marja boermeester · intensive care, microbiologie, urologie acuut darmfalenteam - spelers ....

De ECHT catastrofale buik

Marja Boermeester

Amsterdam UMC, locatie AMC

m.a.boermeester@amsterdamumc.nl

De ECHT catastrofale buik (in < 12 minuten)

Marja Boermeester

Amsterdam UMC, locatie AMC

m.a.boermeester@amsterdamumc.nl

Disclosures

Grants

_______________

Speaker and/or

advisory board

Baxter

Mylan

Ipsen

Acelity / KCI

LifeCell

Bard

Johnson & Johnson / Ethicon

New Compliance

Acelity / KCI

Allergan

Johnson & Johnson / Ethicon

Bard

Gore

Smith & Nephew

De ECHT catastrofale buik in < 12 minuten

- key messages -

• Reconstructive surgery should not be undertaken for 6 to 12 months and until nutrition has been optimised.

ESCP consensus intestinal failure surgery Colorectal Disease 2016

De ECHT catastrofale buik

- key messages -

Early 3-12

weeks 6-12

months >12

months

Mortality 30-100% 7-20% 3-9% 0-3%

ECF recurrence 40-60% 17-31% 10-14% 3%

Mulier WJO, 2003,27,379

Peralta R, 2011

Pertkiewicz M,PhD dissert.1999

Vischers WJS 2008,32,445

References

Conolly PT Ann Surg 2008,247,440

Conter RL AmJS1988,54,589

Datta V Dis Col R 2010,53,192

Draus Surgery 2006, 140,570

Kelly DG:Clin.Nutr 2007, Suppl 2, 42

Levy E, BJS,1989,676

Lynch AC, Ann Surg 2004,240,825

Martinez JGS 2012,16,156.

EC/EA fistula repair: timing of surgery

West JP, SGO 1961,490

De Vries, WJS 2017

• Enterocutane fistel vs enteroatmosferische fistel

• TPV vs oraal short bowel dieet

• Wacht op je beste kans = geen ‘hostile abdomen’, anabool, goed gevoed, en in balans

• BRIDGING TO SURGERY

• Preoperatief – CT road mapping (darmen en buikwand)

• Tijdens operatie: Volledige adhesiolysis + resectie fistels

• Sluit de buik altijd ! Gebruik geen synthetische mat (ook geen vicryl mesh)

De ECHT catastrofale buik

- key messages -

De ECHT catastrofale buik

- key messages -

2018 Richtlijn Littekenbreuken, NVvH

• enterocutane fistel of enteroatmosferisch?

• EAF gaat niet dicht dus TPV + oraal short bowel dieet

• resterende dunne darmlengte ?

> 150 cm of < 150 cm functionele dunne darm

NB werkelijke lengte kan langer zijn

• jejunum verwijderd of ileum verwijderd ?

• fistel output – high vs low?

• nog sepsis / infectie J/N ?

abdominale sepsis / abcessen J/N ?

Voeding bij catastrofale buik met ECF/EAF

Parenteral feeding

• Reduction in fistula output (30-50%)

• Guaranteed delivery of nutrients

• Disadvantage: central venous catheter

Macronutrienten

- eiwitten

- koolhydraten

- vetten

geabsorbeerd < 100-150

cm jejunum

Macronutrienten

- eiwitten

- koolhydraten

- vetten

geabsorbeerd < 100-150 cm

jejunum

Academic Medical Center

Acute intestinal failure due to excessive fluid loss of enterostomy or enterocutaneous fistula

PPI 2 dd 40 mg

Loperamide Melts

Maximum 4 dd 8 mg

Codeine Maximum 3 dd 20 mg

(Somatuline analogue)LIFE study

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What is essential when making choices for reconstruction?

1. Clean or contaminated or dirty (fistula)

2. Comorbidity [obesity, COPD, diabetes, smoking]

3. Diameter of abdominal wall defect, > or < 10 cm

4. Loss of domain, > or < 25%

5. Previous hernia repair / no. recurrences [+ position of old mesh(es) in situ]

6. Infected mesh in situ

7. ‘Loss’ of skin

Wat kan een acuut darmfalenteam ?

• Service:

vroeg ontslag naar home care setting onder supervisie van het darmfalen team in samenwerking met de verwijzer

bridging to surgery & pre-operatieve work-up

reconstructie chirurgie in centrum of verwijzend ziekenhuis

physician assistant } verpleegkundig consulent } case manager dietist } TPV verpleegkundige wond / stoma verpleegkundige internist – endocrinoloog / TPV expert chirurg plastisch chirurg

andere betrokken disciplines: vaatchirurg, radiologie, interventie radiologen, intensive care, microbiologie, urologie

Acuut Darmfalenteam - spelers

Organisatie complexe buik/darmfalen AMC

Gespecialiseerde spreekuren:

• Abd inf /buikwand poli (Boermeester/Gooszen/vdVelde)

