Pioderma gangrenoso y fístulas enterocutáneas tras anastomosis ileoanal con reservorioGangrenous pyoderma and enterocutaneous fistulas after ileal. Introducción: la baja prevalencia de las fístulas enterocutáneas (FEC) en los pacientes con enfermedad de Crohn (EC) justifica la escasez de. Necesidad de formar unidades funcionales especializadas en el manejo médico- quirúrgico de pacientes con fístulas enterocutáneas y fracaso intestinal.
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FISTULAS ENTEROCUTANEAS by Ceci Gigena on Prezi
A management protocol by stages was applied. Demographic aspects, fistula’s characteristics and conservative treatment modality were evaluated. Variables were faced with the mortality event using program SPSS version Categorical variables were analyzed using the chi-square or Fisher’s exact test when suitable.
This study included patients. A systematized management of ECF allows to optimizing treatment results.
Vacuum therapy was highly effective in output control and provided spontaneous healing in many cases. Sepsis, multiple lesions and abdominal wall defect were negatives prognoses factors.
Aspiration methods and octreotide were implemented as alternative or complementary fiatulas. Management were performed using an own protocol, in accordance with Chapman’s Stages , which have been already presented in previous publications . Binary logistic regression was carried out by multivariate analysis of categorical risk factors. Median of abdominal surgeries prior fistula appearance was 2 range 1 to Seventy six cases initially presented sepsis Most frequent primary pathologies were colorectal neoplasia, diverticulitis, abdominal trauma, appendicitis and hernia, of which 62 The direct causes were suture line or intestinal anastomosis disruption in 56 patients Location was jejunoileal in 87 cases In recent years, advances in postoperative care and major surgical procedures rise have further increased the degree of complexity and the number of cases, which justifies further study of this pathology.
The aim of this research is to present the results of a systematized management of this complication, to enterocutaneaz the use of a vacuum system in local treatment of the lesion and to determine factors influencing the evolution of fistulized patients.
Terminally -ill patients and lesions coexisting with biliopancreatic fistula were excluded. Demographics, patient characteristics and injury aspects were recorded. Fourteen out of fistulized patients were initially operated, 4 of them electively, while surgery for peritonitis was indicated in the remaining Enterocutanexs was performed to 4 of them, leaving definitive reconstruction for further surgery.
Mortality in this group was 7. Forty-six presented sepsis during conservative treatment, mainly due to catheter contamination and respiratory disease. Nine of them, with abdominal collections, were treated by percutaneous drainage, 2 of which were completed by directed laparotomy. After reaching stability, 32 patients continued treatment at home.
Regarding local lesion management, 92 cases Collection bag or simple dressing were indicated in the remaining 10 cases with low output fistulas. Output control was obtained in cases During this period 6 patients died 5. Lastly, 49 patients Global healing was possible in patients of the series Logistic regression test did not show meaningful results in any variable probably due to the low number of events deaths recorded in the sample.
Discussion In the early 60’s, Chapman et al. This proposal was the basis of modern approach of this pathology. Years later, several protocols were suggested; they underwent some modifications to update ECF management.
When we began our experience, we observed that, in said protocols, the aims to be achieved were mixed in different stages, some terms were not clearly defined and mainly, rnterocutaneas did not represent faithfully our current conduct. After 14 years of use, this protocol has proved it a practical resource to guide patient management.
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While it is true that these patients require frequent decision-taking during treatment, surgery as initial indication is a major enherocutaneas.
The results of these series, consistent with other studies  , support this procedure in patients with acute abdomen and those who, maintaining a good general condition, developed early fistulas.
Controlling the main mortality factors is a priority for the remaining patients to be treated conservatively. Sepsis treatment and hidroelectrolite balance restoration do not differ substantially from that applied in the routine management of critically ill patients so that it will not be analyzed in this presentation.
The importance of nutritional support for successful treatment in a coordinated way, using parenteral and enteral route, either by naso-jejunal tube, jejunostomy or fistuloclysis, is clear.
The advantages of enteral over parenteral nutrition PN as regards physiological aspects, less morbidity, and cost reduction are widely known  –  However in complex cases, PN is difficult to avoid. Nevertheless, it has not been shown that gastrointestinal secretion and volume overload reduction on the fistula increases the possibility of spontaneous closure . Both EN and PN are resources that the specialist team should handle so as to indicate them, either in combination or alternatively, according to the case nature.
