Entero-Atmospheric Fistula Managed with Kehr’s T-Tube; A Case Report
Shreyas C. Gowda *
Department of Surgery, Dr. R. P. G. M. C., Kangra at Tanda, Himachal Pradesh, India.
Rajkumar Sharma
Department of Surgery, Dr. R. P. G. M. C., Kangra at Tanda, Himachal Pradesh, India.
Amit Dogra
Department of Surgery, Dr. R. P. G. M. C., Kangra at Tanda, Himachal Pradesh, India.
Rajkumar Verma
Department of Surgery, Dr. R. P. G. M. C., Kangra at Tanda, Himachal Pradesh, India.
*Author to whom correspondence should be addressed.
Abstract
Introduction: A fistula is a communication between two epithelialized surfaces. Entero-atmospheric fistula (EAF) is an enteric fistula occurring in the setting of an open abdomen, thus creating a communication between the GI tract and the external atmosphere. The critical tenets in successful management of gastro intestinal fistulas are recognition of fistula, control of infection and further contamination, restoration of fluid and electrolyte losses, and re-establishment of positive nutritional balance before undertaking major definitive corrective procedures. A case of superficial EAF managed successfully with Kehr’s T-tube is presented.
Patient information: A 68-year-old gentleman of rectal trauma managed with loop colostomy with subsequent closure, presented with intestinal obstruction. On laparotomy a small leak with localized faecopurulent collection was present. Resection of the infectious anastomosis bearing segment with fashioning of proximal diversion colostomy with distal mucus fistula was done, post-operative period was uneventful. Restoration of bowel continuity after mobilization of colon and intra peritoneal end to end anastomosis was done at an interval of 6 months. In the post-operative period, patient developed grade IV wound sepsis and burst abdomen. Subsequent abdominal examination revealed an EAF in a small bowel loop lying adjacent to anastomotic site with high fistula output. Placement of short limb of Kehr’s T-tube in the fistulous bowel loop resulted in reducing the fistula output promoting wound healing and successful management of EAF.
Conclusion: In the superficial high output EAF, negotiation of horizontal limbs of Kehr’s T-tube into the fistula bearing bowel loop, helps in reducing the fistula output resulting in better management of fistula, promotion in wound healing and reversion of catabolic state. Subsequently stoma bag/wound manager or effective VAC may be applied to aid the ultimate closure of the fistula.
To conclude management of EAF deserve to be individualized and innovative as per the clinical situation for successful outcome.
Keywords: Entero-atmospheric fistula, high output fistula, Kehr’s T-Tube
How to Cite
Downloads
References
Intro –ist Marinis A, Gkiokas G, Argyra E, Fragulidis G, Polymeneas G, Voros D. "Enteroatmospheric fistulae"—gastroin-testinal openings in the open abdomen: A review and recent proposal of a surgical technique. Scand J Surg. 2013;102(2):61-8.
Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. In: World J Surg. 2014:912–925.
Kirshtein B, Mizrahi S. Vacuum-assisted management of enteroatmospheric fistula within the open abdomen. Am Surg. 2014;80:209–10.
Di Saverio S, Tarasconi A, Walczak DA, Cirocchi R, Mandrioli M, Birindelli A, Tugnoli G. Classification, prevention and management of entero-atmospheric fistula: A state-of-the-art review. Langenbecks Arch Surg. 2016;401(1):1-13. DOI: 10.1007/s00423-015-1370-3.
Epub 2016 Feb 11.
PMID: 26867939.
Schecter WP, Hirshberg A, Chang DS, Harris HW, Napolitano LM, Wexner SD, Dudrick SJ. Enteric fistulas: principles of management. ACS. 2009;209:484–91.
Evenson A, Fischer J. Current management of enterocutaneous fistula. J Gastrointest Surg. 2006;10:455–64.
Layton B, DuBose J, Nichols S, Connaughton J, Jones T, Pratt J. Pacifying the open abdomen with concomitant intestinal fistula: A novel approach. Am J Surg. 2010;199:e48–e50.
Di Saverio S, Villani S, Biscardi A, Giorgini E, Tugnoli G. Open abdomen with concomitant enteroatmospheric fistula: validation, refinements, and adjuncts to a novel approach. J Trauma: Injury, Infec Critical Care. 2011;71:760–2.
l-Khoury G, Kaufman D, Hirshberg A. Improved control of exposed fistula in the open abdomen. J Am Coll Surg. 2008;206: 397–8.
Ramsay PT, Mejia VA. Management of enteroatmospheric fistulae in the open abdomen. In: Am Surg. 2010:637–9.
Tan Ngian Chye, et al. Extraperitoneal approach for closure of epithelized enterocutaneous fistulas following late removal of jejunostomy tube. Annals of Plastic Surgery. 2006;57(5):585–588.