Sub-bagian Bedah Digestif

Bagian Bedah FKUH RSUP Dr.Wahidin Sudirohusodo

MAKASSAR
 Fistel Enterokutaneus
Fistel merupakan hubungan abnormal antara suatu saluran
dengan saluran lain atau suatu saluran dengan dunia luar
melalui kulit.
Saluran penghubung permukaannya dilapisi epitel

Fistel enterokutaneus hubungan abnormal antara usus

dengan kulit

Asal : duodenum, jejunum, ileum bahkan colon

Klasifik
asi
Klasifikasi penting untuk prediksi morbiditas dan mortalitas serta
kemungkinan terjadinya spontaneous closure

ANATOMIC CLASSIFICATION
(Intestinal Stomas, Principle, Techniques and management, John M.MacKeigan and Peter A Cataldo,
1993)

Complex
Simple Type 1
Short, direct tract Associated with abscess
No associated abscess Multiple organ involvement
No other organ involvement Type 2
Open into base of disrupted wound
Simple
Short, direct tract
No associated abscess
No other organ involvement
 Complex
Type 1
Associated with abscess
Multiple organ involvement
Type 2
Open into base of disrupted wound

Type 2
Type 1
Klasifikasi
Seluruh fistel simple / complex dibagi atas 2
kelompok berdasarkan asalnya :

Berasal dari usus halus

Morbiditas dan mortalitas tinggi
Spontaneous closure rendah
Berasal dari colon
Morbiditas dan mortalitas lebih rendah
Spontaneous closure lebih tinggi

Fistel complex Morbiditas dan mortalitas tinggi

Spontaneous closure rendah
Klasifika
si
Berdasarkan volume out put tiap hari
Low out put < 500 cc / 24 jam
Berasal dari colon
High out put > 500 cc / 24 jam
Berasal dari usus halus
 ETIOLOGI
I. Post operative occurance
A. Anastomotic problems
1. Technical factors
a. Tension
b. Blood supply
c. Technique
2. Intestinal factors
a. Inflammation
b. Ischemia
c. Malignancy
d. Infection
3. Systemic factors
a. Malnutrition
b. Steroids
c. Malignancy (incl.chemoth/
and radioth/ )
d. Systemic disease
(DM, renal failure)
B. Incidental injury
1. Lysis of adhesions
II. Spotaneous occurance
A. Intrinsic disease
1. Inflamation
(Inflamation Bowel Disease,
Diverticulosis)
2. Malignancy
3. Infection (TBC, actinomycosis,
amoebiasis)
4. Ischemia (embolus,
thrombosis, low flow)
5. Foreign body
6. Collagen vascular disease
7. Radiation
B. Extrinsic disease
1. Trauma
2. Other organ
 Gejala klinis

Diagnosis of small-bowel fistula usually is not difficult. When the damaged

area of the small bowel breaks down and discharges its contents,
dissemination may occur widely in the peritoneal cavity, producing
generalized peritonitis.
More commonly, however, the process is more or less walled-off in the
immediate area of the leak, with formation of an abscess. This usually
underlies the operative incision, so that when a few skin sutures are
removed to ascertain why the incision is becoming red and
tender, contents of the abscess are discharged and the fistula established.

The discharge initially may be purulent or bloody, but this is followed

sometimes immediately, sometimes within a day or twoby drainage of
obvious small-bowel contents. If the diagnosis is in doubt, confirmation
can be obtained by oral administration of a nonabsorbable marker such as
charcoal or Congo red.
 MORBIDITAS & MORTALITAS
Sangat tergantung dari
Etiologi malignancy / radiasi
Karakteristik individual penderita
Keseimbangan cairan dan elektrolit
Ada tidaknya sepsis
Malnutrisi
Efek lokal korosi cairan usus pada kulit
Beberapa faktor yang mempengaruhi mortalitas
Usia lanjut
Penderita dengan malignancy
Anemia / hipoproteinemia
 Levy et al (1989) risk score for
severity factors :
Multiple fistulas ARDS
Intraabdominal abscess Upper GIT hemorrhage
Septicaemia Renal / hepatic failure
Ileus Thromboembolic
complications

Bila terdapat 3 atau lebih gejala mortalitas rate 50%

 Factors that prevent
spontaneous closure
(Intestinal Stomas, Principle, Techniques and management, John M.MacKeigan and Peter A Cataldo, 1993)

1. Undrained sepsis
2. Distal obstruction
3. Underlying disease
(e.q.,Crohns disease,
radiation-induced bowel
injury and malignancy

4. Other potential factors are

separation of the bowel ends
5. A short fistula tract (<2 cm)
6. A foreign body, a bowell defect
> 1 cm in diameter and
epithelialization of the tract
Underlying sepsis can be a reason for non closure
Distal obstruction may inhibit closure of fistula
Underlying bowel disease may be a reason for nonclosure
Disrupted anastomosis as a reason for non closure
Short tract may explain failure of a fistula to a close spontaneously
Epithelization of the tract may prohibit spontaneous closure
PENATALAKSANAAN
1. Stabilization
2. Investigation
3. Conservative treatment
4. Decision / definitive
surgery
1. Stabilization
Pasien fistel enterokutaneus :
Inflamasi
Malnutrisi
KU jelek
Dehidrasi
Defisit volume intravaskuler