Our approach, especially in high output fistulas, begins with fasting and TPN. Then, after controlling intestinal effluent, the parenteral route is gradually replaced by the enteral one, if it is well tolerated and does not complicate wound management. New methods have been proposed in order to block intestinal flow: Although some, at first, showed encouraging results, they have failed to prove their full effectiveness as most of the published series make reference to a few patients, usually of deep and low output fistulas, which generally heal whichever conservative treatment.
Octreotide, a synthetic somatostatine analogueis a powerful inhibitor of gastrointestinal biliary and pancreatic secretions. It has become widespread used drug when treating ECF since the last two decades so far  – .
In recent years, enthusiasm has waned because it could be seen that, while it is effective to reduce enteric output, and even to accelerate some fistulas closure time, it has not been possible to demonstrate a rise in percentage of spontaneous closure or a fall in mortality rate.
In our experience, it has been a valuable resource in cases of high- output fistulas of gastric, duodenal and jejunal origins, when vacuum proved inconvenient, or as reinforcement of the latter if output reduction was not satisfactory. Consequently, the following benefits have been previously described and were thus confirmed in our experience: Moreover, some recent publications have suggested, after observing certain complications that may be related to the method, taking caution in the application of negative pressure therapy  – .
The right timing to complete conservative treatment and proceed with surgical repair remains controversial. For a long time, it has been convention to wait 4 and 6 weeks for a spontaneous resolution and then, in case of persistence, to proceed with reconstructive surgery . First, it should be pointed out that fistula closure has been achieved in some cases, after this time period, with the assistance of innovative treatments, such as sub-atmospheric pressure  – . Second, the time span previously defined, usually, is not enough to obtain an adequate clinical and nutritional status in order to perform complex reconstructive surgery.
Infectious complications such as sepsis from central line catheter and pulmonary infection may delay nutritional recovery, as well as surgical opportunity. Other authors share his opinion and caution against early reoperation. They reason that dissection in a dense peritoneal reaction is prone to cause hemorrhages and bears high fistula recurrence rates - .
In particular after multiple laparotomies for severe intraabdominal infection, awaiting consolidation and the formation of neoperitoneum seems comprehensible. The latest studies time spectrum ranges from 2 to 11 months. Despite employing meticulous statistical analysis, exact interpretations of these results are limited due to selection of patients and lack comparative studies.
In this series, as in others , sepsis, multiple lesions and abdominal wall defects have been statistically significant mortality factors. Other studies have also identified the following negative factors: Obviously, boththe large number of variables and, consequently, the unlikelihood to perform out comparative studies make it difficult to reach firm conclusions. Initial surgery is a valid option in patients maintaining a good general condition and is a necessity in cases where the fistula coexists with acute abdomen.
Conservative treatment should be extended several weeks, if necessary, to detect a halting in the wound healing process and until achieve a complete patient clinical and nutritional recovery. Sepsis, multiple lesions and those located in open abdomen have proven negative prognostic factors in this study. However, it is possible that many other factors should significantly impact fistulized patient outcomes.
Due to not only substantial differences between patients within one study but also inter-study variations in the currently available data, it is difficult to draw definite conclusion on their respective treatment effect.
It seems, therefore, necessary that multidisciplinary teams gather detailed information to be able to collectively pool the data in order to reach sound conclusions.
Treatment of high-output enterocutaneous fistulas with a vacuum-compaction device. World J Surg ; 32 3: Management of intestinal fistulas. Am J Surg ; General Treatment of Gastrointestinal fistulas. Rev Argent Cirug 87 5—6: J Am Coll Surg ; 4: In Campos ACL ed.
Nutrition and Enterocutaneous Fistulas. J Clin Gastroenterol 2 A Systematic review of the benefit of total parenteral nutrition in the management of enterocutaneous fistulas. Dig Surg ; Endoscopic treatment of postoperative fistulas resistant to conservative management using biological fibrin glue.
Evaluation of the effectiveness of octreotide in the conservative treatment of postoperative enterocutaneous fistulas.
Worl J Surg ; Rev Argent Cirug ; The use of vacuum-assisted closure of abdominal wounds: Colorectal Dis ;9 3: Am J Surg ; 1: University of Buenos Aires. Delayed reconstructive surgery for complex enterocutaneous fistulae. Am Surg ; Reconstructive abdominal operations after laparostomy and multiple repeat laparotomies for severe intra-abdominal infection.