+ parallel PCH spreekuur

+ parallel darmfalen PA

+ parallel wond/stoma VPK – Re-re-recidief littekenbreuk

– Grote littekenbreuk met weefselproblematiek

– Aanwezigheid van geinfecteerde mat

• Darmfalen poli (team) + parallel PCH spreekuur

+ parallel wond/stoma VPK – Aanwezigheid van enterocutane fistel of enteroatmosferische

fistel of high output stoma of short bowel

Case. CT angio

• CT angio: dunne darm ileus – obstructie, kalibersprong. St na resecties ivm ischemie

Case. CT angio

• CT angio: truncus, AMS, AMI dicht, collateralen via

a. hepatica en a. gastroduodenalis

Situatie schets

Reconstructie

Catastrophic abdomen – steps before reconstruction -

• All information available (history, OR reports, lab, cultures, imaging)

• Intestinal failure management (medication, TPN)

• Comorbidity (CPET, consultations)

• Preoperative work-up (CT in all, other imaging when needed)

• Operative plan (surgical concept, timing, botox y/n, prehab y/n)

• Prehabilitation & nutrition

• Definite operative plan (result prehab, result botox)

• Prevention of complications

Symptom-limited

ECG

• HR

Measure expired gas

• Oxygen consumption

• CO2 production

• Minute ventilation

SpO2 or PO2

Perceptual responses

• Breathlessness

• Leg discomfort

Allows calculation of peak oxygen consumption, anaerobic threshold

What is CPET ? CardioPulmonary Exercise Test

Skin defect? yes/no PCH?

Operative plan work-up: complexity assessment

Example Loss of Domain

Loss of domain – volumetrics (3-dimensional)

61 x 231 162 181 x 252 354

HSV = 61x231x162 x 0.52 ACV = 181x252x354 x 0.52

HSV / ACV x 100 = 14% HSV / TPV x 100 = 12%

Total Peritoneal Volume (TPV) = HSV + ACV

Loss of domain: HSV/ACV ratio [Tanaka method]

Loss of domain: HSV/TPV ratio [Sabbagh method]

Poor man’s estimate: repeat this in several planes (3-4), good estimate although not 3-dimensional

Previous meshes

Abdominal wall muscles

Case 1. Recurrence after synthetic mesh AWR

Case 1 Summary - based on history & reports, phys exam, CT -

• VHWG grade 1

• HPW stage 2 (H2P0W0)

• Width 15.3 cm

• LOD > 25% (being 30%)

• No fistula

• First recurrence

• Synthetic mesh present (operative report for type mesh) + multiple tackers

• Done as an onlay repair

• Mesh not infected

• No previous CST / myofascial release

• Good quality muscles

• Retracted bulged lateral muscles

• No skin defect

Case 2

• 3 Jan 2018 appendicitis, diagnostic lapsc, infiltrate + abscess drain

• 27 Feb 2018 large ab wall abscess; surgical drainage

• Nov 2018 incisional hernia with colo-cutaneous fistula

Case 2

Case 2 summary - based on history & reports, phys exam, CT -

• VHWG grade 3

• HPW stage 3 (H2P0W1)

• Width 12 cm

• LOD < 25% (20%)

• Colonic fistula

• No recurrence

• No mesh present

• No previous CST / myofascial release

• Good quality muscles

• Retracted bulged lateral muscles

• Small skin defect

botuline toxin bilateral 3x

Botuline toxin - 4-6 weeks preoperative – Chemical CST

Botox effect evaluation – preoperative CT -

Botuline toxine

• in plaats van CST = chemische CST

• met CST

• minder postoperatieve pijn

• betere compliantie buikwand – respiratoir voordeel ?

Component Separatie Technieken (CST)

• Anterieure open CST

• TAR = Transversus Abdominis Release = extended Reeve-Stoppa

• Endoscopische CST

• Biomesh tractie techniek

Endo-CST (ECST)

- approach from the rib cage, BEFORE laparotomy -

Semilunar line

Musc part of ext obliq

Internal obliq muscle

Aponeurosis of ext obliq

Endo CST

Photographs taken by MA Boermeester, with permission of the patient

Transverse Abdominis Release (TAR)

Transverse Abdominis Release (TAR)

TAR

TAR ????: no posterior plane or layer

Photographs taken by MA Boermeester, with permission of the patient

Drawings by Pieter Zwanenburg, PhD fellow Amsterdam UMC, AMC

Biomesh to avoid bridging even in the extreme

Additionele technieken up and running

• echo duplex identificatie van perforatoren voor huidtransposities

• SPY indocyanine green

• full thickness skin flaps of ALT (anterolateral thigh flap)

• profylactische negatieve druk therapie

• VAC Veraflow = installatie VAC = spoel VAC

VAC VeraflowTM installation NPWT

• Dwell time 10-20 min

• Installation volume varies (usually 50-150 mL)

• Negative pressure time 2-3 hours, usually 2.5 hrs

• 100 - 125 mmHg

• Change every 2-3 days