serum electrolyte levels and by replacing losses. Similarly, vitamins and trace elements are added to enteral formulas and parenteral formulas to prevent deficiencies. Total parenteral nutrition TPN provides initial nutritional support while control of infection and maturation of the fistula tract occur. Normal intestinal motility and function usually return once abdominal sepsis is controlled and fluid and electrolyte imbalances are corrected. Enteral feeding may be initiated orally or via a catheter placed distal to the fistula. The feeds can be started in the form of an elemental diet while fistula output is monitored. Hardware Id Crack here. If fistula output does not significantly increase, enteral nutrition is continued and TPN gradually decreased and then discontinued. At one time, high output fistulas were considered a relative contraindication to initiating enteral nutrition. However, studies have demonstrated that even these fistulas can be effectively treated with enteral nutrition. The benefits of enteral nutrition include decreased gut bacterial translocation and the tropic effects on the intestinal mucosa. Enteral nutrition also helps to avoid the complications associated with TPN. Of all patients with GI fistulas who are treated with TPN, 2. Patients with optimal intake levels of calories and protein have a mortality of 1. Patients who receive inadequate nutritional support have a mortality close to 5. Pharmacologic support.