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Management of Complex Gastrointestinal Fistula

Despite all the medical advances over the last 2 decades the management of gastrointestinal fistula still remains a significant challenge and carries a mortality rate of up to 10%.1 This mortality rate is even higher when the fistula is associated with an open abdominal wound.2-4 These fistulas are most often seen in the postoperative period due to anastomotic leakage. They typically occur following surgery for intestinal obstruction, cancer, or inflammatory bowel disease.5,6 Thus, 75% to 85% are iatrogenic in origin.7 Their management requires input from a wide range of personnel, with attention to the control of sepsis, fluid and electrolyte balance, maintenance of nutrition, and attention to wound/stoma care. The principal participants in patient management include nutritionists, enterostomal therapists (ET), radiologists, psychiatrists/psychotherapists, nurses, internists, surgeons, and other personnel (Table 1). It is a condition that places a considerable economic burden on the healthcare provider. Regardless of the pathogenesis, the management most often requires considerable lengths of hospital stay and extensive multidisciplinary input. The development of an intestinal fistula following surgery is a devastating complication for the patient and their family. It may lead to significant anxiety, loss of self-esteem, depression, and considerable loss of earnings and financial hardship. Fistulas are defined as an abnormal communication between 2 epithelized surfaces. This article focuses on acquired as opposed to congenital fistulas. Several classification systems have been used in their description.8-10 The anatomic classification names the fistula according to the organs involved. The high pressure organ from which the fistula arises is named first (eg, colovesical, aortoenteric, or gastrocutaneous). The physiological classification is based on their output over 24 hours. High-output fistulas produce more than 500 mL/24 h and lead to considerable difficulties with fluid management and skin care. These generally originate from the small bowel and the patient may require total parenteral nutrition (TPN). Moderate-output fistulas produce 200 to 500
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Curr Probl Surg, May 2009

TABLE 1. Members of the multidisciplinary team Enterostomal therapists Surgeons/medical personnel Nurses Radiologists Nutritionists Infectious disease team Psychiatrists/psychologists

mL/24 h. In contrast, low-output fistulas produce less than 200 mL/24 h, are generally of colonic origin, and the patient may be able to tolerate normal oral intake. There is still considerable debate and differing opinions about whether there is a correlation between the volume of fistula output and the potential for closure.9-11 Several publications have shown an association between the extent of fistula output and mortality rate, with high-output fistulas having a greater potential for mortality than low-output fistulas.12,13 Another classification system is based on fistula etiology (eg, diverticular fistula, malignant fistula, etc.).8 In addition, fistulas may be classified as internal or external, simple, or complex. Internal fistulas arise when there is communication between adjacent bowel loops or organs. If the intestinal fistula only bypasses a short segment of bowel then the patient may be relatively asymptomatic without any electrolyte disturbance. However, if the intestinal segment bypassed by the fistula is significant (eg, gastrocolic fistula) then the patient will present with major electrolyte abnormalities and nutritional deficiencies. Potentially any intra-abdominal organ may be affected (Fig 1). In the case of spontaneously occurring fistulas one must have a high index of suspicion for underlying Crohn’s disease or malignancy.5,14-16 These, in addition to fistulas that develop after radiotherapy, tend not to close spontaneously and generally require surgical intervention. Other coexisting factors that make spontaneous fistula closure unlikely include distal obstruction, complete anastomotic dehiscence, ongoing intra-abdominal sepsis, malnourishment, diseased bowel, and the formation of an epithelized tract.7-8 In addition, when an enterocutaneous fistula (ECF) occurs in a patient with an intra-abdominal mesh, it is unlikely to close until the offending foreign material is removed.17 A very useful acronym in the management of patients with intestinal fistula, which has evolved from the experience gleamed from several centers down the years, is “SNAP”; S is for control of sepsis and appropriate skin care; N is for nutrition, ideally via the enteral route (if
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FIG 1. A left ureterocolic fistula that occurred following surgery for retroperitoneal fibrosis. (Courtesy
of the Department of Colorectal Surgery & Radiology, Cleveland Clinic, Cleveland, OH.)

not, then parenterally or a combination of both); A is to define the underlying anatomy; P is for a definite plan to deal with the fistula18 (Table 2). The majority of fistulas that respond to conservative management will close within 6 weeks. If the fistula does not close spontaneously, then the time to surgical intervention is critical to the outcome. It is our experience
386 Curr Probl Surg, May 2009

TABLE 2. SNAP: A useful acronym in management of patients with complex intestinal fistula S: Sepsis/skin care N: Nutrition (enteral/parenteral) A: Define underlying anatomy with appropriate imaging P: Definitive plan to deal with the fistula

that intra-abdominal adhesions achieve a maximum density from the tenth postoperative day to the sixth week. Surgery within this time frame is ill advised because of the difficult dissection with potential for multiple enterotomies with ensuing fistulas. In addition, there is the risk for mesenteric vascular injury, necessitating extensive small bowel resection and the potential for short gut syndrome. We would delay surgery until all the physiologic and metabolic parameters have stabilized and generally like to wait 6 months from the time of previous surgery. Occasionally one may have to intervene within this critical time period because of ongoing sepsis and failure to stabilize or progress. One may also be forced to operate if wound problems lead to an intolerable situation for the patient and family. On occasions one may encounter a very hostile abdomen, in which case the creation of a proximal stoma with minimal distal dissection may be the safest solution until one returns for definitive surgical intervention at a later date. If one is unable to mobilize the bowel and exteriorize it without tension at the marked stoma site then it may have to be brought through the midline wound (Fig 2). When operating on patients with intestinal fistulas surgeons must be aware of the predictors of further recurrence. The Cleveland Clinic experience supports resection and primary anastomosis over wedge repair or oversewing.19 Some fistulas may produce quite dramatic symptoms, such as the discharge of feces per urethra or vagina or onto the skin in the case of a colocutaneous fistula. This will lead to a high level of anxiety for the patient and anyone unfamiliar with such pathology. However, in the absence of underlying malignancy and sepsis these fistulas may be managed conservatively in a subset of patients with extensive comorbidities. One must balance the impingement on patient’s quality of life with the risk of surgical intervention. A fistula associated with an ostomy site may cause considerable wound problems and difficulty with pouching (Fig 3). In patients with internal Crohn’s fistulas that are asymptomatic one should consider the common wisdom that it is impossible to make an asymptomatic patient feel better. A percentage of these patients will become symptomatic and ultimately need surgical intervention, but a proportion may be spared an unnecessary operation with its associated risks.20
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where the trend is to drain any pancreatic sepsis.FIG 2. a well-nourished patient in the absence of extensive 388 Curr Probl Surg. and delay surgical intervention until a reasonable amount of time has elapsed from the primary event. Cleveland. Cleveland Clinic. given the difficulties with care and multidisciplinary input required. Etiology and Prevention The majority of fistulas are due to preceding surgery or trauma. Typically the patient has undergone a bowel anastomosis that has subsequently leaked. intraoperative and patient circumstances must be favorable for an anastomosis (ie. In addition. Thus when performing any anastomosis one must pay careful attention to the basic principles of ensuring a tension-free repair and good blood supply to the bowel segments (Table 3). careful attention to intraoperative detail and meticulous hemostasis are important if one is to reduce the incidence. OH. (Courtesy of the Enterostomal Nursing Department.21-23 If the fistula does not close spontaneously then we would recommend that such patients should be managed in a specialized unit with appropriate expertise.) Given that the majority of intestinal fistulas arise following an abdominal procedure. On occasions one may have to be prepared to bring a stoma through the midline laparotomy wound if tension is a problem. We would liken the developments in the care of intestinal fistula to that of pancreatic necrosis. maintain adequate nutrition. May 2009 .

