PK X-\_rels/PK X-\ docProps/PK X-\ppt/PK X-\ ppt/_rels/PK X-\ ppt/charts/PK X-\ppt/charts/_rels/PK X-\ppt/embeddings/PK X-\ ppt/media/PK X-\ppt/slideLayouts/PK X-\ppt/slideLayouts/_rels/PK X-\ppt/slideMasters/PK X-\ppt/slideMasters/_rels/PK X-\ ppt/slides/PK X-\ppt/slides/_rels/PK X-\ ppt/theme/PK X-\ppt/notesMasters/PK X-\ppt/notesMasters/_rels/PK X-\ppt/notesSlides/PK X-\ppt/notesSlides/_rels/PK X-\` [Content_Types].xml PK X-\]] _rels/.rels PK X-\ 0 0 Microsoft Office PowerPoint On-screen Show (16:9) 0 15 15 0 0 false Fonts Used 2 Theme 1 Slide Titles 15 Arial Calibri Office Theme Slide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15 PptxGenJS false false false 16.0000 PK X-\KdocProps/core.xml Fecal Fistula and Enterocutaneous Fistulas PptxGenJS Presentation PptxGenJS PptxGenJS 1 2026-04-02T05:42:49Z 2026-04-02T05:42:49Z PK X-\ ppt/_rels/presentation.xml.rels PK X-\Oݨ ppt/theme/theme1.xmlPK X-\;G#yyppt/presentation.xml PK X-\Xppt/presProps.xml PK X-\ppt/tableStyles.xml PK X-\D >00ppt/viewProps.xml PK X-\H7t!ppt/slideLayouts/slideLayout1.xml PK X-\ђ77,ppt/slideLayouts/_rels/slideLayout1.xml.rels PK X-\Eppt/slides/slide1.xml SURGICAL EDUCATIONFecal Fistula &Enterocutaneous FistulasDiagnosis · Investigations · TreatmentGeneral Surgery | Gastrointestinal DivisionPK X-\3 ppt/slides/_rels/slide1.xml.rels PK X-\.ppt/notesSlides/notesSlide1.xml 1PK X-\:A*ppt/notesSlides/_rels/notesSlide1.xml.rels PK X-\[kQQppt/slides/slide2.xml LEARNING OBJECTIVES 1Define fecal fistula and enterocutaneous fistula (ECF) 2Identify common etiologies and risk factors for ECF formation 3Classify ECF using anatomical, functional, and SNAP criteria 4Describe the diagnostic approach including clinical and radiological assessment 5Outline appropriate investigations including laboratory and imaging studies 6Explain medical, nutritional, and surgical management strategies 7Recognize indications for operative intervention and principles of surgery 8Discuss prognosis, complications, and factors affecting spontaneous closurePK X-\2- ppt/slides/_rels/slide2.xml.rels PK X-\ppt/notesSlides/notesSlide2.xml 2PK X-\xշ*ppt/notesSlides/_rels/notesSlide2.xml.rels PK X-\nFFppt/slides/slide3.xml DEFINITIONS & CLASSIFICATION Enterocutaneous Fistula (ECF)An abnormal communication between the GI tract and the skin surface. Can involve any segment from stomach to rectum. Fecal FistulaA specific ECF involving the large bowel or distal small bowel, producing feculent output at the skin. Output is typically >500 mL/day. Enteroatmospheric FistulaA variant occurring in an open abdomen wound, where bowel opens directly to atmosphere without a tunnel. CLASSIFICATIONBy Output▶ Low: <200 mL/day▶ Moderate: 200–500▶ High: >500 mL/dayBy Anatomy▶ Simple (no abscess)▶ Complex (abscess/radiation)By Origin▶ Spontaneous▶ Post-operative (75–85%)PK X-\W/ ppt/slides/_rels/slide3.xml.rels PK X-\K |Őppt/notesSlides/notesSlide3.xml 3PK X-\9 Y*ppt/notesSlides/_rels/notesSlide3.xml.rels PK X-\2=PbPbppt/slides/slide4.xml ETIOLOGY & RISK FACTORS 75–85%Post-operativeOrigin Post-operative (most common)• Anastomotic leak• Inadvertent enterotomy• Drain erosion• Missed bowel injury Inflammatory Bowel Disease• Crohn's disease (commonest non-operative)• Ulcerative colitis (rare) Radiation Enteritis• Pelvic/abdominal radiotherapy• Endarteritis → ischemia → perforation Malignancy• Colorectal, gynecological, lymphoma• Tumor invasion or post-resection leak Infection & Inflammation• Intra-abdominal abscess drainage• Diverticulitis, appendicitis Trauma• Abdominal trauma (penetrating/blunt)• Foreign body perforationPK X-\` ppt/slides/_rels/slide4.xml.rels PK X-\vsppt/notesSlides/notesSlide4.xml 4PK X-\J *ppt/notesSlides/_rels/notesSlide4.xml.rels PK X-\pssppt/slides/slide5.xml PATHOPHYSIOLOGY STEP 11Bowel DisruptionAnastomotic breakdown, ischemia, or transmural inflammation creates a defect in bowel wall▶ STEP 22Abscess FormationLuminal contents extravasate → loculated fluid collection → abscess cavity develops▶ STEP 33Track FormationHigh intraluminal pressure forces content along path of least resistance toward the skin▶ STEP 44EpithelializationTrack becomes lined with granulation then epithelial tissue — preventing spontaneous closure▶ STEP 55Systemic EffectsFluid/electrolyte loss, sepsis, malnutrition, protein depletion, immune suppressionFRIEND Mnemonic for non-closure: Foreign body Radiation Infection/Inflammation Epithelialisation Neoplasm Distal obstructionPK X-\5 ppt/slides/_rels/slide5.xml.rels PK X-\W8ppt/notesSlides/notesSlide5.xml 5PK X-\Qe*ppt/notesSlides/_rels/notesSlide5.xml.rels PK X-\Q O Oppt/slides/slide6.xml CLINICAL PRESENTATION Local Signs✓ Visible skin defect or wound breakdown✓ Feculent/enteric discharge from wound✓ Erythema, maceration of surrounding skin✓ Pain or tenderness at fistula site✓ Associated wound dehiscence Systemic Features✓ Fever, tachycardia (sepsis)✓ Dehydration, electrolyte imbalance✓ Profound weight loss / cachexia✓ Hypoalbuminemia (malnutrition)✓ Metabolic acidosis (high-output ECF) Complications✓ Sepsis (leading cause of death ~75%)✓ Severe malnutrition & muscle wasting✓ Skin excoriation / breakdown✓ Intra-abdominal abscess✓ Psychological distress & depression⚠ Onset typically Day 5–10 post-operatively with unexpected wound drainage — 'test the discharge with Gastrografin!'PK X-\ج+ ppt/slides/_rels/slide6.xml.rels PK X-\zppt/notesSlides/notesSlide6.xml 6PK X-\=|*ppt/notesSlides/_rels/notesSlide6.xml.rels PK X-\ /PEaEappt/slides/slide7.xml SNAP CLASSIFICATION SYSTEMThe SNAP system guides treatment prioritization by addressing four key domains: SSepsis• Control source: drainage / antibiotics• Blood cultures if systemic sepsis• IV antibiotics: broad-spectrum coverage• Goal: Achieve sepsis-free state NNutrition• Assess nutritional status (albumin, BMI)• Enteral preferred over parenteral• TPN if high-output or distal obstruction• Target: 25–30 kcal/kg/day AAnatomy• Delineate fistula tract (CT / fistulogram)• Identify associated abscess or obstruction• Assess bowel continuity & length• Document any foreign bodies PProcedure• Consider definitive surgery only after S, N, A• Minimum 3–6 months non-operative trial• Surgery: resection + primary anastomosis• Avoid surgery in hostile abdomenPK X-\F ppt/slides/_rels/slide7.xml.rels PK X-\)lppt/notesSlides/notesSlide7.xml 7PK X-\|g*ppt/notesSlides/_rels/notesSlide7.xml.rels PK X-\mnUUppt/slides/slide8.xml DIAGNOSIS: HISTORY & PHYSICAL EXAMINATION 📋 HISTORYPresenting Complaint: Nature, colour & volume of discharge from wound/drain siteSurgical History: Recent abdominal procedures, anastomoses, mesh placementOnset & Duration: Day of discharge onset post-operatively (typically day 5–10)IBD/Malignancy: Previous Crohn's, UC, colorectal or pelvic cancerRadiation: Prior pelvic or abdominal radiotherapy historyMedications: Steroids, immunosuppressants (impair healing), NSAIDsNutritional Status: Pre-morbid weight, recent losses, diet tolerance 🔍 PHYSICAL EXAMINATIONGeneral:→ Malnutrition, cachexia, pallor, jaundice→ Vital signs: fever, tachycardia, hypotensionWound Assessment:→ Document number, location & size of openings→ Character of output: colour, odour, consistency→ Skin excoriation / maceration extentAbdominal Exam:→ Tenderness, peritonism (abscess/leak)→ Palpable mass, abdominal wall defect→ Stoma assessment if applicableNutritional Markers:→ BMI, muscle wasting (temporal, thenar)→ Mid-arm circumference, hand-grip strengthPK X-\6 ppt/slides/_rels/slide8.xml.rels PK X-\iސppt/notesSlides/notesSlide8.xml 8PK X-\pO*ppt/notesSlides/_rels/notesSlide8.xml.rels PK X-\hf={={ppt/slides/slide9.xml INVESTIGATIONS: LABORATORY STUDIES Full Blood Count (FBC)• Hb ↓: anaemia of chronic disease / bleeding• WBC ↑: infection / sepsis• Platelets: assess coagulopathy• MCV: nutritional deficiencies Metabolic Panel• Na⁺, K⁺, Cl⁻: electrolyte losses (critical!)• Bicarbonate: metabolic acidosis• BUN/Creatinine: dehydration, AKI• Blood glucose: stress hyperglycaemia Liver Function & Proteins• Albumin < 3.0 g/dL: severe malnutrition• Pre-albumin (rapid turnover marker)• Total protein: overall nutritional status• LFTs: hepatic involvement, TPN toxicity Inflammatory Markers• CRP / ESR: infection / inflammatory activity• Procalcitonin: bacterial sepsis indicator• Blood cultures: if systemic sepsis• Wound swab/MC&S: guide antibiotic therapy Haematological & Special• Coagulation (PT, aPTT): coagulopathy• Zinc, Magnesium, Phosphate levels• Thiamine, Folate, Vit B12: deficiencies• Calprotectin: IBD activity monitoring Fistula Output Analysis• Volume per 24 hours (low / mod / high)• Amylase: pancreatic fistula if elevated• Bilirubin: biliary communication• Creatinine: urinary fistula if elevatedPK X-\>$ ppt/slides/_rels/slide9.xml.rels PK X-\qppt/notesSlides/notesSlide9.xml 9PK X-\1*ppt/notesSlides/_rels/notesSlide9.xml.rels PK X-\eCppt/slides/slide10.xml INVESTIGATIONS: IMAGING STUDIES CT Abdomen & PelvisFIRST-LINEWith IV & oral contrast◆ Locate associated collections◆ Assess fistula origin & course◆ Detect distal obstruction◆ Guide percutaneous drainage💡 Best initial imaging for all suspected ECF FistulographyDEFINITIVEWater-soluble contrast injection◆ Delineate complex multi-track fistulas◆ Identify enteric communication◆ Pre-operative road-mapping◆ Assess healing progress💡 Gold standard for tract anatomy Small Bowel Follow-ThroughADJUNCTBarium / water-soluble◆ Assess intestinal continuity◆ Detect downstream stricture◆ Document bowel length◆ IBD activity assessment💡 Avoid barium if peritonitis risk MRI Abdomen/PelvisSELECTEDSoft tissue detail◆ Pelvic/perianal fistulas◆ Post-radiation assessment◆ Soft tissue characterisation◆ Pre-operative planning💡 Avoids radiation; limited in acute settingPK X-\Ѳ!ppt/slides/_rels/slide10.xml.rels