Management of Acute Intestinal Failure from EnteroCutaneous Fistula

Management of Acute Intestinal Failure from Entero-Cutaneous Fistula in a Resource Deprived Environment Makafui Seth C-J. K. Đayie (MBCh. B) CCTH

OUTLINE • Introduction – Definition – Classification • The study • Conclusion 2/25/2021 2

Introduction • Intestinal failure is defined as the reduction in intestinal absorption so that micronutrients and/or water and electrolyte supplements are needed to maintain health and growth. • It is a clinical syndrome. • Route of supplementation 1: oral, enteral, parenteral 1 Nightingale Limited. 2/25/2021 JMD. Definition and classification of intestinal failure. In Intestinal failure 2001; pp. ix-x. London: Greenwich Medical Media 3

• Intestinal failure – Acute • Very common; 90% in perioperative period 1 • Surgery is pivotal in its management; some resolve spontaneously • Type 1 and type 2 – Chronic 1 Nightingale JMD. Definition and classification of intestinal failure. In Intestinal failure 2001; pp. ix-x. London: Greenwich Medical Media Limited. 2/25/2021 4

The study • Adopting simple yet effective and proven strategies to reduce severity of intestinal failure. • A prospective longitudinal descriptive study • Patients recruited from the Central Regional Hospital, Cape Coast – 18 month period from April 2010 2/25/2021 5

Data extent Epidemiological profile Underlying disease Nature of the primary operation Number of operations Number and nature of fistulae Wound care technique Mode of nutrition employed Nature and dosage of drug therapy to slow bowel transit • Serial weight and serum albumin measurements • • 2/25/2021 6

Results sex distribution females 42% male 58% 2/25/2021 7

total number of cases 4. 5 4 4 4 3. 5 3 2. 5 total number of cases 2 1. 5 1 1 1 stab abdomen post caesarean section 0. 5 0 perforated typhoid strangulated hernia small bowel volvulusperforated appendix disease 2/25/2021 8

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• Each patient had at least one laparotomy at the referring centre before laparostomy (median=2; range=1 -3). • One case was nursed a the ICU; had the most surgeries done (7). • Dressings were done on the ward under sedation. 2/25/2021 10

Patient care • Decision to proceed to the initial laparotomy after the diagnosis of entero-cutaneous fistula was made largely on clinical grounds. – Contrast enhanced CT scan not available • Procedures – Diverting loop ileostomy – Proximal end stoma with distal mucus fistula + peritoneal lavage. • Abdominal wound care – Mass closure of the wound with loop PDS; skin unstitched – Bogota bag (1/4) – Entero-atmospheric sandwich dressing (2/3) 2/25/2021 11

• Post operative fluid requirements – IV dextrose saline + ORS then free fluids; water deliberately avoided • High protein, high calorie low fibre diet 2/25/2021 12

Discussion • Multidisciplinary approach to management – Surgeon, nutritionist, dedicated ward nurses and counselors. • Control of sepsis – Soeters et al 2 – laparotomy and lavage +/-ileostomy +/- mucus fistula – ? CT scan + drainage • Obviating need for repeated surgeries. 2 Soeters PB, Ebeid AM, Fischer JE. Review of 404 patients with gastrointestinal fistulas. Impact of parenteral nutrition. Ann Surg 1979; 190: 189 -202. 2/25/2021 13

Nutritional care • Fistulae +/- surgery affected distal ileum – Positive water and sodium balance was achieved; no need for parenteral nutrition (particularly total parenteral nutrition) • Had Plumpy’Nut (nutritional value as F-100; 2100 k. J) • Daily egg consumption • Monitoring: – Weekly weight – 2 x monthly Hb 2/25/2021 14

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Wound care (mass closure) 2/25/2021 16

Wound care with Bogota bag 2/25/2021 17

Enteroatmospheric sandwich dressing 2/25/2021 19

Decreasing effluent from high output fistulae • Avoiding oral administration of water 3, 4, 5 • Loperamide use • Use of codeine phosphate *octreotide 3 Newton CR, Gonvers JJ, Mc. Intyre PB, Preston DM, Lennard-Jones JE. Effect of different drinks on fluid and electrolyte losses from a jejunostomy. Journal of the Royal Society of Medicine 1985; 78, 27 -34. 4 Rodrigues CA, Lennard-Jones JE, Thompson DG, Farthing MJG. What is the ideal sodium concentration of oral rehydration solutions for short bowel patients? Clinical Science 1989; 74, Suppl. 18, 69. 5 Nightingale JMD, Lennard-Jones JE, Walker ER, Farthing MG. Oral salts supplements to compensate for jejunostomy losses: comparison of sodium chloride capsules, glucose electrolyte solution and glucose polymer electrolyte solution (Maxijul). Gut 1993 b; 33, 759 -761 2/25/2021 21

• Delineating fistula anatomy • Definitive management – Restoration of bowel continuity 2/25/2021 22

Conclusion • A structured multidisciplinary approach and cheaper innovations are readily available in resource deprived regions to ensure improved morbidity and mortality outcomes. 2/25/2021 23

• Thank you! 2/25/2021 24