Cleveland. May 2009 389 . or in high-risk patients who would not tolerate the clinical consequences of a leak.25 It is important to close any mesenteric defects to prevent postoperative internal hernia that may lead Curr Probl Surg. We would also generally favor diverting an ileal pouch-anal anastomosis and would only consider omission of the ileostomy under optimal conditions.FIG 3. if one is performing a coloanal anastomosis. (Courtesy of the Enterostomal Nursing Department.24 The authors favor performing a temporary diverting loop stoma if the patient has had preceding chemoradiotherapy for rectal cancer. OH. Cleveland Clinic. An ileostomy with associated fistula may give rise to a wound that is difficult to manage.) TABLE 3. If the patient has risk factors for leakage then a diverting stoma is more prudent. Conditions required when creating an anastomosis Adequate exposure Tension-free anastomosis Good blood supply Well-nourished patient Patient must not be immunocompromised Minimal contamination of operative field Hemodynamically stable patient comorbidities or immunosuppression).

Any episode of hypotension may reduce blood supply to the anastomosed bowel segments with subsequent ischemia.27 All abdominal procedures carry the inherent possibility of the development of a fistula and this should be explained to the patient as part of the informed consent. particularly after a long case. In addition. and fistulization. However. Although the incidence is low. colonic.26 In addition. but there is no randomized trial to prove its validity. despite all the advances. The immediate postoperative period is critical. One must avoid catching small bowel or the stoma in the closure suture. Although successful in the control of bleeding it may render the treated segment of bowel ischemic with resulting perforation and fistulization. which may necessitate the insertion of a biological mesh. May 2009 . one of the risk factors with these indwelling stents. retraction of the abdominal wall tissues means that the patient may ultimately require abdominal wall reconstruction. whether esophageal. Iatrogenic causes due to instrumentation/ interventional procedures are another relatively common cause of intestinal fistulas. Before closure one should examine the entire small bowel several times to identify serosal tears or inadvertent enterotomies. All organs must be well perfused. the open abdomen and exposed intestinal contents carry a risk for fistulization. one must pay utmost attention to the fascial closure. Many surgeons favor wrapping the omentum around the anastomosis. which. Instinct would suggest that it may help to control a small leak. In patients with extensive comorbidities or metastatic disease.28. palliative stents are often used to deal with the impending obstruction from a primary malignancy.29 With advances in interventional radiology. patients with significant gastrointestinal bleeding may be managed by mesenteric angiography with embolization. However. the devastating effects of an intestinal fistula mean that the patient should have some knowledge of this potential complication. pancreatic necrosis) or surgery for extensive trauma may develop considerable edema of all tissues and organs. Patients who require several abdominal procedures for the control of sepsis ( bowel obstruction and anastomotic dehiscence. is still susceptible to infection. or biliary. is the potential for erosion and fistula formation. The anastomosis should be placed well removed from the abdominal wound. In this scenario it may not be possible to close the abdomen and therefore one may have to perform a laparostomy because of the risk of abdominal compartment syndrome.30-32 Even 390 Curr Probl Surg. Operative times extending beyond 2 hours and contamination of the field from spillage of intestinal contents are risk factors for anastomotic leakage. perforation. One of the most common is a gastrocolic or colocutaneous fistula arising from percutaneous endoscopic gastrostomy (PEG) tube insertion.

At laparotomy. OH. Cleveland. Spontaneous fistulas may occur due to inflammatory bowel disease. which becomes adherent and then fistulizes to the sigmoid colon (Fig 4). which causes a transmural inflammation. which have a more insidious onset.33 Iatrogenic fistulas tend to present quickly. Often the point of communication with the sigmoid colon is subtle and requires careful examination. (Courtesy of the Department of Colorectal Surgery & Radiology. in particular Crohn’s disease.) ventricular-peritoneal shunts have been reported to migrate into the intestines. In particular. Fistulas may also arise following blunt or penetrating abdominal trauma. Cleveland Clinic.8 The typical scenario is the presence of terminal ileal disease. May 2009 391 . in contrast to spontaneously occurring fistulas. Computed tomographic enterography identifying an ileosigmoid fistula with arrow pointing to site of communication. In many cases it may fistulize to the sigmoid at its mesenteric border.FIG 4. if the site of fistulization is not obvious then submerging the sigmoid colon in water and performing a flexible sigmoidoscopy may help.5. A fistula may be the primary presentation of almost any intra-abdominal condition. injuries to the upper abdomen may result in a duodenal or pancreatic fistula. In addition to identifying the point of communication this will help to confirm that the fistula is due to terminal ileal disease and that the sigmoid colon is free Curr Probl Surg.

causing an abscess.41 Undue tension on the anastomosis and accompanying pouch mesentery may result in pouch ischemia and the development of a pouch fistula.34. This will drain any collection and reduce 392 Curr Probl Surg. as sequelae to radiation enteritis. hypoalbuminemia. anemia. bowel ischemia. the efferent limb should be only 2 to 3 cm since excessive length may give rise to obstructed defecation.39 In addition.38 Although a diverting ileostomy will not prevent anastomotic leakage it will reduce the clinical consequences of the ensuing sepsis. reducing the re-laparotomy rate and potential for pouch loss.of Crohn’s disease. Other causes for spontaneous fistulas include diverticular disease.36. may require surgical intervention.5% and 10%. This is very important when deciding the subsequent surgical management. Crohn’s disease may also give rise to an ECF or extend retroperitoneally to involve the psoas muscle. which is quite traumatic for the patient and their family because their initial perception was that they were undergoing a simple. perforated duodenal ulcers.40. if symptomatic. and erosion of indwelling catheters.35 Special Fistulas The development of a fistula following the creation of a pelvic pouch is disappointing and may lead to pouch loss (Figs 5 and 6). In rare cases a fistula may arise from appendicitis or following an appendectomy. scoring the mesentery. any surgeon contemplating the formation of an ileal pouch anal anastomosis (IPAA) must be aware of all the clinical steps that may be required to ensure the pouch reaches the pelvis without any undue tension on the mesentery. Crohn’s fistulas tend not to close spontaneously and. If reach is a significant problem (that may particularly occur in tall men) then one may use an “S” pouch since this will afford additional length (Fig 8).30 The management of a fistula following radiotherapy may be particularly difficult. May 2009 . Technical tips include dividing the ileocolic artery just distal to the superior mesenteric artery. nearly risk-free procedure. A perforated tumor giving rise to an ECF is associated with a poor prognosis. The incidence varies between 4. In the review of our institute’s experience we have found that the use of a double-stapled technique over a handsewn anastomosis is associated with fewer septicrelated problems and better functional results. The existence of these factors or any intraoperative technical difficulties again mandates the need for a diverting ileostomy. mobilizing to the level of the duodenum. pancreatitis. However. At the end of the procedure we recommend inserting a drain into the pelvis.37 Risk factors for leakage include prolonged steroid use. and ensuring that the pouch reaches before dividing the distal rectum (Fig 7). and tension at the anastomotic site.

) Curr Probl Surg.FIG 5. Cleveland. (Courtesy of the Department of Colorectal Surgery & Radiology. May 2009 393 . OH. Cleveland Clinic. Pouchography demonstrating a pouch vaginal fistula with an obvious fistulous tract (arrow).

and pouch contrast. The clinical manifestations of pouch leakage may be mild including tachycardia. back pain. or difficulty with urination. We recommend that when performing the anastomosis using a circular stapler. On other occasions the presentation may be more dramatic. If one has an index of suspicion for a fistula. The fistula may also occur between the bladder. the trocar should emerge posterior to the distal staple line to reduce the potential for vaginal entrapment. Presentation early in the postoperative course suggests a technical factor such as when the posterior wall of the vagina is inadvertently caught in the anterior portion of the IPAA staple line. Cleveland. or perineal skin. The presence of persistent ileus is often a telltale sign. then perform a computed tomographic (CT) scan of the abdomen and pelvis using intravenous. May 2009 . giving rise to a fistula. Any pelvic hematoma may become infected and discharge through a pouch suture line. but more importantly will help identify if there is any undrained pelvic sepsis. (Courtesy of the Department of Colorectal Surgery & Radiology. OH. vagina. Occasionally it may exit at a previous drain site. providing renal function is satisfactory. Cleveland Clinic. A pouch-cutaneous fistula.) the potential for the development of a presacral hematoma. including peritonitis or a pouch cutaneous fistula. oral. leukocytosis. This may confirm the presence of a leak.FIG 6. The occurrence 394 Curr Probl Surg.