PK X-\O ppt/notesSlides/notesSlide10.xml 10PK X-\T+ppt/notesSlides/_rels/notesSlide10.xml.rels PK X-\~__ppt/slides/slide11.xml FISTULOGRAPHY, ENDOSCOPY & SPECIAL TESTS Fistulography (Sinogram)→ Catheter inserted gently into external opening→ Water-soluble contrast (Gastrografin) injected under fluoroscopic guidance→ Identifies: tract length, course, depth, side branches→ Demonstrates communication with bowel lumen→ Assesses healing on follow-up studies→ Can be combined with CT for 3D reconstruction Endoscopy (OGD / Colonoscopy)→ Identifies intraluminal pathology at fistula origin→ Biopsies: confirm malignancy, IBD, or ischaemia→ Detects anastomotic dehiscence / stricture→ Distal obstruction evaluation (critical for closure)→ ERCP if biliary fistula suspected→ Therapeutic: endoscopic clips, fibrin glue injection Methylene Blue TestOral MB → observe for blue drainage at fistula opening. Simple bedside confirmation of GI communication. Nuclear MedicineLabelled WBC scan for occult sepsis. Helpful when CT inconclusive for collection localisation. UltrasoundIdentifies superficial abscesses, guides drainage. Limited in deep or complex fistulas. Biopsy / HistologyEssential when malignancy or Crohn's suspected. Guides definitive oncological or medical management.PK X-\;!ppt/slides/_rels/slide11.xml.rels PK X-\s6ӑ ppt/notesSlides/notesSlide11.xml 11PK X-\O+ppt/notesSlides/_rels/notesSlide11.xml.rels PK X-\bkp{{ppt/slides/slide12.xml MEDICAL MANAGEMENT Fluid & Electrolyte Replacement• IV fluid resuscitation: normal saline / Hartmann's• Replace Na⁺, K⁺, Mg²⁺, phosphate, zinc• Monitor urine output, daily weights• High-output ECF: aggressive replacement critical Sepsis Management• Blood cultures → broad-spectrum IV antibiotics• Percutaneous CT-guided drainage of abscesses• Surgical source control if drainage insufficient• Antifungals if prolonged illness or immunosuppression Output Reduction• Nil by mouth / bowel rest: reduces fistula output• Octreotide / Somatostatin: ↓ GI secretions by 50%• Proton pump inhibitors: reduce gastric acid secretion• Anti-motility agents: loperamide (low-output only) Wound & Skin Care• Fistula effluent collection device / pouch• Barrier creams / hydrocolloid dressings• Vacuum-Assisted Closure (VAC): selected cases• Stomal therapist involvement: essential Disease-Specific Therapy• Crohn's: anti-TNF (infliximab), immunosuppressants• Radiation: hyperbaric oxygen (adjunct)• Malignancy: oncology referral, palliative approach• Review / stop NSAIDs, steroids if possible Monitoring & Targets• Daily fistula output measurement & charting• Weekly: albumin, FBC, electrolytes, CRP• Nutritional targets: albumin > 3.0 g/dL• Assess fistula healing response at 4–6 weeksPK X-\c!ppt/slides/_rels/slide12.xml.rels PK X-\*)@ ppt/notesSlides/notesSlide12.xml 12PK X-\Fb+ppt/notesSlides/_rels/notesSlide12.xml.rels PK X-\\yyppt/slides/slide13.xml NUTRITIONAL SUPPORT IN ECF Choosing the Nutritional Route❓ Is the gut functional & accessible?YES: → Enteral Nutrition (EN)NO: → Total Parenteral Nutrition (TPN)❓ Is fistula output low-moderate (<500)?YES: → Oral diet if toleratedNO: → Bowel rest + TPN❓ Is fistula distal to feeding site?YES: → Nasojejunal / jejunostomy feedNO: → Reassess anatomy⚠ Key