Abdominal abscesss

- Clearance of intraabdominal collections:

o Acute: clearance via diaphragmatic lymphatics & phagocytosis
o Long term: sequestration and walling off
- IV contrast via CT can help identify abscesses
o CT generally better than US but may not be able to distinguish infected vs non-infected,
or subphrenic vs pleuritic
- Bacteria involved often e coli and b fragilis
o Abx: ancef + flagyl -> CTx + flagyl -> piptazo; genta + flagyl if allergy
o Same effect if treated with resolution of symptoms +2 days, versus 5 days flat of Abx
- No benefit to adding suction to abscesses; but flushing once a day ensures patency
- Fungal abscess, infected hematoma, peripancreatic collection, and necrotic collections have less
success with perQ drainage and may required surgical drainage
-

Fistula

- Mortality as high as 20%

- Classified based on cause (iatrogenic vs natural), what organs involved, and
amount/composition of fluid
o Most (70-90%) of small bowel fistulas are post op; crohns is most common cause of
spontaneous
- Delayed abdo closure – ideally within the first 8 days of open abdo
o 25% fistula formation for open abdomen related to sepsis
o Avoidable causes with post op vac: inserting feeding tube during surgery or
manipulation of anastomoses during vac changes
- Enteroatmosphereic are some of the hardest to manage
- Gastrocutaenous fistula most often seen in kids with G-tube post removal, related to length of
time tube has been in place
- Fistula after gastric cancer resection has high mortality
- Crohns fistula early after resection of disease bowel: likely involves healthy bowel is likely to
spontaneously close
o If arising from diseased bowel, has slow rate of closure
o IBD fistula may close spont but may reopen with resuming of oral intake ; should be
treated with surgical management
- Appendiceal fistula can follow abscess and often forms from TI rather than appendix
- Colonic fistula is usually from anastomotic leak
- Enteroatmohspheric fistula is following open abdomen;; 25% if due to sepsis, up to 50% if
pancreatic necrosis
- High output (500), moderate (200-500) and low (200);; high output has 50% mortality and low
output 25%
- Risk factors: age, immunosuppression, contamination, emergency surgery, malnutrition,
radiation, duration of surgery, blood loss, technical issues, steroids
 o Diabetes is not a risk factor but increases mortality significantly if there is fistula
- Butressing omentum does not reduce rate of leak, but reduces risk of tacking bowel during
closure
- Treatment
o Abx
o Operative intervention is aimed at cleaning our peritonitis and exteriorizing the defect
o Managing outputs: goal is to reduce irritation to surrounding skin and monitor outputs
o Vaccuum assisted devices can help increase rate of closure; reduces number of dressing
changes and irritation to skin
 Some risk of additional fistulas forming, so must cover the other areas with non
adherent gauze
o Reduce outputs:
 NG not indicated in absence of obstruction (can cause issues with pulmonary
toilet, alar necrosis, esophageal stricture)
 Histamine antagonist
 PPI
 Somatostatin analogues
 Loperamide
 Codeine
 Infliximab good in situations with IBD
o Have been some description of plugging the opening with biologic material with some
success
o TPN has been route for nutrition to help with healing and also to reduce PO intake /
outputs of outputs
o For high output proximal fistulas, can consider feeding via the fistula itself
- Investgiation
o Fistulograph
o CT with oral contrast
- Operative intervention
o In acute phase only for peritonitis
o After 15 week period, adhesions are a bit better to work with?
o Very long delay can also have negative impact; operative intervention 3-6 months post
is ideal
o Lots of complications for surgical management – sepsis, pna, bacteremia, clots, etc
o Idavertent enterotomy in as high as 20% of patients
o Interloop obstructions should be untouched, but if distal to a stoma consider LOA to
prevent a missed / covered obstruction
o Closure of abdominal wall can often be difficult
 Ideally non mesh with component separation if needed; but mesh if you must

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- Less likely to spontaneously close after 4-8 weeks?