the presence of ulcers within the proximal small bowel or efferent limb of the pouch would be more suggestive of Crohn’s disease. The presence of ulcers or inflammation within the pouch may be due to pouchitis or the use of nonsteroidal anti-inflammatory drugs (NSAIDs). If the internal opening of the fistula is accessible from the perineum then a local repair in the form of a vaginal or pouch advancement flap may be considered. Cleveland. (Courtesy of the Art Department. typically 12 months after the reversal of the ileostomy or the indexed pouch surgery. However. OH. Cleveland Clinic. painless fissures or those in atypical places.44 This is critically important since a Curr Probl Surg. in the absence of complications should raise an index of suspicion for underlying Crohn’s disease. One should carefully examine for other manifestations of perianal Crohn’s disease including large. Techniques for ensuring adequate pouch reach.) of a pouch vaginal fistula carries a significant risk of pouch loss. edematous skin tags.FIG 7. On occasion a temporary ileostomy may be required to control the sepsis and to restore the patient to a satisfactory quality of life before considering intervention. One should only contemplate surgery once the inflammatory effects have attenuated.43 A delayed presentation. and anal canal strictures (Fig 9).42 Initial management again consists of eradication of sepsis and may require the insertion of draining setons for a considerable period of time. May 2009 395 .

Cleveland. This may then be combined with 396 Curr Probl Surg. Rather than offering an advancement flap or redo pouch for the fistula one may consider the insertion of draining setons as a means of controlling anorectal sepsis (Fig 10). (Courtesy of the Art Department. OH. May 2009 . Creation of an “S” pouch reservoir. Cleveland Clinic.FIG 8.) diagnosis of Crohn’s disease of the pouch will alter the management options.

May 2009 397 . (Courtesy of the Department of Colorectal Surgery. Elephant skin tags and external os of a fistula tract in a female with perianal Crohn’s disease.FIG 9.) Curr Probl Surg. Cleveland. OH. Cleveland Clinic.

46 The patient should be counseled on the potential need for a diverting ileostomy and the risk of pouch loss. Cleveland.45. May 2009 . omental interposition.FIG 10. Generally. Pouch-vaginal fistula with a loose draining seton to control sepsis. followed by bladder and pouch repair. OH. If conservative measures fail or the patient’s quality of life is significantly impaired then one may consider surgical intervention. disconnection of the fistulous communication between the pouch and bladder.) infliximab therapy. Cleveland Clinic. In patients with a pouch-vesical fistula the communication is usually between the pouch and bladder dome. and a diverting ileostomy is associated with a successful 398 Curr Probl Surg. (Courtesy of the Department of Colorectal Surgery.

Patients with a colovesical fistula should undergo a diagnostic colonosCurr Probl Surg.outcome. surgical intervention may be planned electively when the patient’s nutritional status and medical condition is optimized. Our usual practice is to perform a colonoscopy 6 weeks after resolution of diverticular symptoms to exclude malignancy. it may be difficult to identify the fistulous tract despite radiological and endoscopic investigations. this usually requires pouch disconnection with resection of the diseased segment and a new pouchanal anastomosis. The most sensitive diagnostic test is the CT scan. which will determine whether one performs a standard sigmoid colectomy or oncological resection.50 The fistula may also arise following an elective procedure for diverticular disease. Patients with colovesical fistulas may present with frank feces per urethra.47 Intestinal fistulas may occur due to complicated diverticular disease. this may be attributed to the potential underlying diagnosis of Crohn’s disease. In these cases one may have to rely on clinical symptoms. In many cases. no intra-abdominal sepsis. unless there is a very large communication. if the origin of the fistula is from the anastomosis between the pouch and anal transition zone. However. These may be internal or external. May 2009 399 .48 This condition is seen in up to 20% of patients hospitalized with acute diverticulitis. It may also identify the adjacent implicated bowel loop and determine whether there is any intra-abdominal abscess. which may report air in the bladder that should not be present unless the patient has undergone recent instrumentation. especially if there is no distal blockage. Barium enema is rarely diagnostic since one cannot generate enough pressure to fill the fistulous tract. In some instances the fistula may close with conservative management. with the patient and family pressuring the surgeon to intervene. Most patients present in the elective setting with symptoms attributed to the involved appendage. A colocutaneous fistula may also arise following percutaneous drainage of a diverticular abscess. The patient typically develops a local diverticular perforation with involvement of an adjacent organ. The presence of feces in the percutaneous drain may create a sense of panic. However. and the patient has had a true colorectal anastomosis. in the absence of uncontrollable sepsis. There is a higher incidence in male patients attributed to the protective effect of the uterus and broad ligament in women. or recurrent urinary tract infections. Again. The presentation of a pouch fistula beyond 12 months is associated with a poor prognosis. pneumaturia.49. In either scenario the longer one leaves before the ensuing intervention the easier the subsequent surgery should be. A small percentage may present in a critical condition with malnutrition and sepsis due to smoldering intra-abdominal infection.

generally no treatment of the bladder is required once the adherent sigmoid loop is resected. It is the leakage of stool from the fistulous tract that causes the sensation of incontinence. The patient typically complains of feces per vagina. contrary to perception. In the management of a fistula due to complicated diverticular disease an abdominal approach is required. If one suspects that the area of communication is in the region of the bladder trigone then involvement of an urologist is strongly suggested. bladder cancer. If there is a large fistula to the bladder then the edges may be trimmed and the bladder defect closed in 2 layers. Again the perforated diverticulum may give rise to an inflammatory phlegmon and abscess. Anatomically the confluence of the tenaie coli will help to identify the upper rectum. Examination of the vagina is again imperative. we will leave the Foley catheter in place for 5 400 Curr Probl Surg. including edema. which would influence the ensuing management.copy and cystoscopy to ensure there is no associated colorectal malignancy. and a bullous lesion in the bladder mucosa. It may identify an opening in the vault. They can be maintained on long-term antibiotics and. In some instances they may present with incontinence. the potential for bacteremia and sepsis is minimal. In elderly patients with comorbidities one may adopt a conservative approach. in which a Foley catheter is inserted into the vagina and filled with contrast. particularly where the operative risks outweigh the extent of symptoms. which becomes adherent to the vault of the vagina. it is imperative that the entire sigmoid colon is resected. which will aid in identification of the ureters and reduce the incidence of unrecognized injury. or undiagnosed Crohn’s disease. For colovesical fistulas. The colon used for the colorectal anastomosis must be soft and without muscle hypertrophy. Vaginoscopy allows one to assess the tissues and take biopsies if required.48 This generally requires splenic flexure mobilization to allow a tension-free anastomosis and resection to the upper rectum ensures that no high pressure zone of distal sigmoid colon is left in situ with the potential for recurrence. Postoperatively. On examination the sphincters are intact and functional. but more importantly it helps to rule out an associated malignancy. The majority of patients diagnosed with a colovaginal fistula have undergone a previous hysterectomy. In complex diverticular communications one may also consider the insertion of ureteric stents. May 2009 . erythema. Regardless of whether this is done using an open or laparoscopic technique. has a high sensitivity and will help to determine if there are multiple tracts involved.51 On cystoscopy the findings may be subtle. It is important to determine if the trigone of the bladder is involved. Vaginography.