principle: 'Feed the patient, not the fistula' — enteral feeding is preferred even in high-output fistulas if bowel is accessible distal to opening TPN & Nutritional TargetsParameterTargetNoteEnergy25–35 kcal/kg/dayHigher in catabolic stateProtein1.5–2.0 g/kg/dayKey for wound healingGlucose< 180 mg/dLTight glycaemic controlGlutamine0.3–0.5 g/kg/dayMucosal trophic effectZinc15–25 mg/dayReplace losses in ECFTarget Albumin> 3.0 g/dLPredicts surgical outcomeOral supplementation (zinc, vitamins A, C, E) should accompany any nutritional regimen.PK X-\x!ppt/slides/_rels/slide13.xml.rels PK X-\Ї ppt/notesSlides/notesSlide13.xml 13PK X-\yv+ppt/notesSlides/_rels/notesSlide13.xml.rels PK X-\5jooppt/slides/slide14.xml SURGICAL MANAGEMENT⏱ Timing: Spontaneous closure typically within 4–6 weeks (25–40% of ECFs). If not closed by 3–6 months, surgical intervention is planned. Pre-Operative Prerequisites (SNAP Complete)✓ Sepsis controlled (no active infection)✓ Nutrition optimised (albumin > 3.0 g/dL)✓ Anatomy delineated (CT + fistulogram)✓ Patient on optimal medical therapy✓ Minimum 3–6 months conservative treatment Indications for Surgery→ Failure to close after 3–6 months→ Distal bowel obstruction (mandates surgery)→ Malignancy at fistula site→ Radiation-induced ECF (poor spontaneous closure)→ Enteroatmospheric fistula→ Patient preference / quality of lifeOperative Sequence 1AdhesiolysisTake down all adhesions; anticipate prolonged dissection in re-operative fields 2Fistula ResectionEn-bloc excision of fistula tract and involved bowel segment 3AnastomosisPrimary resection & anastomosis if well-nourished; diversion if hostile abdomen 4Abdominal ClosureComponent separation if large defect; biological mesh in contaminated fieldsPK X-\O!ppt/slides/_rels/slide14.xml.rels PK X-\0 ppt/notesSlides/notesSlide14.xml 14PK X-\?ݤ+ppt/notesSlides/_rels/notesSlide14.xml.rels PK X-\?yccppt/slides/slide15.xml PROGNOSIS & KEY TAKEAWAYS75–85%Post-operative originMost ECFs are iatrogenic25–40%Spontaneous closure rateWithin 4–6 weeks conservative Rx~75%Deaths due to sepsisPrimary cause of mortality3–6Months before surgeryMinimum conservative trial1Most ECFs are post-operative; early recognition on Day 5–10 is critical.2Apply the SNAP framework (Sepsis → Nutrition → Anatomy → Procedure) before any surgical intervention.3CT abdomen with contrast is the first-line investigation; fistulography defines anatomy.4Nutritional optimisation (albumin > 3.0 g/dL) is mandatory before surgery.5FRIEND mnemonic identifies reasons for failure to close: Foreign body, Radiation, Infection, Epithelialization, Neoplasm, Distal obstruction.6Surgery (resection + anastomosis) is reserved for failures after 3–6 months conservative management.Fecal Fistula & Enterocutaneous Fistulas · Surgical Education Series · For Academic Use OnlyPK X-\*R!ppt/slides/_rels/slide15.xml.rels PK X-\Qz ppt/notesSlides/notesSlide15.xml 15PK X-\$Q+ppt/notesSlides/_rels/notesSlide15.xml.rels PK X-\K !ppt/slideMasters/slideMaster1.xml PK X-\N),ppt/slideMasters/_rels/slideMaster1.xml.rels PK X-\6TT!ppt/notesMasters/notesMaster1.xml 7/23/19Click to edit Master text stylesSecond levelThird levelFourth levelFifth level‹#›PK X-\s **,ppt/notesMasters/_rels/notesMaster1.xml.rels PK