Tujuan tindakan pada fase ini menstabilkan penderita :

Menurunkan intestinal out put
Mengurangi kehilangan cairan & elektrolit sekaligus makes wound
and skin care easier

Tindakan pertama segera mengembalikan volume intravaskuler

dengan :
Kristaloid, koloid dan darah untuk memperbaiki perfusi jaringan
 Bila sepsis kontrol sepsis
Abses drainase
Antibiotik

Berikan H2 antagonis untuk mencegah stress erosion

dan menurunkan sekresi gaster
 An abscess associated with an enterocutaneous
fistula (complex type 1) should be drained
percutaneous whenever feasible

Attempt percutaneous drainage

 When percutaneous drainage fails (or is not
technically feasible) for complex type 1 fistulas,
a laparotomy with drainage of abscess plus
proximal diversion should be performed
 2.
Investigatio
Investigasi dilakukan bila pasien sudah :
n Teresusitasi
Stabil
Sepsis sudah terkontrol

Investigasi untuk menentukan :

1. Course & origin of the fistula tract
2. Presence of a persistence abscess
3. Condition of adjecent bowel
4. The presence of distal obstruction or discontinuity
 Fistulogram terbaik

CT scan :
Terbatas
Berguna untuk re-evaluasi
penderita yang tidak
respons terhadap terapi
konservatif

Pemeriksaan lain :
Sistoskopi & IVP bila
sudah melibatkan
organ-organ urogenital
Fistulogram performed in a patient with a small-
bowel fistula. A distal obstruction is
demonstrated (arrow).
3. Conservative
treatment
a. Total Parenteral
Nutrition
Wolfe ,et al (1972) TPN menurunkan output
spontaneous closure
TPN
Allowed better timing for operative intervention when
required
Improved the nutritional status of patients undergoing
reoperation
Increased the rate of post operative recovery

TPN dimulai sedini mungkin setelah :

Koreksi defisit volume dan elektrolit
Sepsis sudah terkontrol
 TPN :
30 40 kcal/kg/hari dengan ratio kalorinitrogen 150 : 1

0,25 0,35 gr Nitrogen /kgBB/hari diberikan untuk

mempertahankan balans nitrogen positif

Lipid emulsion
3 hari /minggu
Untuk meningkatkan densitas kalori dan untuk
mencegah defisiensi asam lemak esensial

Trace elements, multivitamin dan vitamin K diberikan tiap

minggu
b. Enteral
Nutrition
Walau TPN EN juga harus diberikan pada selected patients

Tujuan EN untuk mempertahankan balans nitrogen positif

EN diet low residu

Relatif low in cost
Simple to administer
Require verry little special equipment or preparation
Help to preserve gut integrity

Diet low residual memilki keterbatasan pada fistel GIT proximal

(fistel gastro-duodenalis) sedangkan pada fistel bhg. Distal
(fistel pada colon) EN hasil bagus
 Diet low residual (EN) tidak boleh diberikan pada
Pasien sepsis atau peritonitis
Ileus paralitik
Abses intra abdominal
Obstruksi usus bahagian distal

Route pemberian EN
NG tube
ND tube
Feeding yeyunostomy
Needle catheter yeyunostomy (elemental diets only
 Diet elemental atau diet low residual yang hyperosmolar
diberikan dengan cara infus perlahan untuk mencegah
terjadinya cramping dan dumping

Bury, et al (1971) penggunaan EN :

Spontaneous closure 54%
Penurunan out put fistel 14% - 80%

Voitk, et al (1973) penggunaan EN :

Spontaneous closure 75%
Mortality rate 16%
c.
Somatostat
Diberikan untuk menurunkan fistula out put
in
Kerja somatostatin
Menurunkan sekresi gastrointestinal dengan cara
menghambat sekresi gastrin, gastric acid, biliary flow,
pancreatic out put dan intestinal secretion
Menghambat motilitas sistem GI tract
Meningkatkan intestinal transit time
d. Fibrin
glue
Menyuntik bahan tertentu kedalam fistula tract obliterasi

Bahan yang disuntik

Cyanoacrylate glue
Fibrin glue yang terbaik
MoA fibrin glue fibrin glue menginduksi respons
seluler sehingga terbentuk neovaskularisasi dan
proliferasi fibroblast

Dengan endoskopik fibrin glue disuntik melalui internal

origin
 Hasil terapi
konservatif
Secara keseluruhan dengan tindakan konservatif spontaneous
closure 60% - 70% tergantung dari :
Anatomi
Etiologi
Ada tidaknya sepsis
Fistel simple highest sucsess rate and spontaneous closure 90%
Fistel kompleks tipe 2 spontaneous closure < 10%

Fistel karena penyakit intrinsik spontaneous closure lebih rendah

dari fistel karena post operasi

Reber, et al (1978) melaporkan spontaneous closure rates :

Chrons disease 8%
Cancer 26%
Radiasi 14%
4. Decision / definitive surgery

The operation of choice for a simple

fistula is resection and primary
end-to-end anastomosis
A radiation-induced fistula is often
best managed with a bypass
procedure
TERIMA KASIH