58 These complications arise 6 to 12 months following radioCurr Probl Surg. On upper endoscopy one may see the aortic graft fistulizing through the abdominal wall. which is a rapid large volume hemorrhage followed by a period of stabilization. We would also tend to leave a pelvic drain in situ until the Foley catheter is removed. is particularly sensitive to its deleterious effects arising from DNA damage and the generation of oxygen-free radicals. either atherosclerotic or inflammatory. Early manifestations of injury include diarrhea. An aortoenteric fistula (AEF) occurs when a communication arises between the aorta and gastrointestinal tract. Less common causes include tuberculosis. Radiotherapy as a primary or adjuvant therapy plays an important role in the management of pelvic malignancies. It may be a primary or secondary event.52 A primary AEF occurs when an abdominal aortic aneurysm (AAA).53. The patient will typically present with massive hematemesis and hemorrhagic shock. strictures. This typically occurs between the abdominal aorta and the third or fourth parts of the duodenum. is extremely rare. fistulas. erodes in to the intestines.days with a cystogram before removal to ensure there is no urinary leakage. When diagnosed. whether open or endovascular. This technique allows stabilization of the patient with definitive repair performed in a more elective. with its rapid cell turnover.56 Gastrointestinal fistulas may arise following radiotherapy. and usually fatal if not recognized early. The risk of graft infection is balanced against operating in a hostile abdomen with dense adhesions. It is often associated with collateral damage to adjacent organs. hemodynamically stable setting. The small bowel. Its tumorcidal ability in most cases is dose-dependent. malignancy or foreign bodies. However. The traditional repair consists of laparotomy. May 2009 401 . and tenesmus. radiotherapy.57. ligation of the aorta. and creation of an extra-anatomic bypass. should raise an index of suspicion for an aortoenteric fistula. cramping. Long-term radiotherapy-induced sequelae in relation to small bowel injuries include malabsorption syndromes. a percentage of patients may have a herald bleed. excision of the native graft. this condition requires urgent definitive intervention. These symptoms are most often self-limiting and not predictive of long-term complications.55 The presence of an upper gastrointestinal bleed in a patient with a previous aortic aneurysm repair. The risk of small intestinerelated complications is significant from 50 Gy and above and also correlates with the volume of organ exposed. Many centers are now using endovascular stents to cover the fistula. and perforation.54 Secondary AEF generally occur following aortic reconstructive procedures.

pancreatitis. despite the absence of clinical signs and that the addition of bevacizumab may lead to complete anastomotic dehiscence. which drives tumor growth and the development of metastasis. If an anastomosis is required it is best to avoid using the cecum and terminal ileum.therapy and the underlying pathology is attributed to changes in the microvasculature and the development of an “obliterative vasculitis. which will elevate the small bowel out of the radiation field for the duration of therapy. its mesentery is thickened and it loses its mobility (Fig 11). However. which most often suffers the most severe effects of pelvic radiotherapy. esophageal.59 Bevacizumab is a humanized monoclonal antibody that inhibits vascular endothelial growth factor (VEGF).61 These serious gastrointestinal complications have led to a warning label from both the manufacturer and the FDA. particularly if there is small bowel grossly adherent within the pelvis.62 It 402 Curr Probl Surg. If noninvasive methods are insufficient then one may consider the laparoscopic placement of a pelvic mesh. August and colleagues postulated that in many cases patients may have an occult leak. its effectiveness in inhibiting blood supply is not limited to the tumor site and there have been recent reports of it causing spontaneous gastrointestinal perforations and anastomotic leakages in the postoperative period. bowel obstruction. The management of pancreatic.61 Thus one should delay elective gastrointestinal surgery until at least 4 weeks have elapsed from the cessation of bevacizumab therapy. May 2009 . Clinical trials have demonstrated that bevacizumab will augment the effects of chemotherapy in the treatment of metastatic colorectal cancer.” When operating on such patients one will often encounter dense adhesions and a hostile abdomen. Vascular endothelial growth factor plays a central role in angiogenesis. and neuroendocrine tumors. a history of abdominal radiotherapy. leading to ECFs. or gastric fistula generally comes under the care of surgeons specializing in upper gastrointestinal pathology. A pancreatic fistula most commonly occurs following surgery for pancreatic neoplasms. The presence of diverticulitis.60 In several cases the fistulas developed several months to years after a previously unproblematic anastomosis. and existing tumor on the bowel are additional risk factors for perforation in patients receiving bevacizumab therapy. One must proceed with caution. identifying these risks. Microthrombosis has been postulated as a reason for these effects. in which case it may be safer to bypass the affected segment rather than resect. Affected small bowel has a gray appearance. It binds to the 2 VEGF receptors (VEGF receptor-1 and VEGF receptor-2) found on the surface of vascular endothelial cells. Today we are more conscious of excluding small bowel from the pelvic radiotherapy field.

) Curr Probl Surg. Cleveland. Small bowel affected by radiation enteritis with associated stricturing disease. OH. (Courtesy of the Department of Colorectal Surgery. Cleveland Clinic.FIG 11. May 2009 403 .

a fistula may arise between the mid esophagus and left mainstem bronchus. An esophageal stent 404 Curr Probl Surg. percutaneous drainage. The fistula is only considered clinically relevant if it is associated with fever.67 The underlying pathology is thought to be a pancreatic pseudocyst arising following pancreatitis.68 Some authors advocate stenting of the pancreatic duct. Although the true definition of a fistula is a communication between 2 epithelized surfaces. Less commonly it may involve the trachea and right mainstem bronchus. giving rise to a pancreatico-bronchial fistula. In patients with an advanced esophageal malignancy. most often in the form of antibiotics. In most patients the diagnosis is established when the amylase content of a high-output drain effluent is measured. Alternatively. organ dysfunction. and the need for drainage of an associated collection.64 These tend to resolve spontaneously. The amylase content of the drain is only considered significant if it is 3 times the upper normal serum amylase value. the persistent escape of pancreatic enzymes from a transected pancreatic surface or a pancreatic-enteric anastomosis is referred to as a pancreatic fistula.63 It is a difficult condition to manage and is associated with a prolonged hospital stay and the potential for mortality. one would begin with conservative management with tube thoracostomy insertion.may also occur due to blunt or penetrating abdominal trauma. The mainstay of care is palliative to avoid ongoing pulmonary soiling. A grading system that differentiates the severity has been proposed based on 9 clinical criteria. may necessitate reintervention.65 Pancreatic fistulas have been reported to communicate with the pulmonary system. Grade B fistulae are symptomatic and require active clinical management. Grade C fistulae are those associated with significant postoperative problems including organ dysfunction that requires major deviation from the planned postoperative course. If one has an index of suspicion for this type of fistula then one should analyze the amylase content of broncho-alveolar lavage. Many authors refer to a biochemical pancreatic fistula as one in which there is elevated amylase content in the drain at the third postoperative day in an asymptomatic patient. giving rise to a pancreatico-pleural fistula. Grade A fistulae are transient and characterized by an elevated drain amylase level in an asymptomatic patient. which is extremely distressing for the patient and family.66. nutrition. In most patients. The patient may present with recurrent pneumonitis or a lung abscess. and are associated with significant risk of morbidity and mortality. which may decompress into the pleura. and so forth. leukocytosis. May 2009 . It is a very sinister development and may arise de novo or following radiotherapy. it may decompress into the bronchial tree.

Percutaneous drainage using either CT scan or ultrasound guidance is the least invasive means of draining any collection and avoids the considerable inflammatory “second-hit” response that would be generated by surgical intervention. This can occur when the abscess is surrounded by critical structures or is a multi-loculated collection.72 Thus one requires input from an experienced radiologist. Any patient with an intestinal fistula and evidence of organ dysfunction such as cardiac.2. and impaired immune function. However. In this scenario the fistula will not close spontaneously and the patient is ill equipped for the subsequent surgery. thus improving the patient’s quality of life and survival period.69.74 We would generally not give antibiotics for an abscess that is draining adequately unless there is accompanying cellulitis.71 Operating on these patients in such a catabolic state may very quickly lead to multi-organ failure and death. as clinically indicated. all of which provide a fertile environment for opportunistic Curr Probl Surg. by the time of referral to a tertiary unit. respiratory. or renal failure will most likely have an undrained focus of sepsis. Although it will not allow fistula closure. By sealing the fistula it prevents respiratory contamination and restores the ability to swallow. Rather than the classical signs of infection they present with significant weight loss. percutaneous drainage may not be feasible or may be inadequate. ongoing nutritional losses. jaundice.18. In several studies this has been found to be the most important determinant of outcome. it can downsize a complex fistula to a simpler one that makes elective resection more feasible. with the resources for frequent imaging and percutaneous drainage of any collections. which leads to increased catabolism. Very often these patients will not present with the typical inflammatory response.73 The initial catheter can be upsized if required. contrast studies may be performed through the catheter (tubogram) to confirm that the abscess cavity is decreasing in size. many patients with intestinal fistulas are immunocompromised and have received several different courses of antibiotics. In these cases open surgical drainage may be required and can be guided by the CT findings.would appear to offer the best palliation using the least invasive means. In addition.70 Management Principles in Patients with Intestinal Fistula The initial management of affected patients is to ensure the eradication and control of sepsis.11 The majority of deaths from intestinal fistula are related to uncontrolled intra-abdominal sepsis. and hypoalbuminemia.8. We would have a low tolerance to repeat CT scans at appropriate intervals. On occasion. May 2009 405 .