X-\_rels/PK X-\ $docProps/PK X-\Kppt/PK X-\ mppt/_rels/PK X-\ ppt/charts/PK X-\ppt/charts/_rels/PK X-\ppt/embeddings/PK X-\ ppt/media/PK X-\Bppt/slideLayouts/PK X-\qppt/slideLayouts/_rels/PK X-\ppt/slideMasters/PK X-\ppt/slideMasters/_rels/PK X-\  ppt/slides/PK X-\3ppt/slides/_rels/PK X-\ bppt/theme/PK X-\ppt/notesMasters/PK X-\ppt/notesMasters/_rels/PK X-\ppt/notesSlides/PK X-\ppt/notesSlides/_rels/PK X-\` P[Content_Types].xmlPK X-\]] T$_rels/.relsPK X-\00nppt/viewProps.xmlPK X-\H7t!Xrppt/slideLayouts/slideLayout1.xmlPK X-\ђ77,Fuppt/slideLayouts/_rels/slideLayout1.xml.relsPK X-\Evppt/slides/slide1.xmlPK X-\3 ppt/slides/_rels/slide1.xml.relsPK X-\.ppt/notesSlides/notesSlide1.xmlPK X-\:A*ppt/notesSlides/_rels/notesSlide1.xml.relsPK X-\[kQQppt/slides/slide2.xmlPK X-\2- Hppt/slides/_rels/slide2.xml.relsPK X-\Tppt/notesSlides/notesSlide2.xmlPK X-\xշ*!ppt/notesSlides/_rels/notesSlide2.xml.relsPK X-\nFF4ppt/slides/slide3.xmlPK X-\W/ C?ppt/slides/_rels/slide3.xml.relsPK X-\K |ŐOAppt/notesSlides/notesSlide3.xmlPK X-\9 Y*Hppt/notesSlides/_rels/notesSlide3.xml.relsPK X-\2=PbPb/Jppt/slides/slide4.xmlPK X-\` ppt/slides/_rels/slide4.xml.relsPK X-\vsppt/notesSlides/notesSlide4.xmlPK X-\J *ppt/notesSlides/_rels/notesSlide4.xml.relsPK X-\pssppt/slides/slide5.xmlPK X-\5 *ppt/slides/_rels/slide5.xml.relsPK X-\W8,ppt/notesSlides/notesSlide5.xmlPK X-\Qe*3ppt/notesSlides/_rels/notesSlide5.xml.relsPK X-\Q O O5ppt/slides/slide6.xmlPK X-\ج+ ppt/slides/_rels/slide6.xml.relsPK X-\zppt/notesSlides/notesSlide6.xmlPK X-\=|*ppt/notesSlides/_rels/notesSlide6.xml.relsPK X-\ /PEaEappt/slides/slide7.xmlPK X-\F vppt/slides/_rels/slide7.xml.relsPK X-\)lppt/notesSlides/notesSlide7.xmlPK X-\|g*Oppt/notesSlides/_rels/notesSlide7.xml.relsPK X-\mnUUbppt/slides/slide8.xmlPK X-\6 Qppt/slides/_rels/slide8.xml.relsPK X-\iސSppt/notesSlides/notesSlide8.xmlPK X-\pO*~Zppt/notesSlides/_rels/notesSlide8.xml.relsPK X-\hf={={\ppt/slides/slide9.xmlPK X-\>$ ppt/slides/_rels/slide9.xml.relsPK X-\q ppt/notesSlides/notesSlide9.xmlPK X-\1*ppt/notesSlides/_rels/notesSlide9.xml.relsPK X-\eCppt/slides/slide10.xmlPK X-\Ѳ!bppt/slides/_rels/slide10.xml.relsPK X-\O dppt/notesSlides/notesSlide10.xmlPK X-\T+kppt/notesSlides/_rels/notesSlide10.xml.relsPK X-\~__mppt/slides/slide11.xmlPK X-\;!ppt/slides/_rels/slide11.xml.relsPK X-\s6ӑ ppt/notesSlides/notesSlide11.xmlPK X-\O+ppt/notesSlides/_rels/notesSlide11.xml.relsPK X-\bkp{{ppt/slides/slide12.xmlPK X-\c!Tppt/slides/_rels/slide12.xml.relsPK X-\*)@ Wppt/notesSlides/notesSlide12.xmlPK X-\Fb+]ppt/notesSlides/_rels/notesSlide12.xml.relsPK X-\\yy_ppt/slides/slide13.xmlPK X-\x!ppt/slides/_rels/slide13.xml.relsPK X-\Ї ppt/notesSlides/notesSlide13.xmlPK X-\yv+ppt/notesSlides/_rels/notesSlide13.xml.relsPK X-\5jooppt/slides/slide14.xmlPK X-\O!Tppt/slides/_rels/slide14.xml.relsPK X-\0 Vppt/notesSlides/notesSlide14.xmlPK X-\?ݤ+]ppt/notesSlides/_rels/notesSlide14.xml.relsPK X-\?ycc_ppt/slides/slide15.xmlPK X-\*R!ppt/slides/_rels/slide15.xml.relsPK X-\Qz ppt/notesSlides/notesSlide15.xmlPK X-\$Q+ppt/notesSlides/_rels/notesSlide15.xml.relsPK X-\K !ppt/slideMasters/slideMaster1.xmlPK X-\N),ppt/slideMasters/_rels/slideMaster1.xml.relsPK X-\6TT!ppt/notesMasters/notesMaster1.xmlPK X-\s **,[ ppt/notesMasters/_rels/notesMaster1.xml.relsPK__D