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General Surgery
Abdominal Abscess and Enteric Fistulae
Built from Maingot's Abdominal Operations
What’s inside
3 sections · 190 slides
Overview
- Scope of this topic
Abdominal Abscess
Formation, presentation, imaging, and drainage
- Definition of an intraabdominal abscess
- Sites where abscesses form
- Two routes to an extravisceral abscess
- Postoperative abscesses
- Abscess without previous surgery
- Visceral and retroperitoneal abscesses
- Anatomy of the opened peritoneal cavity
- Peritoneal defence against bacterial contamination
- Timing of the three defence mechanisms
- Initial peritoneal response to contamination
- Cytokine response in the peritoneal cavity
- Cytokine levels and clinical outcome
- Compartmentalisation of the inflammatory response
- Role of fibrin deposition
- Progression from contamination to abscess
- Local factors that prevent complete resolution
- Microbial factors in abscess persistence
- Abscess as a contained but active infection
- Classic clinical presentation
- Variability in clinical appearance
- Subphrenic abscess
- Paracolic and pelvic abscesses
- Retroperitoneal and psoas abscesses
- Paraspinal collection on coronal CT
- Effect of ready access to computed tomography
- Plain abdominal radiography
- Computed tomography as the investigation of choice
- Use of contrast in computed tomography
- 82%
- Ultrasound and computed tomography of a liver collection
- Computed tomography criteria for an abscess
- Limitations of computed tomography
- Complementary roles of ultrasound and magnetic resonance imaging
- Principles of treatment
- Resuscitation and supportive care
- Route of nutritional support
- Shift in microbial flora with increasing severity
- Microbiology of community-acquired versus health care-associated peritonitis
- Other predictors of resistant flora
- Risk stratification for empiric therapy
- Factors that move a patient into the high-severity group
- Recommended antimicrobial regimens for community-acquired infection
- Practical rules for antibiotic use
- Empiric therapy for health care-associated infection
- Antimicrobial choices for health care-associated infection
- Antifungal and anti-MRSA cover
- Source control defined
- Evidence for percutaneous drainage
- Why percutaneous drainage became the default
- Prerequisites for catheter drainage
- Situations that are not contraindications
- Access routes for difficult collections
- Technique of catheter placement
- Monitoring the response to drainage
- Criteria for drain removal
- Complications of catheter placement
- Percutaneous versus surgical drainage: outcomes
- Peridiverticular abscess and staged resection
- Determinants of outcome after percutaneous drainage of abscesses
- Predictors of a successful percutaneous drainage
- Collections with a lower rate of success
- Computed tomography features that do not predict outcome
- Management of small abscesses
- Contraindications to percutaneous drainage
- Choosing between percutaneous drainage and surgery
- Indications for surgical drainage
- Operative technique for abscess drainage
- Management of the wound in heavily contaminated cases
Enteric Fistulas
Classification, prediction of closure, and the five phases of care
- Definition of a fistula
- Settings in which enteric fistulas arise
- Why postsurgical fistulas are the difficult group
- The multidisciplinary team
- Collected series of outcomes after operative repair of enterocutaneous fistulas
- Quality of the published evidence
- Ways of classifying fistulas
- Value of classification
- Spontaneous versus postoperative fistulas
- How a postoperative fistula declares itself
- Early presentation as a septic complication
- Delayed and very late presentation
- Fistula complicating the open abdomen
- Spontaneous fistulas
- Internal versus external fistulas
- Oral, pharyngeal and oesophageal fistulas
- Causes of oesophagocutaneous fistula
- Gastric fistulas
- Fistula after bariatric surgery
- Duodenal fistulas
- Small bowel fistulas
- Crohn's disease as a cause of fistula
- Two courses of Crohn's fistulas
- Appendiceal fistulas
- Colonic fistulas
- Output-based classification
- Losses through an enterocutaneous fistula
- Predicted output and electrolyte composition of fistulas by location
- Reading the fistula output table
- 54%
- Conflicting evidence on output and closure
- Why output predicts closure only indirectly
- Rates of spontaneous closure
- Factors that predict failure of spontaneous fistula closure
- Modifiable and fixed predictive factors
- Patient factors associated with anastomotic leak
- Surgical factors associated with anastomotic leak
- Interventions that do not affect anastomotic integrity
- Preoperative optimisation
- Operative measures to reduce fistula formation
- Omentoplasty and diverting stomas
- Five phases in the management of enterocutaneous fistula
- Phases in the management of enterocutaneous fistulas
- Recognition of a postoperative fistula
- Catastrophic presentation with diffuse contamination
- Resuscitation and early antibiotic therapy
- Control of sepsis
- Goals of operative source control in peritonitis
- Exteriorisation of the enteric defect
- Consequences of a failed primary repair
- Defunction and drain
- Control of fistula drainage and skin care
- Appliances and vacuum-assisted closure
- Reduction in fistula output
- Drugs used to reduce enteric secretions
- Infliximab in fistulising disease
- Plugging techniques for the fistula opening
- Endoscopic stenting after gastric bypass leak
- Scale of malnutrition in fistula patients
- Parenteral nutrition
- Preference for enteral nutrition
- Practicalities of enteral feeding
- Fistuloclysis
- Recombinant human growth hormone
- Psychological support
- Radiological investigation of the fistula
- Information gathering before definitive care
- Likelihood of spontaneous closure
- Two contrasting fistulas
- Time window for spontaneous closure
- Deciding whether to operate at all
- Timing of definitive operative closure
- Judging readiness within the operative window
- Consent and expected complications
- The physician-patient relationship before reoperation
- Preoperative definition of the anatomy
- Investigation before stoma closure
- General preparation and bowel preparation
- Patient positioning
- Planning the incision
- Alternative incisions and tissue bridges
- Entering through a re-epithelialized abdominal wall
- Adhesiolysis at reoperation
- Extent of interloop adhesiolysis
- Technical hazards during adhesiolysis
- Sequence of dissection around the fistula
- Resection versus simple closure of the fistula
- Hand-sewn versus stapled anastomosis
- Adjunctive measures at definitive surgery
- Laparoscopic approaches
- The abdominal wall problem after fistula repair
- Managing the abdominal wall after elective closure of a gastrointestinal fistula
- Preparation before closing the abdominal wall
- Ladder of abdominal wall closure options
- Primary closure and relaxing incisions
- Component separation technique
- Component separation in a contaminated field
- Prosthetic options for the defect
- Objectives of abdominal wall management
- Early postsurgical period
- Recurrence of the fistula after repair
- Factors predicting recurrence after elective repair of enterocutaneous fistula
- Physical and emotional state at the end of treatment
- Rehabilitation and long-term support
- General principles of care
- Points to carry away
- References
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- Maingot's Abdominal Operations, 12th Edition