Indeed. Most units will have an infectious disease team that will aid one in making appropriate decisions on the need for and type of antimicrobial therapy. One of the long-term complications of patients with a continent ileostomy (K-pouch) is the development of a fistula between the pouch and nipple valve (Fig 13). The fistula effluent may be acidic or alkaline and very quickly lead to skin excoriation. (Courtesy of the Enterostomal Nursing Department. Cleveland. On occasion patients may come with horrendous abdominal wounds that are extremely difficult to manage. OH. with the fistula exiting within the center.) infections. This leads to pouch incontinence and excoriation of the surrounding skin. in a spontaneously occurring fistula. Skin protection is a critical part of the care pathway. Cleveland Clinic.75 The enzymes within the enteral succus may digest the abdominal wall leading to an almost unmanageable wound (Fig 12). May 2009 . The enterostomal therapy team must be consulted immediately since appropriate appliances and skin protection may prevent this downward spiral of skin excoriation and resulting difficulties in getting containment of the fistula effluent. In this patient group the potential for superimposed infection with methicillin-resistant Staphylococcus aureus (MRSA) or fungal infection is considerably higher. spreading cellulitis may be the first manifestation of its presentation.FIG 12. Insertion of a Waters tube with the application of a face-plate is a means of controlling the effluent until 406 Curr Probl Surg.

76 It is important to be aware that the presence of a fistula discharging malodorous body contents onto the skin leads to loss of self-esteem.FIG 13. their partners. (Courtesy of the Department of Colorectal Surgery. anxiety. and depression. Origin of a fistula tract (arrow) at the base of the nipple valve in a patient with a continent ileostomy. When the patient becomes comfortable with changing the stoma appliance. May 2009 407 .) pouch revision can be performed. Cleveland. poor body image. A well-managed fistula ensures that the patient has a good quality of life and may even be able to return to work during the recovery period. particCurr Probl Surg. OH. In this regard patient education is important. Cleveland Clinic. and caregivers should be taught how to change the stoma and associated appliances. Prolonged hospital admission. Patients. this provides them with independence and reduces anxiety levels when the appliance leaks and there is no one available to help.

80 With low-output fistula ( 200 mL/day). May 2009 . Whether enteral nutrition is appropriate depends on the nature of the gastrointestinal fistula. In some patients without underlying sepsis and a low-output fistula there may be no change in their basal metabolic rate. transferrin. then nutrition should be administered orally. As a rule. inappropriate nutrients may have damaging effects. Markers of the patient’s nutritional status include proteins with a short half-life such as albumin. Malnutrition can led to depression.14 Fazio and colleagues found that for ECF patients with an albumin less than 2. and retinol binding protein. In this patient subset the time to recovery may be weeks or months. Hypoalbuminemia is a significant risk factor for mortality. nutritional support is required when the duration of illness is anticipated to be longer than 10 days.5 g/dL the mortality rate was 42% in contrast to 0% mortality for patients with albumin greater than 3. if the gastrointestinal tract functions. Eradication of sepsis is performed in tandem with meeting the nutritional needs of the patient. Thus they may especially require psychological support. Ideally the patient would be fed using the oral route. enteral 408 Curr Probl Surg. The basal metabolic rate accounts for the greatest energy expenditure and in normal individuals is estimated at 25 kcal/kg per day. isolates them from their friends and removes them from the home environment at a time that may be critical to their development. As a rule. The majority of hospitals managing such complex patients will have a nutritional team in place that will be able to guide the patient’s caloric requirements. lethargy. There must be very close interaction between all teams to ensure that the appropriate calories and nutrients are being administered to the patients since excess.79. These patients very quickly lose more than 10% of their body weight and many at presentation look cachectic with the appearance of a patient with metastatic cancer.ularly for young patients.5 g/dL. but if this is not possible then parenteral nutrition may be required. This malnourishment leads to an impaired immune system with reduced ability to fight underlying and opportunistic infections. There are several formulas such as the Harris-Benedict formula that allow precise calculations.78 It is important that one assesses early in the course of the illness whether the patient’s nutritional needs are being met. and a poorly motivated patient with little enthusiasm for recovery. Underlying sepsis is a major cause of increased metabolism and these patients will require greater nutritional support until the infection is eradicated. Generally these patients are managed on the ward unless there is associated multiorgan failure requiring supportive therapy. prealbumin.77 Serum transferrin is also a strong predictor of fistula-associated mortality. Generally these patients are quite debilitated and catabolic at the time of presentation.

or both) is important so that one can rule out coexisting pathology before considering definitive intervention. Understanding the underlying pathology and associated anatomy is the next part of this management algorithm. In this scenario one may consider the administration of enteral nutrition via the distal limb of the efferent bowel (fistuloclysis). and presence or absence of sepsis will allow one to Curr Probl Surg. The patient is also allowed oral intake. supplementation of the diet with high-calorie supplements is sufficient to meet the calorie requirements. Naturally the patient will be anxious to know the subsequent course of action and management plan. In addition to identifying the origin of the fistula it will help determine if the gastrointestinal tract is in continuity.81.82 More than 75 cm of distal small bowel is required to facilitate absorption. extravasation of barium within the thoracic or peritoneal cavity can induce an intense inflammatory response. insertion of a percutaneous endoscopic gastrostomy tube (PEG)/jejunostomy tube with enteral nutrition is preferable to TPN. The radiologic modality chosen depends on the fistula type. but its lower radiographic density means it has less reliability in identifying small leaks or fistulous tracts. May 2009 409 . Thus. endoscopic. whether due to neurological or iatrogenic causes. its principal function is to identify any intra-abdominal sepsis that may require drainage. In some cases one may encounter patients who require a small bowel resection with a proximal jejunostomy and the orifice of the distal small bowel brought to the surface as a mucus fistula. Although a CT scan performed in the early stages gives information on the nature of the fistula. However. associated anatomy. These patients may still have a considerable amount of distal bowel in circuit. We find the images provided by CT enterography to be of very high quality (Fig 14). The study should only be performed once the tract has matured. Fistulograms provide invaluable information in patients with a fistula communicating with the skin. barium is considered the ideal medium to use when investigating the lumen of the gastrointestinal tract. Very often.nutrition is generally well tolerated. which allows the patient to pursue normal activities throughout the day. Imaging (whether radiologic. With its ability to delineate mucosal detail. Knowledge of the cause of the fistula. In patients with dysphagia. In some cases it may be very useful for the surgeon to be present while the procedure is being performed since one can interact with the radiologist to ensure the pertinent information is obtained. water-soluble contrast medium is considered safer. When operating on a patient with a fistula one should always anticipate the possibility of intraoperative findings that do not correlate with the preoperative radiographic findings. The feeds are generally administered at night. which will help psychologically but will be of no nutritional value.

ileal. In this scenario one must plan an appropriate management course with the patient. Some fistulas are more likely to close in response to conservative management than others. Cleveland.8. the presence of a foreign body such as mesh. pancreas. Fistulas associated with inflammatory bowel disease.83 In favorable circumstances the general consensus is that 80% to 90% of fistulas will close within 6 weeks.1. and fistulas arising from the lateral aspect of the gastrointestinal tract that is in continuity. (Courtesy of the Department of Colorectal Surgery & Radiology. bowel discontinuity. Computed tomographic enterography identifying an ileovesicular fistula with arrow pointing to site of communication. malignancy. May 2009 . Cleveland Clinic. Less likely to close are gastric.84 Also.) be able to counsel the patient about the potential outcomes.FIG 14.11. and duodenal stump. This includes those arising from the esophagus. OH. radiotherapy. giving a potential time frame of 410 Curr Probl Surg. and lateral duodenal fistulas. fistulas involving multiple sites or organs are unlikely to close without surgery. or a large adjacent abscess are unlikely to close of their own accord. jejunum.

If symptomatic this may require the insertion of a PEG tube to decompress the small bowel until resolution of the obstruction or definitive surgery. The triad of sepsis. The patient and his family must understand the difficult situation and have realistic goals.12 Stoma Considerations in Patients with Intestinal Fistula When considering surgical intervention in a patient with intestinal fistula whether in the elective or emergency setting. close coordination with the ET team is important in achieving a successful outcome. On occasions we have encountered significant gastrointestinal bleeding in association with the fistula. Rather than attacking the fistula head-on one should identify and free up the afferent and efferent limbs. A large percentage of patients will require a prolonged hospital course with numerous interventions. We advise entering the abdomen away from the initial incision. This is done with optimal lighting. This may be above or below the initial laparotomy site or alternatively via a totally separate incision. A subset of patients in addition to the fistula may have a small bowel obstruction. Everybody involved in patient care should understand the complex nature of these cases.85 In many cases the small bowel obstruction will resolve once the inflammatory process has settled. In optimal conditions the fistula may be resected and a primary anastomosis performed. then the wound must be carefully examined. May 2009 411 . In some cases one may be forced to intervene earlier than anticipated at which time the surgeon is likely to encounter a hostile abdomen with dense adhesions. This carries the risk of further enterotomies and fistulas. If the bleeding is persistent. then mesenteric angiography may be both diagnostic and therapeutic.86 This will take into account the intended incision site and location of the fistula and will reduce the potential for a poorly positioned stoma that gives difficulty Curr Probl Surg. Although one may not be planning on diversion it is always prudent to mark the patient for a stoma before any intervention. A laparotomy should only be considered as a last resort. and the source cannot be identified. In some patients the adhesions are so dense that the only safe course of action is the creation of a very proximal stoma. and electrolyte disturbance as reported in the 1960s are still the 3 major determinants of mortality in patients who develop intestinal fistula today. if indicated. One should consider the possibility of a proximal gastrointestinal source and perform an upper endoscopy. malnutrition.greater than 6 months to subsequent reintervention. but in suboptimal conditions or when the surrounding bowel is diseased then an end stoma may be more prudent. One may identify a bleeding point arising from the wound edges or the abdomen as it undergoes granulation. If it is an ECF. significant.

or near bony prominences or folds as this will create difficulties with pouching. One should always take into account that the patient may require the stoma for a considerable amount of time before reversal and that in a percentage of cases it may be permanent.) with pouching and may ultimately require revision (Fig 15). On some occasions patients may have had so many operations that it is difficult to identify a suitable site. scars. This is in contrast to surgery for a colonic fistula in which case one could reasonably assume that the diverting stoma will be formed in the lower quadrants. If the patient has a fistula involving the mid-small bowel then it is likely that any ensuing stoma will be placed within the upper quadrants. and the ability of the patient to see the stoma. one should anticipate all possibilities. This is associated with improved patient satisfaction postoperatively.FIG 15. It is important that one avoids placing the stoma within deep crevices. In this scenario the enterostomal therapist may mark nontraditional sites. Cleveland Clinic. A recessed stoma may be impossible to pouch and require revisional surgery. If the patient is confined to a wheelchair then the optimal stoma site should be marked with them sitting in the chair. Cleveland. However. OH. We still follow the mantra of placing the stoma through the rectus abdominis muscle whenever possible since this is associated with a lower incidence of 412 Curr Probl Surg. Preoperative marking allows one to take into account body habitus. (Courtesy of the Enterostomal Nursing Department. where the patient wears his belt. May 2009 .

) parastomal herniation. Klempa and colleagues reported on the beneficial effects of somatostatin in reducing the complication rate following Whipple resection. We prefer to mark our selected sites with India ink (Fig 16). In patients with increased abdominal girth a loop end ileostomy may be required. May 2009 413 .FIG 16. allowing it to be administered subcutaneously 3 times a day. As a rule we would prefer to manage a parastomal hernia. octreotide.88 The limitation of its short half-life (2 to 3 minutes) was overcome with the development of a synthetic analog. (Courtesy of the Enterostomal Nursing Department.87 It is important that the abdominal wall opening is of sufficient caliber to allow the stoma to be brought to the surface without tension. which had similar pharmacological properties and a longer half-life (2 hours). Octreotide and Gastrointestinal Fistula In 1979. Often in these cases the mesentery of the bowel is extremely thickened and requires a considerable opening in the rectus sheath to allow the identified bowel loop to be brought to the surface without tension. In some situations it may be necessary to bring the stoma through the laparotomy wound. Cleveland.89 They work by inhibiting Curr Probl Surg. in patients who are already critically ill. Cleveland Clinic. We ideally like to mark our stoma site with India ink to leave a permanent tattoo. in contrast to the ill effect of an ischemic stoma. OH. This provides a permanent tattoo and avoids the intended site being lost.

This may leave the patient with a short gut syndrome.92 Overall. This reduces the potential for encountering a “frozen abdomen” due to dense adhesions.77 Intervention within this period may result in multiple enterotomies and damage to the mesentery of the bowel with resulting loss of significant bowel segments. the general consensus is that they provide a modest benefit only. well nourished.90 Subsequent prospective randomized.both endocrine and exocrine pancreatic secretion and by decreasing splanchnic blood flow. Exposure is critical. gallbladder emptying. and the fistula has not closed spontaneously within 6 weeks then it is unlikely to do so without operative intervention. However. the consensus of other trials by Sancho and colleagues. They have been typically used in conjunction with TPN. placebo-controlled trials investigated the merits of octreotide in patients with postoperative ECF. if the patient is free of sepsis. May 2009 .19 Of critical importance when considering intervention is that one delays the ensuing surgery until a minimum of 6 months has passed from the prior surgery.91. In a subset of patients they may reduce the fistulous output and limit the electrolyte disturbance. Generally. Operative Intervention Once the patient has been stabilized and a trial period of conservative management has failed then one may have to plan a surgical course. Additional effects include the inhibition of other gastrointestinal hormones. 414 Curr Probl Surg. A multicenter trial by Torres and colleagues reported that the continuous intravenous infusion of somatostatin in combination with TPN reduced the time to healing and associated morbidity in comparison to TPN alone in patients with postoperative gastrointestinal fistulas. Operative treatment is successful in more than 80% of patients allowing restoration of gastrointestinal continuity. gastrointestinal secretions. was that octreotide. and Scott and colleagues. The majority of cases require a major laparotomy via an incision extending from the xiphisternum to the symphysis pubis. helping in wound management. double-blinded. did not aid fistula closure or reduce the closure time. Fazio and colleagues have shown that operative intervention between 10 days and 6 weeks carries a significantly higher mortality rate in comparison to intervention outside this critical time period. and gut motility. If a beneficial effect is seen it typically occurs within the first 48 hours. when combined with TPN.1. In our own practice we use octreotide only to control fistula output when other antimotility agents have failed. Only 1 of the studies demonstrated a beneficial effect reducing the fistula output after 24 hours of treatment (53% reduction with octreotide TPN vs 9% TPN placebo).

FIG 17. OH.) leaving the patient with a major wound and often several drains (Fig 17). (Courtesy of the Department of Colorectal Surgery. Cleveland. Cleveland Clinic. Typical wound following the repair of multiple enterocutaneous fistulas with a diverting ileostomy and Penrose drains (arrows) to aid drainage at the site of communication between fistulas and skin. Care must be taken to avoid an inadvertent enterotomy at the time of peritoneal entry. May 2009 415 .93 Thus one should enter the abdomen well removed from existing fistula sites with particular care at the point of peritoneal entry as the underlying bowel may be fused to the peritoneum and posterior rectus Curr Probl Surg.

Their use of a biological mesh was strongly associated with further fistulization and incisional hernia formation. in complex cases they greatly aid the identification of the ureters. This may require extensive lateral dissection or fascia splitting incisions to allow midline approximation. Many centers are now inserting ureteric stents selectively if at the time of the laparotomy one encounters significant intra-abdominal pathology that increases the risk of ureteric damage.94 The addition of a ureteric injury to the already complex situation may be fatal. If there is a considerable abdominal defect then we would involve the plastic surgery team to aid the abdominal wall reconstruction. The intra-abdominal anatomy must be clearly identified.1%) reconstructed with a prosthetic mesh.fascia. We recommend using a scalpel at this point. In these cases one generally must mobilize the entire small bowel from the ligament of Trietz to the ileocecal junction. If resection carries considerable risks then the diseased segment may have to be bypassed. again highlighting that surgery in this group is high risk. The majority of enterotomies at re-laparotomy are made on reentering the abdomen. when one uses prosthetic mesh in comparison to native tissues. Connolly and colleagues reported on the outcomes for 61 patients undergoing 63 operations to close ECF associated with open abdominal wounds. This was in contrast to 7 of 29 (24. They may use a myocutaneous flap or other autologous tissue repair. Their postoperative mortality rate was 4. including fistulization and incisional hernia formation. The refistulization rate was 11%. Some authors suggest serosal patching and Roux-en-Y drainage of fistula defects. Ureteric stents should be considered if there is the possibility of retroperitoneal or pelvic dissection.95 If the tension is too great and carries the risk of abdominal compartment syndrome then one may have to consider mesh insertion. several studies have reported significantly higher complication rates. None of the 34 patients who had primary closure of the abdomen developed fistula. May 2009 . If there is a segment of bowel that is particularly diseased then it may have to be resected. Although many surgeons lament the wasted time associated with their insertion. They concluded that simultaneous reconstruction of the intestinal tract and abdominal wall was associated with a high complication rate and that 416 Curr Probl Surg.8%. with the highest rate of refistulization in patients in whom a porcine collagen mesh was used. but these are techniques we would not generally use. This may require a considerable amount of time. However. We occasionally use hydrodissection for densely adherent bowel loops. These were patients who had several preceding laparotomies and ultimately required a laparostomy at the initial presentation since abdominal closure was not feasible. Primary closure of the abdomen should be attempted.

colovesical. there are now several studies reporting the successful use of minimally invasive surgery in the management of a subset of patients with colovaginal.93 Loss of defined planes may also result in damage to the mesentery with excessive bleeding. One can then make a plan for further intervention in 6 to 12 months when the adhesions may be more manageable. If this situation is encountered or anticipated it may be best to abandon the laparotomy. in a percentage of patients. If mesh insertion is required then we would advise mobilizing the omentum off the transverse colon to a sufficient degree so that it may be interposed between the abdominal wall mesh and underlying abdominal contents. Preoperatively. which ensures that it is a proximal loop and not distal to the existing fistula sites.such patients should be managed in a specialized unit.97-99 The use of composite meshes is also quite popular. May 2009 417 . condemning the patient to lifelong TPN.48 However. tissues may be densely adherent and result in multiple enterotomies. If possible one may try and bring a more proximal loop of bowel to the surface to make the downstream fistula more manageable in terms of wound care. Previous reports indicated that these biological materials appear to offer greater resistance to infection despite the presence of a contaminated field.96 However. These patients may also very quickly develop disseminated intravascular coagulation leading to significant blood loss and multiorgan failure. This is done in conjunction with the ET team and will improve patient satisfaction with the resulting stoma if required. Despite waiting a reasonable period of time following their previous intervention. in the absence of a more favorable alternative most surgeons resort to using inert materials such as Permacol or Alloderm if abdominal wall reconstruction is required. This may be the first loop of jejunum distal to the ligament of Trietz. This must be a key part of the preoperative discussion with the patient and their family. The resulting injury may necessitate removal of an excessive amount of small bowel and the potential for short bowel syndrome. Laparoscopic Surgery for ECF At one time the presence of a fistula was considered a contraindication to pursuing a laparoscopic approach. When operating on such patients one must always be cognizant that the small bowel is a limited resource and extensive resection may commit the patient to lifelong TPN and its associated complications. Management of Intraoperative Complications It is imperative when undertaking operative intervention in this patient group that one has an exit strategy in case of intraoperative difficulties. patients should be marked for an ostomy site in all abdominal quadrants. and Curr Probl Surg.

The site of bladder or vaginal fistulization is typically small and does not require repair. associated abscesses.106 At the end of the case the greater omentum is placed between the small or large bowel anastomosis and bladder or vagina. Laparoscopic fistula takedown can be assisted using an endoscopic stapling device. In many cases the laparoscopic approach allows one to identify the area of pathology and then make a small incision over this critical region. laparoscopic colorectal surgery. the site of fistulization and extent of the defect can be assessed by distending the bladder with methylene blue diluted in saline. in particular. Novel Techniques in the Management of Gastrointestinal Fistula Proponents of novel methods are of the opinion that the techniques are minimally invasive and associated with low morbidly and that. they provide an attractive alternative option to a major laparotomy. once the bowel is sufficiently mobilized it may be safer for the resection and ligation of mesenteric vessels to be performed extracorporeally.107 Lisle and colleagues subsequently reported its use in the management of intestinal and colonic fistulas using a percutaneous radiologically-guided method. May 2009 . avoiding the need for a major laparotomy. If a large defect is identified it can be closed using intracorporeal suturing. The operative principles in the laparoscopic approach are in keeping with open surgery. However. Preoperatively patients should undergo endoscopy and radiological imaging as appropriate to rule out cancer. This generally requires splenic flexure mobilization and subsequent anastomosis to the upper rectum. before undertaking these complex cases the surgeon must have a considerable amount of experience with laparoscopy and.Crohn’s-related fistula. Thus. or failure to make progress in a timely fashion. although outcomes are variable and still under investigation.104 One should have a low index to convert to an open approach in the presence of dense adhesions. An initial CT scan is 418 Curr Probl Surg. an inflammatory phlegmon.100-103 However. Khairy and colleagues reported on the use of percutaneous gelfoam embolization in the management of duodenal fistula. Great care should be taken since missed enterotomies are a significant cause of morbidity in laparoscopic colorectal surgery.105 When patients have a diverticular fistula the affected segment of sigmoid colon is resected. We would particularly advise caution in patients with their fistula arising from small bowel Crohn’s disease since the mesentery is often quite thick with a significant risk for bleeding. The first port is inserted under direct vision at a site removed from previous scars and underlying pathology.

Aside from the use of fibrin glue we have no personal experience in the use of these “novel” techniques. a major laparotomy is required to deal with the problem definitively. A guidewire is passed through the fistula into the bowel lumen.111 These were all low-output ECFs. In 1996 Hwang and Chen reported on the successful use of fibrin glue in 6 patients with ECF. Gelfoam pledgets are then pushed down the sheath with the introducer until they occlude the fistula. A 5-Fr Berenstein catheter was then advanced over the guidewire to the origin of the fistula tract from the bowel and its position was confirmed by injection of contrast. but the low associated morbidly and the fact that one may avoid an operation does create some interest. The technique itself consisted of inserting a guidewire before removing the percutaneous drain. May 2009 419 . there must be no distal obstruction or intra-abdominal foreign body such as mesh. The sheath is then removed. soiling.7. An introducer sheath is then passed over the guidewire until it lies at the point that the fistula tract exits the bowel lumen. and the origin of the tract.108 Kumar and colleagues reported on the endoscopic closure of fecal colocutaneous fistulas using metal clips in 2 patients. The origin of this concept developed with the successful closure of colonic perforations occurring following colonoscopy using metal clips. and skin excoriation. A fistulogram is then performed to outline the anatomy.110 Gage and colleagues reported on the treatment of 3 ECFs arising in pancreas transplant recipients using percutaneous drainage and fibrin sealant. tortuosity. The guidewire and central introducer are then removed.109 There have also been some reports of ECF closure using fibrin glue. After the fistulogram the embolization procedure is performed using fluoroscopic guidance. They reported its successful use in 3 patients with ECF. The tissue seal was then injected and the catheter slowly removed until the entire tract was obliterated to the level of the skin.required to ensure that there is no undrained sepsis. Skin Grafting and VAC Dressing An ECF that drains through a large open abdominal wound can lead to major problems with fluid loss. In addition.83 TradiCurr Probl Surg. leaving the sheath. in the vast majority of ECF cases. One patient had a fistula arising from a cecal perforation due to a stab injury and the second patient developed a colocutaneous fistula following a left hemicolectomy for an adenocarcinoma of the descending colon. This will provide important information on the length. However. In all patients the anastomotic leak presented as an intra-abdominal fluid collection that was converted to a controlled fistula by percutaneous drain insertion.

This is covered by a clear dressing.116-118 Reported success has been achieved for pilonidal. It has been found to be superior to the traditional management of open abdominal wounds and reduces the nursing care involved. 420 Curr Probl Surg.tionally these wounds were managed using large ostomy appliances often connected to a sump system to draw off effluent in an attempt to reduce skin maceration. and so forth. Once the skin graft takes. sacral.113 In our experience if one has a very large open abdominal wound and a skin graft can be applied to 70% or 80% of the area then this will greatly aid the patient and wound management. Also it allows one to discharge a patient to community heath care. If a patient is a suitable candidate for a skin graft then the involvement of a plastic surgery colleague will aid in the decision making. reduces tissue edema. It consists of a polyurethrane foam dressing that is cut to the required size and inserted onto the exposed wound. The graft may or may not be done in conjunction with the vacuum-assisted closure (VAC) system. In more recent years we are beginning to explore other alternatives for wound management. The removal of purulent material reduces the bacterial count within the wound. It is changed every 2 to 3 days. but it significantly promotes time to closure and thus in the long-term is more cost-effective than the use of traditional saline-soaked gauze dressings. an ostomy bag can be applied to collect the fistulous output. It has equal efficacy in adults and children. whereas traditionally the patient was kept in the hospital until significant wound healing was achieved. and encourages angiogenesis with ensuing granulation. facial wounds. One of the dangers is that the fistula effluent may get under the skin graft and lift it from the bed. Skin grafting is a useful adjunct in these patients. Before grafting the granulated abdominal wound is debrided of any necrotic or purulent material.114 The VAC system has revolutionized the management of open wounds that previously may have taken months to heal. If successful it makes the wound more manageable until the time of definitive fistula repair.112 If the graft is successful then it reduces fluid loss and bacterial colonization of the wound.115 Since its introduction it has gained widespread popularity and has been applied to the management of a wide range of wounds in different anatomical locations. The device works by applying a negative subatmospheric pressure. Typically a negative pressure is applied at 125 mm Hg. Costs involved have been raised as an issue. It aids the removal of purulent material. Temporary intubation of the fistula lumen while the graft is healing may reduce the incidence of this problem. Contrary to one’s instinct and the presence of bacterial contamination a large percentage of these grafts will take with little morbidity to the donor site. taking care not to cause an inadvertent enterotomy. May 2009 . but this can be varied.

In the 4 patients with exposed intestinal mucosa no closure was achieved.One of the concerns with the use of the VAC dressing is that contact with unprotected bowel may give rise to additional ECFs. Often at this initial stage the surgeon involved in the patient’s care comes under considerable pressure from the family and patient to provide a quick resolution. we would advise caution in this scenario and agree with the sentiments of Fischer that the application of a VAC device directly onto exposed bowel has the potential to lead to the development of further fistula and a more difficult surgical problem to manage. When the fistula is iatrogenic the feelings of guilt often lead surgeons to Curr Probl Surg.120 Although the series was small they found no correlation between the volume of fistula output and the potential for closure. Gunn and colleagues reported on its use in 15 patients with ECFs. Most specialized centers will have interventional radiologists experienced in the management of these complex cases. The initial principle of care is to control and eradicate underlying sepsis. Some authors advocate if the patient has an open wound plus a fistula then the VAC may be applied directly to the fistula. prevent skin excoriation. However. Patients with intestinal fistulas may present with a myriad of symptoms and diagnostic difficulties.121 Summary Large series reporting outcomes in the management of complex gastrointestinal fistulas have greatly improved our knowledge of this subject. the underlying fistula must be carefully isolated from the VAC device and this requires a lot of care and expertise from the wound care team (Fig 18). lack of appropriate radiological resources. If the patient has an external fistula then early involvement of the enterostomal therapist is required to gain control of the wound. On occasion open surgical drainage may be indicated due to overwhelming sepsis. or where the septic focus is in a location that is inaccessible or surrounded by structures that may be damaged with a radiological approach. In 11 patients with no visible intestinal mucosa they achieved closure with a mean time of 14 days. an aggressive approach with repeat scanning and insertion or upsizing of drains as clinically indicated.119 We believe that it has a role in the management of patients with large open wounds and associated fistulas. if the patient has an open wound plus a fistula. May 2009 421 . We would advocate. With radiologic advances this is typically achieved with CT. It was also successful in 1 patient who had preceding neoadjuvant therapy. However. which is not surprising since these fistulas are generally well epithelialized and not amenable to conservative measures. and to provide a means of measuring the fistulous output.or ultrasound-guided percutaneous drainage.

Cleveland Clinic. (B) The same patient with a vacuum-assisted closure system applied and the enterocutaneous fistula opening carefully isolated. This helped to control the abdominal wound until time for definitive surgery. May 2009 . OH. (A) Open abdominal wound with enterocutaneous fistulae and a left sided ileostomy (arrow).FIG 18. Cleveland.) 422 Curr Probl Surg. (Courtesy of the Enterostomal Nursing Department & Wound Care Team.

However. psychiatry. Stoma reversal also carries the potential for complications. A multidisciplinary approach with input from radiology. These patients most often have been very sick for a considerable period of time and are ill equipped medically and psychologically to deal with a further anastomotic problem. and difficulties with wound care. In addition. However. ongoing weight loss. and physiological output will help in this decision. Therefore. May 2009 423 . Knowledge of the anatomical origin of the fistula.consider early operative intervention. if the fistula arises from the proximal bowel a stoma to protect this will invariably commit the patient to a further 3 months of TPN. the care of each patient must be individualized according to their underlying pathology. Again most centers have experienced nutritional personnel who will help assess the patient’s status and determine if TPN is indicated. Total parenteral nutrition may be required because of associated bowel obstruction. These patients require a significant amount of time and commitment from personnel involved in their care. Advances in health care mean that people are living longer and we are pushing the boundaries of surgical intervention. age. In most cases this is inappropriate and may lead to further fistulas when “masterly inactivity” with appropriate supportive care would have been the correct course of action. the decision to form a stoma will be guided by the patient’s clinical status and operative findings. The necessary experience required to deal with many of these complex cases can only be acquired with exposure and time. Strong consideration should be given to creating a diverting stoma. At the time of definitive operative intervention a sufficient amount of time must be allocated to the intended procedure. enterCurr Probl Surg. nutritional deficiencies. and high-output fistulas giving rise to electrolyte disturbances. there is going to be an inevitable percentage of patients who will develop intestinal fistula. If the fistula arises from the small or large bowel then the segment of origin will generally have to be excised and a primary anstomosis performed as appropriate. The preceding monograph provides many guidelines and principles to follow when dealing with intestinal fistula. In most cases one will be able to decide relatively quickly whether nutritional support is required. In this situation a second opinion from a supportive colleague may be valuable. its etiology. and response to treatment. then use the enteral route. comorbidities. Division of dense adhesions may take a considerable amount of time until one reaches the area of relevant pathology. If the patient has sufficient gastrointestinal tract. In the initial catabolic stage additional calories may be required above the patient’s basic metabolic needs.

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